Scientific Abstract Presentations: Breast Session 6 Saturday, October 11 Sat, Oct 11 8:00-9:30 a.m. CDT

Purpose: Increasing rates of obesity in the US and incidence of breast cancer have resulted in growing demand for larger breast implant sizes for implant-based breast reconstruction(1). This study aims to evaluate whether the largest implant sizes (1340cc and 1445cc) from the Athena Clinical Trial (ClinicalTrials.gov NCT02724371) for breast reconstruction show clinically significant differences in outcomes compared to smaller sizes in the study and the benefit/risk ratio associated with these devices.

Methods: 3-year follow-up of 53 patients who received either 1340cc or 1445cc devices was conducted as part of a 10-year multicenter prospective investigational study evaluating safety and effectiveness of larger-volume implants in women undergoing post-mastectomy two-stage reconstruction. Safety (complications) and performance (satisfaction, including BREAST-Q) were analyzed using descriptive statistics.

Results: The largest implants in the Athena study were predominantly used in patients with BMI ≥35 (65.4% of those receiving 1340cc and 92.6% of those receiving 1440cc). Most patients, 42 (79.2%), with 1340cc or 1445cc devices retained their original implants at 3 years, while 11 (20.8%) required explantation. Ten of the 11 explanted patients were successfully reimplanted with another device from the study. In the revision reconstruction cohort, 90.9% of participants engaged in the study to increase their implant size due to the perception of insufficient volume in their reconstructed breasts. No significant differences were observed when comparing complication rates (including any reoperation, asymmetry, Baker Grade 3/4 capsular contracture, delayed wound healing, explantation, extrusion, malposition, infection) across device sizes using a univariate logistic regression model (Figure 1). Via BREAST-Q, patient-reported satisfaction levels showed similar high scores across lower (930-1240cc) and higher (1340-1445cc) sized devices in the study (Figure 2).

Conclusion: High BMI patients represent approximately half of the women currently presenting for breast reconstruction after mastectomy due to breast cancer(2). This highlights the need for larger breast implant sizes than 800cc for obese women, leading to the Athena Study of breast implants with volumes up to 1445cc. Although obese breast reconstruction patients have historically faced a higher risk of complications compared to their non-obese counterparts, data from this study revealed a favorable risk/benefit ratio for what are now the largest breast implants available on the US market. Implants larger than 1300cc required minimal revisions beyond size adjustments, with complication rates comparable to those of smaller devices. These high-volume implants demonstrated an acceptable explantation rate and high retention rates over three years. There was a strong association between the selection of these largest volume implants and women with a BMI ≥35, suggesting tailored utility for obese patients. Finally, patient and surgeon-reported outcome scores were high for these largest-volume implants, further justifying their use.

References: 1. Barone I, Giordano C, Bonofiglio D, Andò S, Catalano S. The weight of obesity in breast cancer progression and metastasis: Clinical and molecular perspectives. Semin Cancer Biol. 2020 Feb;60:274-284. 2. Srinivasa DR, Clemens MW, Qi J, Hamill JB, Kim HM, Pusic AL, Wilkins EG, Butler CE, Garvey PB. Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study. Plast Reconstr Surg. 2020 Mar;145(3):481e-490e.

Purpose: Increasing rates of obesity in the US and incidence of breast cancer have resulted in growing demand for larger breast implant sizes for implant-based breast reconstruction(1). This study aims to evaluate whether the largest implant sizes (1340cc and 1445cc) from the Athena Clinical Trial (ClinicalTrials.gov NCT02724371) for breast reconstruction show clinically significant differences in outcomes compared to smaller sizes in the study and the benefit/risk ratio associated with these devices.

Methods: 3-year follow-up of 53 patients who received either 1340cc or 1445cc devices was conducted as part of a 10-year multicenter prospective investigational study evaluating safety and effectiveness of larger-volume implants in women undergoing post-mastectomy two-stage reconstruction. Safety (complications) and performance (satisfaction, including BREAST-Q) were analyzed using descriptive statistics.

Results: The largest implants in the Athena study were predominantly used in patients with BMI ≥35 (65.4% of those receiving 1340cc and 92.6% of those receiving 1440cc). Most patients, 42 (79.2%), with 1340cc or 1445cc devices retained their original implants at 3 years, while 11 (20.8%) required explantation. Ten of the 11 explanted patients were successfully reimplanted with another device from the study. In the revision reconstruction cohort, 90.9% of participants engaged in the study to increase their implant size due to the perception of insufficient volume in their reconstructed breasts. No significant differences were observed when comparing complication rates (including any reoperation, asymmetry, Baker Grade 3/4 capsular contracture, delayed wound healing, explantation, extrusion, malposition, infection) across device sizes using a univariate logistic regression model (Figure 1). Via BREAST-Q, patient-reported satisfaction levels showed similar high scores across lower (930-1240cc) and higher (1340-1445cc) sized devices in the study (Figure 2).

Conclusion: High BMI patients represent approximately half of the women currently presenting for breast reconstruction after mastectomy due to breast cancer(2). This highlights the need for larger breast implant sizes than 800cc for obese women, leading to the Athena Study of breast implants with volumes up to 1445cc. Although obese breast reconstruction patients have historically faced a higher risk of complications compared to their non-obese counterparts, data from this study revealed a favorable risk/benefit ratio for what are now the largest breast implants available on the US market. Implants larger than 1300cc required minimal revisions beyond size adjustments, with complication rates comparable to those of smaller devices. These high-volume implants demonstrated an acceptable explantation rate and high retention rates over three years. There was a strong association between the selection of these largest volume implants and women with a BMI ≥35, suggesting tailored utility for obese patients. Finally, patient and surgeon-reported outcome scores were high for these largest-volume implants, further justifying their use.

References: 1. Barone I, Giordano C, Bonofiglio D, Andò S, Catalano S. The weight of obesity in breast cancer progression and metastasis: Clinical and molecular perspectives. Semin Cancer Biol. 2020 Feb;60:274-284. 2. Srinivasa DR, Clemens MW, Qi J, Hamill JB, Kim HM, Pusic AL, Wilkins EG, Butler CE, Garvey PB. Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study. Plast Reconstr Surg. 2020 Mar;145(3):481e-490e.

Purpose: Increasing rates of obesity in the US and incidence of breast cancer have resulted in growing demand for larger breast implant sizes for implant-based breast reconstruction(1). This study aims to evaluate whether the largest implant sizes (1340cc and 1445cc) from the Athena Clinical Trial (ClinicalTrials.gov NCT02724371) for breast reconstruction show clinically significant differences in outcomes compared to smaller sizes in the study and the benefit/risk ratio associated with these devices.

Methods: 3-year follow-up of 53 patients who received either 1340cc or 1445cc devices was conducted as part of a 10-year multicenter prospective investigational study evaluating safety and effectiveness of larger-volume implants in women undergoing post-mastectomy two-stage reconstruction. Safety (complications) and performance (satisfaction, including BREAST-Q) were analyzed using descriptive statistics.

Results: The largest implants in the Athena study were predominantly used in patients with BMI ≥35 (65.4% of those receiving 1340cc and 92.6% of those receiving 1440cc). Most patients, 42 (79.2%), with 1340cc or 1445cc devices retained their original implants at 3 years, while 11 (20.8%) required explantation. Ten of the 11 explanted patients were successfully reimplanted with another device from the study. In the revision reconstruction cohort, 90.9% of participants engaged in the study to increase their implant size due to the perception of insufficient volume in their reconstructed breasts. No significant differences were observed when comparing complication rates (including any reoperation, asymmetry, Baker Grade 3/4 capsular contracture, delayed wound healing, explantation, extrusion, malposition, infection) across device sizes using a univariate logistic regression model (Figure 1). Via BREAST-Q, patient-reported satisfaction levels showed similar high scores across lower (930-1240cc) and higher (1340-1445cc) sized devices in the study (Figure 2).

Conclusion: High BMI patients represent approximately half of the women currently presenting for breast reconstruction after mastectomy due to breast cancer(2). This highlights the need for larger breast implant sizes than 800cc for obese women, leading to the Athena Study of breast implants with volumes up to 1445cc. Although obese breast reconstruction patients have historically faced a higher risk of complications compared to their non-obese counterparts, data from this study revealed a favorable risk/benefit ratio for what are now the largest breast implants available on the US market. Implants larger than 1300cc required minimal revisions beyond size adjustments, with complication rates comparable to those of smaller devices. These high-volume implants demonstrated an acceptable explantation rate and high retention rates over three years. There was a strong association between the selection of these largest volume implants and women with a BMI ≥35, suggesting tailored utility for obese patients. Finally, patient and surgeon-reported outcome scores were high for these largest-volume implants, further justifying their use.

References: 1. Barone I, Giordano C, Bonofiglio D, Andò S, Catalano S. The weight of obesity in breast cancer progression and metastasis: Clinical and molecular perspectives. Semin Cancer Biol. 2020 Feb;60:274-284. 2. Srinivasa DR, Clemens MW, Qi J, Hamill JB, Kim HM, Pusic AL, Wilkins EG, Butler CE, Garvey PB. Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study. Plast Reconstr Surg. 2020 Mar;145(3):481e-490e.

Purpose: Increasing rates of obesity in the US and incidence of breast cancer have resulted in growing demand for larger breast implant sizes for implant-based breast reconstruction(1). This study aims to evaluate whether the largest implant sizes (1340cc and 1445cc) from the Athena Clinical Trial (ClinicalTrials.gov NCT02724371) for breast reconstruction show clinically significant differences in outcomes compared to smaller sizes in the study and the benefit/risk ratio associated with these devices.

Methods: 3-year follow-up of 53 patients who received either 1340cc or 1445cc devices was conducted as part of a 10-year multicenter prospective investigational study evaluating safety and effectiveness of larger-volume implants in women undergoing post-mastectomy two-stage reconstruction. Safety (complications) and performance (satisfaction, including BREAST-Q) were analyzed using descriptive statistics.

Results: The largest implants in the Athena study were predominantly used in patients with BMI ≥35 (65.4% of those receiving 1340cc and 92.6% of those receiving 1440cc). Most patients, 42 (79.2%), with 1340cc or 1445cc devices retained their original implants at 3 years, while 11 (20.8%) required explantation. Ten of the 11 explanted patients were successfully reimplanted with another device from the study. In the revision reconstruction cohort, 90.9% of participants engaged in the study to increase their implant size due to the perception of insufficient volume in their reconstructed breasts. No significant differences were observed when comparing complication rates (including any reoperation, asymmetry, Baker Grade 3/4 capsular contracture, delayed wound healing, explantation, extrusion, malposition, infection) across device sizes using a univariate logistic regression model (Figure 1). Via BREAST-Q, patient-reported satisfaction levels showed similar high scores across lower (930-1240cc) and higher (1340-1445cc) sized devices in the study (Figure 2).

Conclusion: High BMI patients represent approximately half of the women currently presenting for breast reconstruction after mastectomy due to breast cancer(2). This highlights the need for larger breast implant sizes than 800cc for obese women, leading to the Athena Study of breast implants with volumes up to 1445cc. Although obese breast reconstruction patients have historically faced a higher risk of complications compared to their non-obese counterparts, data from this study revealed a favorable risk/benefit ratio for what are now the largest breast implants available on the US market. Implants larger than 1300cc required minimal revisions beyond size adjustments, with complication rates comparable to those of smaller devices. These high-volume implants demonstrated an acceptable explantation rate and high retention rates over three years. There was a strong association between the selection of these largest volume implants and women with a BMI ≥35, suggesting tailored utility for obese patients. Finally, patient and surgeon-reported outcome scores were high for these largest-volume implants, further justifying their use.

References: 1. Barone I, Giordano C, Bonofiglio D, Andò S, Catalano S. The weight of obesity in breast cancer progression and metastasis: Clinical and molecular perspectives. Semin Cancer Biol. 2020 Feb;60:274-284. 2. Srinivasa DR, Clemens MW, Qi J, Hamill JB, Kim HM, Pusic AL, Wilkins EG, Butler CE, Garvey PB. Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study. Plast Reconstr Surg. 2020 Mar;145(3):481e-490e.

Background: Mastectomy skin necrosis is problematic in tissue expander reconstruction with rates between 7 to 30%. Partial or full-thickness skin necrosis may harbor bacterial colonization promoting infection and risk of implant loss. Absorbable antibiotic-impregnated calcium-sulfate antibiotic beads have been described to reduce tissue expander (TE)/implant infection when used prophylactically for prepectoral breast reconstruction. The purpose of this study is to evaluate the effect of absorbable antibiotic beads on outcomes in patients who develop mastectomy skin necrosis after immediate postmastectomy tissue expander breast reconstruction.

Methods: A single-center retrospective review was performed for patients who underwent mastectomy, immediate prepectoral TE reconstruction on the same day (2018-2024). Patients who developed mastectomy skin necrosis were included. Patients were divided into two groups: Group 1 (absorbable antibiotic beads with TE placement) and Group 2 (no antibiotic beads with TE). Demographical information was recorded. Surgical-site infection (90-days) and implant removal were the outcome variables.

Results: The study included 61 patients (75 total breasts with necrosis) who underwent prepectoral TE breast reconstruction following mastectomy and developed mastectomy skin necrosis. The patients included in the study with mastectomy skin necrosis were 12 patients in Group 1 (16 breasts) and 49 patients in Group 2 (59 breasts). Baseline characteristics were not significantly difference between groups (p=1). There was no difference between nipple-sparing mastectomy or skin-sparing mastectomy between groups (p=0.1094). Acellular dermal matrix was used in 66.7% (8/12) of Group 1 compared to 83.7% (41/49) of Group 2 (p=0.2285). Operative management of mastectomy skin necrosis including debridement and reclosure was required in 50% (6/12) of Group 1 compared to 69.4% (34/49) of Group 2 patients (p=0.3093). There was one occurrence (6.3%, 1/16 TEs) of surgical-site infection in Group 1 and 35.6% (21/59 TEs) in Group 2 (p=0.0288). TE removal resulted in 6.3% (1/16 TEs) in Group 1 and 33.9% (20/59 TEs) in Group 2 (p=0.0310). The mean follow-up time was 189 days (range 146-236 days).

Conclusion: Patients who develop mastectomy skin necrosis after prepectoral tissue expander reconstruction may experience lower rates of TE removal and infection when prophylactic absorbable antibiotic-impregnated beads are used. Patients who develop mastectomy skin necrosis are at high risk for infection and TE loss. Prophylactic antibiotic beads used at the time of mastectomy with prepectoral TE reconstruction decrease the risk of infection and TE loss in patients who experience mastectomy skin necrosis.

[Purpose] As the prevalence of migraines and breast cancer morbidity continue to rise among women globally, it is crucial to consider that female patients undergoing breast reconstruction may also be receiving migraine treatments. Calcitonin gene-related peptide (CGRP) is an inflammatory protein known to initiate migraine attacks, which also plays a critical role in wound healing by promoting revascularization and enhancing keratinocytes proliferation. Since the FDA approved CGRP antibodies in 2018, they have become a promising therapeutic option for chronic migraines. While some preliminary case reports have suggested a possible link between CGRP antibodies and impaired wound healing, there's limited evidence on their impact on perioperative outcomes. With the increased use of CGRP antibodies in the migraine population, understanding the association of this medication and surgical outcomes is crucial for preventing clinical complications. This study aims to determine the perioperative impact of CGRP antibodies on free flap breast reconstruction.

[Methods] Adult female patients who were diagnosed as migraine or chronic headache and underwent free flap breast reconstruction at our Health System between November 2018 and December 2024 were included in our retrospective study. We compared two cohorts: migraine patients treated with CGRP antibodies within 30days before and/or after free flap reconstruction and migraine patients not treated with CGRP antibodies. Demographics, comorbidities, preoperative and postoperative medications, and perioperative complication data were analyzed.

[Results] Among 1338 free flap breast reconstruction patients, 81 were diagnosed as migraine or chronic headache: 13 patients (25 flaps) in CGRP-treated cohort and 68 patients (117 flaps) in control cohort. There was no significant difference in demographics, comorbidities, and perioperative details such as flap types between cohorts. Multivariate regression analysis revealed that CGRP-treated cohort had a significantly higher incidence of flap skin necrosis (16% vs 5.1%, OR 5.74, p=0.0307). When triptan use, the first line treatment for acute migraine attacks, was accounted for as a confounding factor in the analysis, delayed wound healing in flap site was also significantly prevalent in the CGRP group (20.0% vs 8.5%, OR 1.35 p= 0.0478). Other complications such as vascular compromise, surgical site infection, hematoma, and hernia were not significantly different between the two cohorts. The median time to heal from delayed wound was longer in the CGRP group with 86 days (IQR: 48.5 - 121.5 days) and 59 days (IQR 42 – 123 days) for the control group. Median healing time from skin necrosis in the CGRP group was 100 days (IQR 67.25- 173.25 days) and 100 days (IQR 32.5 – 105 days) for the control group.

[Conclusion] This is the first comprehensive study evaluating the impact of CGRP antibodies on perioperative outcomes of free flap reconstruction. Our findings further imply the potential impaired wound healing, particularly an increased incidence of skin necrosis, when CGRP antibodies are in effect during surgical interventions. These results align with preliminary case reports, underscoring the need for cautious administration of this treatment, especially in patients undergoing surgery. Further research with larger patient population is needed to validate these findings.

Objective：The aim of this study is to offer a completely scar-free breast reconstruction approach with implant for patients undergoing abdominoplasty combined with breast augmentation. Methods: First，the abdominoplasty was performed. After the skin flap has been dissected, we proceed with scarfree breast augmentation. For dual-plane breast augmentation, subcutaneous tunnels were created starting from the subxiphoid region, extending laterally at the 11 and 1 o'clock positions, with each tunnel measuring 4 cm in width. Dissection was performed carefully along the deep fascia until reaching the medial-inferior segment of the inframammary fold. The pectoralis major muscle was incised, and pocket dissection was continued beneath the pectoralis major muscle to create a dual-plane pocket. Dissection proceeded in the order of medial → superior → lateral → inferior regions, with particular attention to distinguishing the pectoralis minor muscle. After precise hemostasis and pocket irrigation with antibiotic solution, the implant was inserted and positioned. Bilateral drains were placed under the abdominal flap, exiting at the pubic area. The abdominoplasty was then completed. Results: A cohort of 39 patients was included in the study, with a mean age of 29.84±2.94 years and a mean Body Mass Index (BMI) of 20.83±1.73 kg/m². The median volume of the implanted prosthesis was 290.40±40.80 ml, and the mean extubation time was 3.08±0.95 days. Among the 39 patients, one patient had a follow-up period of 1 year, 11 patients had a follow-up period exceeding 6 months, and the remaining 27 patients had follow-up periods ranging from 1 to 5 months. No significant complications, such as infection, hematoma, abnormal breast morphology, implant displacement, or exposure, were observed. Conclusion: Endoscopic-assisted dual-plane implant breast augmentation through an abdominoplasty incision is a straightforward, feasible, safe, and effective procedure that results in no scarring in the breast region. Postoperative outcomes indicate an absence of serious complications, and patient satisfaction rates are high. This method offers a safe and efficient solution for patients requiring both abdominoplasty and breast augmentation.

Purpose Statement Challenges of standard breast reduction techniques include providing stable, long-term breast contour, projection, and position. Over time, loss of upper pole volume, lower pole stretching, and overall breast descent inevitably lead to a less aesthetically pleasing appearance and may result in patient dissatisfaction. In the past several years, slowly absorbable meshes such as poly-4-Hydroxybutyrate (P4HB) have been introduced as soft tissue reinforcement material to address breast ptosis. Several studies have demonstrated the effectiveness of P4HB mesh in the correction of ptosis and long-term maintenance of results. We introduce a novel technique that combines a P4HB mesh internal bra with an inferior pedicle suspension to not only address ptosis, but to improve the stability of breast contour, upper pole fullness, cleavage, and lateral sweep.

Methods and Materials This novel technique builds upon the standard Wise pattern inferior pedicle reduction mammoplasty technique by supplementing it with two additional maneuvers: pedicle suspension and internal bra mesh placement. The base of the inferior pedicle is suspended to the pectoralis fascia along the breast meridian starting from the second to fifth intercostal spaces using a slowly absorbable running suture. The internal bra consists of P4HB mesh that is customized to create a bra-like sling. The mesh is attached laterally and medially to the pectoralis fascia, and superiorly and inferiorly to the de-epithelialized dermal component of the pedicle. To evaluate the effectiveness of the combined internal bra and suture suspension technique, we will measure the nipple-to-inframammary fold distance, sternal notch-to-nipple distance, and breast width. We will also compare 3-, 6-, and 9-month postoperative images. Patient satisfaction will be evaluated using a Breast Q scale.

Results Since January 2023, 9 patients have undergone breast reduction using the internal bra and suspension technique. An average of 4.8 months (range of 1.8 to 9.8 months) has elapsed post-operatively for this cohort. There were no significant postoperative breast complications. This surgical technique provided satisfactory breast shape and lift, which has been maintained to date. A comparison of postoperative images at 3 and 6 months postoperatively reveals no significant changes in breast position.

Conclusions The combination of the internal bra and inferior pedicle suspension technique is a novel approach that can be added to breast reduction techniques to maximize results. While using this technique, we were able to improve breast contour, upper pole fullness, cleavage, and lateral sweep as compared to standard techniques. Patients have high satisfaction with the aesthetic results and reliable, optimized breast appearance with improved medium-term results that will likely translate to long-term outcomes. Positive initial findings with this technique warrant further exploration of its potential to improve the longevity of breast reduction results and to provide implant-like outcomes.

Introduction: Mastectomy skin flap necrosis (MSFN) is a challenging complication that adversely impacts the reconstructive outcomes of patients undergoing prosthetic-based breast reconstruction. Its management ranges from conservative medical treatment to the use of an entirely new flap for coverage in resistant or advanced cases.

Methods: We developed a pilot machine learning-powered computer vision framework designed to predict the ultimate fate of MSFN based on initial breast images taken at the time of presentation. The models were trained to classify outcomes into one of four categories: response to medical treatment, requirement for clinical debridement, requirement for surgical debridement, or need for a new flap. A total of 166 images were utilized for training and 5-fold cross-validation of several models, including a 100-layer neural network (NN), gradient boosting model (GBM), random forest (RF), k-nearest neighbor (kNN), and a stacked model combining NN and GBM. An external testing dataset, consisting of 17 blinded images, was used to evaluate model performance.

Results: During 5-fold cross-validation, the NN model demonstrated superior predictive performance with an AUC of 0.79, followed by the stacked NN+GBM model with an AUC of 0.76. On the external testing dataset, both the NN (AUC = 0.72) and stacked models (AUC = 0.75) outperformed the other approaches.

Conclusions: Deep learning-powered computer vision shows significant potential in predicting the outcomes of MSFN based solely on the initial presentation image. Our pilot models achieved AUCs above 70% on both cross-validation and external testing, underscoring the promise of this technology in guiding clinical decision-making in prosthetic-based breast reconstruction.

Background: Reducing postoperative length of stay (LoS) benefits both patients and hospital systems [1, 2]. This study leverages the National Surgical Quality Improvement Program (NSQIP) database to identify predictors of extended LoS following microsurgical free flap breast reconstruction.

Methods: We retrospectively analyzed NSQIP data (2007–2022) to identify factors influencing LoS after DIEP flap reconstruction, using CPT code 19364 to select cases. Candidate predictors were chosen based on clinical relevance and entered into a Poisson regression model. A backward stepwise selection approach, guided by Akaike's Information Criterion (AIC), was applied to derive the most parsimonious model. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were reported to quantify associations. Model diagnostics confirmed minimal overdispersion, validating the Poisson assumptions. Analyses were performed in R.

Results: A total of 21,771 cases of DIEP flap breast reconstruction were analyzed. The number of procedures increased annually between 2007 and 2022, with a concurrent decline in length of stay (LoS) over time. Each additional year was associated with a 2.6% reduction in LoS (IRR = 0.974; 95% CI: 0.972–0.976), reflecting advancements in perioperative care and surgical efficiency. Surgical duration was a significant predictor of extended hospitalization, with each additional hour in the operating room increasing LoS by 6.2% (IRR = 1.062; 95% CI: 1.060–1.065). Additionally, comorbidities played a notable role in prolonged hospital stays. Patients with diabetes experienced a 5.8% increase in LoS (IRR = 1.058; 95% CI: 1.029–1.088), while those with a bleeding disorder had a 15.1% longer LoS (IRR = 1.151; 95% CI: 1.061–1.246). When stratified by American Society of Anesthesiologists (ASA) classification, patients with ASA II and ASA III had 4.4% and 8.5% longer hospital stays, respectively, compared to those classified as ASA I. Racial differences in LoS were also observed. Hispanic patients had the most pronounced increase in LoS, with a 22.0% longer stay (IRR = 1.220; 95% CI: 0.844–1.694). Black (IRR = 1.022) and Asian (IRR = 1.034) patients also exhibited slightly extended hospitalization durations. In contrast, Native Hawaiian/Pacific Islander (IRR = 0.915) and American Indian/Alaska Native (IRR = 0.895) patients had shorter LoS compared to the reference population.

Discussion: From 2007 to 2022, LoS for DIEP flap breast reconstruction significantly declined, reflecting advancements in surgical techniques, perioperative care, and patient management. Key predictors of extended LoS included longer operative time, comorbidities (diabetes, bleeding disorders), and higher ASA classification. The findings provide valuable insights for risk stratification and surgical planning, optimizing patient care and resource allocation.

References: 1. Fischer, J. P., Fox, J. P., Nelson, J. A., Kovach, S. J., & Serletti, J. M. (2015). A longitudinal assessment of outcomes and healthcare resource utilization after immediate breast reconstruction-comparing implant-and autologous-based breast reconstruction. Annals of surgery, 262(4), 692-699. 2. Holoyda, K. A., Magno-Padron, D. A., Carter, G. C., Agarwal, J. P., & Kwok, A. C. (2022). National trends in length of stay for microvascular breast reconstruction: an evaluation of 10,465 cases using the American College of Surgeons National Surgical Quality Improvement Program database. Plastic and Reconstructive Surgery, 149(2), 306-313.

Background: Lymphedema is a chronic complication following axillary lymph node dissection (ALND). While breast reconstruction has been associated with a reduced risk of lymphedema, the role of immediate lymphatic reconstruction (ILR) in implant-based breast reconstruction (IBR) remains underexplored. ILR may provide functional and aesthetic benefits, yet its impact on postoperative complications, including infection, seroma, wound dehiscence, and reoperation, remains unclear. This study evaluates complication rates associated with ILR in the context of IBR after ALND.

Methods: An IRB-approved retrospective review was conducted on 126 consecutive patients undergoing mastectomy with ALND and IBR. Among them, 41 patients underwent ILR, while 85 did not. Data collected included demographics, treatment characteristics, perioperative details, and postoperative complications. Assessed complications included infection (minor and major), seroma, hematoma, wound issues, deep vein thrombosis (DVT), mastectomy flap necrosis, reoperation, implant explantation, and hospital readmission. The primary outcome was the comparison of complication rates between the ILR and non-ILR groups. Results: The ILR and non-ILR groups were similar in age (52.05 ± 10.76 vs. 48 ± 10.57 years, p = 0.14), BMI (27.03 vs. 27.21, p = 0.55), smoking status (0% vs. 5.9%, p = 0.44), and comorbidities, except for a higher prevalence of hypertension in the non-ILR group (42.4% vs. 22%, p = 0.02). The ILR group had higher rates of radiation therapy (100% vs. 75.3%, p = 0.001) and chemotherapy (95.1% vs. 71.8%, p = 0.002).

Mean operative time was significantly longer in the ILR group (333.44 ± 119.66 minutes vs. 247.98 ± 75.93 minutes, p < 0.001). Despite this, overall complication rates were comparable (39% vs. 35.3%, p = 0.69). No significant differences were observed in readmission rates (2.4% vs. 9.4%, p = 0.269), minor infections (2.4% vs. 1.2%, p = 0.55), major infections (12.2% vs. 18.8%, p = 0.45), seroma requiring intervention (7.3% vs. 4.7%, p = 0.68), wound issues (9.8% vs. 4.7%, p = 0.44), or implant exposure (7.3% vs. 3.5%, p = 0.39). The rates of DVT/pulmonary embolism were comparable in two groups (4.9% vs. 0%, p = 0.104. Reoperation rates (24.4% vs. 27.1%, p = 0.831) and implant explantation rates (22% vs. 23.5%, p = 1) were also comparable.

Conclusions: ILR is a safe adjunct to IBR following ALND, demonstrating similar complication rates compared to non-ILR cases despite longer operative times. The comparable rates of infection, seroma, reoperation, and implant explantation suggest that ILR does not introduce additional postoperative risks. Given the known benefits of ILR in reducing lymphedema risk, its use in IBR may offer significant advantages without increasing morbidity. Future prospective studies are needed to further assess the long-term impact of ILR in this patient population.

Background: Unplanned readmissions following deep inferior epigastric artery perforator (DIEP) flap breast reconstruction pose significant challenges, increasing healthcare costs and patient morbidity. Machine learning models have shown potential in predicting surgical outcomes, but their application to DIEP flap procedures remains underexplored. This study aimed to develop a stacking ensemble model to predict unplanned 30-day readmissions in DIEP flap breast reconstruction patients using the National Surgical Quality Improvement Program (NSQIP) dataset.

Methods: A retrospective analysis was performed on NSQIP data from 13,312 DIEP flap procedures conducted between 2016 and 2022. Data preprocessing included cleaning, feature standardization, and missing value imputation. A 70/15/15 train-validation-test split was utilized, and a stacking ensemble approach was employed to handle nonlinear relationships and class imbalance. The ensemble integrated multiple base learners (Random Forest, Extra Trees, SVM, XGBoost, and Logistic Regression) with an optimized XGBoost classifier as the meta-estimator. Hyperparameter tuning was performed via randomized search, with a 3-fold stratified cross-validation ensuring model robustness. Performance was evaluated using precision, recall, and F1-score, with emphasis on effectively identifying readmission cases.

Results: Among the cohort, 5.4% experienced unplanned readmissions. The stacking classifier achieved an accuracy metric of 0.8788 and demonstrated high recall score of 0.79 for readmission prediction on the test set.

Conclusion: The artificial intelligence machine learning stacking ensemble model effectively predicted unplanned readmissions in DIEP flap breast reconstruction patients, prioritizing the identification of at-risk patients. This approach holds promise for integration into clinical workflows to enhance patient management and reduce readmission rates through targeted interventions for high-risk patients.

10493 – Introducing the PRIME DIEP flap: The latest evolution in autologous breast reconstruction

Purpose: The Deep Inferior Epigastric Perforator (DIEP) flap is a mainstay of autologous breast reconstruction, yet inadvertent damage to the abdominal wall can lead to bulge, hernia, and/or functional deficits. In order to minimize morbidity, several adaptations have been described (i.e. fascial-sparing, robotic-assisted). Herein, we introduce the latest evolution, the paramedian reflection for innervated muscle enhancement (PRIME) DIEP flap. This technique minimizes splitting of the muscle, avoids the muscular nerves to the muscle, provides excellent visualization for pedicle dissection, and limits fascial closure to a midline plication.

Methods: From July 2024 to January 2025, patients undergoing DIEP flap reconstruction were screened with preoperative magnetic resonance angiography (MRA). Inclusion criteria were a single perforator (or multiple closely oriented perforators) arising from the medial row with a short (< 4 cm) intramuscular course. After suprafascial flap elevation, a limited fascial incision is made directly over the chosen perforator(s) to allow for complete intramuscular dissection. Once through the muscle, the fascial opening is extended inferomedially towards the medial border of the rectus muscle and then inferiorly towards the pubic symphysis. The medial border of the rectus muscle is mobilized superficially and laterally, exposing the deep inferior epigastric pedicle. This paramuscular or paramedian approach to the pedicle negates the need for further muscle splitting, while preserving all of the nerve supply to the rectus abdominus. After harvest of the flap, the fascial closure is included in a midline plication.

Results: Twelve PRIME DIEP flaps were performed in patients with an average age of 52 years and mean body mass index of 26. Most (70%) cases were delayed reconstructions with a mean flap weight of 657g. A single perforator was used in 77% of flaps, with an average perforator diameter of 1.8mm. There were no donor-site bulges, hernias, or fascial dehiscences noted. One recipient-site hematoma requiring operative evacuation was the only notable complication.

Conclusions: The PRIME DIEP flap preserves the integrity and innervation of the rectus abdominis by limiting muscle disruption and maintaining nerve supply. We feel that this technique offers advantages similar to robotic-assisted DIEP flaps without the need for specialized training or instrumentation. Further studies with longer follow up are needed to confirm our belief that this technique improves outcomes and limits donor-site morbidity compared to standard DIEP flaps.

Purpose: Ketorolac is an effective postoperative analgesic; however, its potential to increase the risk of postoperative bleeding remains unclear. In a previous retrospective study (McCormick, 2021), our institution found that intraoperative ketorolac use was associated with a higher rate of bleeding-related complications in mastectomy patients. As a result, we removed ketorolac from our ERAS protocol and now aim to compare reoperation and opioid use rates in mastectomy patients before and after this protocol revision.

Methods: We identified all women undergoing mastectomy at our ambulatory surgery cancer center from January 2016 to June 2024. We removed ketorolac from our post-mastectomy ERAS protocol on May 1, 2020. We tested for an association between the risk of reoperation due to bleeding on postoperative day 0 or 1 and study period using a multivariable logistic regression model adjusted for age, body mass index (BMI), preoperative prescription for an anticoagulant, preoperative prescription for an antiplatelet medication, and reconstruction status (no immediate reconstruction, subpectoral, prepectoral) separately in unilateral and bilateral procedures. As a secondary outcome we tested the association between study period and requiring the top quartile opioids (intravenous or oral) within first 24 hours postoperatively with a multivariable logistic regression model, adjusting for age, BMI, receipt of a peripheral nerve block, and reconstruction status (no immediate reconstruction, subpectoral, prepectoral) separately in unilateral and bilateral procedures.

Results: Overall, 9085 patients were analyzed. The risk of reoperation due to bleeding was 3.2% (n=141) before ketorolac removal and 2.0% (n=94) following ketorolac removal. On multivariable analysis, removal of ketorolac was associated with a significant reduction in the risk of reoperation in unilateral procedures (OR=0.33, 95% CI 0.20, 0.51, p<0.001). In bilateral procedures the effect size was smaller and missed the standard cutoff for statistical significance (OR=0.71; 95% CI 0.47, 1.06; p=0.10) however on adjusted analysis ketorolac receipt was associated with a significant increase in the risk of reoperation (OR=2.08; 95% CI 1.37, 3.11; p<0.001). We noted a 30% reduction in the odds of requiring the top quartile of postoperative opioids after the removal of ketorolac in both unilateral and bilateral procedures (OR=0.69, 95% CI 0.60, 0.81, p<0.001; OR=0.76, 95% CI 0.63, 0.92, p=0.005, respectively).

Conclusions: Removal of ketorolac from our ERAS protocol resulted in a significant reduction in the risk of bleeding-related reoperation and was not associated with an increase in opioid administration. These findings provide further support against routine use of ketorolac in the perioperative care of the mastectomy patient.

References: McCormick PJ, Assel M, Van Zee KJ, et al. Reply to: "Ketorolac Following Mastectomy: Is There an Increased Risk of Reoperation?". Ann Surg Oncol. Dec 2021;28(Suppl 3):777-778. doi:10.1245/s10434-021-10073-3

Purpose: Implant-based breast reconstruction (IBBR) remains the most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral (PP) IBBR has resurged in popularity, especially with direct-to-implant (DTI) reconstruction. Studies have reported conflicting evidence regarding complication rates of PP DTI versus subpectoral (SP) DTI. Given the variability in reported outcomes for these two planes, this head-to-head meta-analysis pools data from 33 comparative studies on complication rates and BREAST-Q patient-reported outcomes to establish definitive conclusions that help inform clinical decision-making regarding the optimum plane for DTI reconstruction.

Methods: PubMed, Scopus, and Web of Science were screened in February 2025. PRISMA guidelines were followed. Observational studies were included if they compared the two planes in DTI reconstruction and had reported at least one of the primary outcomes (surgical complications). The secondary outcomes assessed were pain scores, BREAST-Q scores, and length of hospital stay. Review Manager 5.4 was used for analysis. Dichotomous data were presented as risk ratios (RR) with their respective confidence intervals (CI) using the Mantel-Haenszel method. Continuous data were presented as mean differences (MD) or standardized mean differences (SMD) with their respective CI using the inverse variance method. SMD was used when pooling an outcome measured by different scales in the included studies. Heterogeneity was assessed using I² statistics. A random-effects model was applied in case of significant heterogeneity followed by sensitivity analysis. Subgroup analyses (ADM, synthetic mesh, and implant texture) were performed where appropriate.

Results: A total of 33 studies (5652 implants) were included in the meta-analysis. SP DTI placement was associated with a slightly lower risk of implant loss or explantation compared to prepectoral placement (RR = 0.73, 95% CI = 0.55 to 0.97, P = 0.03); subgroup analysis with ADM rendered this difference statistically insignificant (RR = 0.79, 95% CI = 0.56 to 1.12, P = 0.19). SP DTI also showed a significantly higher risk of animation deformity (RR = 8.02, 95% CI = 3.72 to 17.33, P < 0.00001), higher risk of malposition (RR = 6.88, 95% CI = 1.66 to 28.46, P = 0.008), higher pain scores (SMD = 0.31, 95% CI = 0.14 to 0.48, P = 0.0005), lower BREAST-Q breast satisfaction (SMD = -1.44, 95% CI = -2.26 to -0.61, P = 0.0006), lower physical wellbeing (SMD = -0.27, 95% CI = -0.52 to -0.02, P = 0.04), and longer length of stay in days (MD = 0.69, 95% CI = 0.26 to 1.12, P = 0.002). Nonetheless, no statistically significant differences were found between the two techniques (even after subgroup analysis) for rates of seroma, hematoma, infection, skin flap necrosis, nipple necrosis, dehiscence, implant exchange, reoperation, and capsular contracture rates.

Conclusion: Although both planes in DTI reconstruction appear to result in similar postoperative complications, PP DTI seems to result in higher patient satisfaction, lower risk of animation deformity, malposition, and shorter length of hospital stay. This meta-analysis suggests that PP DTI may be a better choice depending on patient-specific factors and surgeon preference.

Purpose: Implant-based breast reconstruction (IBBR) remains the most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral (PP) IBBR has resurged in popularity, especially with direct-to-implant (DTI) reconstruction. Studies have reported conflicting evidence regarding complication rates of PP DTI versus subpectoral (SP) DTI. Given the variability in reported outcomes for these two planes, this head-to-head meta-analysis pools data from 33 comparative studies on complication rates and BREAST-Q patient-reported outcomes to establish definitive conclusions that help inform clinical decision-making regarding the optimum plane for DTI reconstruction.

Methods: PubMed, Scopus, and Web of Science were screened in February 2025. PRISMA guidelines were followed. Observational studies were included if they compared the two planes in DTI reconstruction and had reported at least one of the primary outcomes (surgical complications). The secondary outcomes assessed were pain scores, BREAST-Q scores, and length of hospital stay. Review Manager 5.4 was used for analysis. Dichotomous data were presented as risk ratios (RR) with their respective confidence intervals (CI) using the Mantel-Haenszel method. Continuous data were presented as mean differences (MD) or standardized mean differences (SMD) with their respective CI using the inverse variance method. SMD was used when pooling an outcome measured by different scales in the included studies. Heterogeneity was assessed using I² statistics. A random-effects model was applied in case of significant heterogeneity followed by sensitivity analysis. Subgroup analyses (ADM, synthetic mesh, and implant texture) were performed where appropriate.

Results: A total of 33 studies (5652 implants) were included in the meta-analysis. SP DTI placement was associated with a slightly lower risk of implant loss or explantation compared to prepectoral placement (RR = 0.73, 95% CI = 0.55 to 0.97, P = 0.03); subgroup analysis with ADM rendered this difference statistically insignificant (RR = 0.79, 95% CI = 0.56 to 1.12, P = 0.19). SP DTI also showed a significantly higher risk of animation deformity (RR = 8.02, 95% CI = 3.72 to 17.33, P < 0.00001), higher risk of malposition (RR = 6.88, 95% CI = 1.66 to 28.46, P = 0.008), higher pain scores (SMD = 0.31, 95% CI = 0.14 to 0.48, P = 0.0005), lower BREAST-Q breast satisfaction (SMD = -1.44, 95% CI = -2.26 to -0.61, P = 0.0006), lower physical wellbeing (SMD = -0.27, 95% CI = -0.52 to -0.02, P = 0.04), and longer length of stay in days (MD = 0.69, 95% CI = 0.26 to 1.12, P = 0.002). Nonetheless, no statistically significant differences were found between the two techniques (even after subgroup analysis) for rates of seroma, hematoma, infection, skin flap necrosis, nipple necrosis, dehiscence, implant exchange, reoperation, and capsular contracture rates.

Conclusion: Although both planes in DTI reconstruction appear to result in similar postoperative complications, PP DTI seems to result in higher patient satisfaction, lower risk of animation deformity, malposition, and shorter length of hospital stay. This meta-analysis suggests that PP DTI may be a better choice depending on patient-specific factors and surgeon preference.

Purpose: Implant-based breast reconstruction (IBBR) remains the most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral (PP) IBBR has resurged in popularity, especially with direct-to-implant (DTI) reconstruction. Studies have reported conflicting evidence regarding complication rates of PP DTI versus subpectoral (SP) DTI. Given the variability in reported outcomes for these two planes, this head-to-head meta-analysis pools data from 33 comparative studies on complication rates and BREAST-Q patient-reported outcomes to establish definitive conclusions that help inform clinical decision-making regarding the optimum plane for DTI reconstruction.

Methods: PubMed, Scopus, and Web of Science were screened in February 2025. PRISMA guidelines were followed. Observational studies were included if they compared the two planes in DTI reconstruction and had reported at least one of the primary outcomes (surgical complications). The secondary outcomes assessed were pain scores, BREAST-Q scores, and length of hospital stay. Review Manager 5.4 was used for analysis. Dichotomous data were presented as risk ratios (RR) with their respective confidence intervals (CI) using the Mantel-Haenszel method. Continuous data were presented as mean differences (MD) or standardized mean differences (SMD) with their respective CI using the inverse variance method. SMD was used when pooling an outcome measured by different scales in the included studies. Heterogeneity was assessed using I² statistics. A random-effects model was applied in case of significant heterogeneity followed by sensitivity analysis. Subgroup analyses (ADM, synthetic mesh, and implant texture) were performed where appropriate.

Results: A total of 33 studies (5652 implants) were included in the meta-analysis. SP DTI placement was associated with a slightly lower risk of implant loss or explantation compared to prepectoral placement (RR = 0.73, 95% CI = 0.55 to 0.97, P = 0.03); subgroup analysis with ADM rendered this difference statistically insignificant (RR = 0.79, 95% CI = 0.56 to 1.12, P = 0.19). SP DTI also showed a significantly higher risk of animation deformity (RR = 8.02, 95% CI = 3.72 to 17.33, P < 0.00001), higher risk of malposition (RR = 6.88, 95% CI = 1.66 to 28.46, P = 0.008), higher pain scores (SMD = 0.31, 95% CI = 0.14 to 0.48, P = 0.0005), lower BREAST-Q breast satisfaction (SMD = -1.44, 95% CI = -2.26 to -0.61, P = 0.0006), lower physical wellbeing (SMD = -0.27, 95% CI = -0.52 to -0.02, P = 0.04), and longer length of stay in days (MD = 0.69, 95% CI = 0.26 to 1.12, P = 0.002). Nonetheless, no statistically significant differences were found between the two techniques (even after subgroup analysis) for rates of seroma, hematoma, infection, skin flap necrosis, nipple necrosis, dehiscence, implant exchange, reoperation, and capsular contracture rates.

Conclusion: Although both planes in DTI reconstruction appear to result in similar postoperative complications, PP DTI seems to result in higher patient satisfaction, lower risk of animation deformity, malposition, and shorter length of hospital stay. This meta-analysis suggests that PP DTI may be a better choice depending on patient-specific factors and surgeon preference.

Purpose: Implant-based breast reconstruction (IBBR) remains the most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral (PP) IBBR has resurged in popularity, especially with direct-to-implant (DTI) reconstruction. Studies have reported conflicting evidence regarding complication rates of PP DTI versus subpectoral (SP) DTI. Given the variability in reported outcomes for these two planes, this head-to-head meta-analysis pools data from 33 comparative studies on complication rates and BREAST-Q patient-reported outcomes to establish definitive conclusions that help inform clinical decision-making regarding the optimum plane for DTI reconstruction.

Methods: PubMed, Scopus, and Web of Science were screened in February 2025. PRISMA guidelines were followed. Observational studies were included if they compared the two planes in DTI reconstruction and had reported at least one of the primary outcomes (surgical complications). The secondary outcomes assessed were pain scores, BREAST-Q scores, and length of hospital stay. Review Manager 5.4 was used for analysis. Dichotomous data were presented as risk ratios (RR) with their respective confidence intervals (CI) using the Mantel-Haenszel method. Continuous data were presented as mean differences (MD) or standardized mean differences (SMD) with their respective CI using the inverse variance method. SMD was used when pooling an outcome measured by different scales in the included studies. Heterogeneity was assessed using I² statistics. A random-effects model was applied in case of significant heterogeneity followed by sensitivity analysis. Subgroup analyses (ADM, synthetic mesh, and implant texture) were performed where appropriate.

Results: A total of 33 studies (5652 implants) were included in the meta-analysis. SP DTI placement was associated with a slightly lower risk of implant loss or explantation compared to prepectoral placement (RR = 0.73, 95% CI = 0.55 to 0.97, P = 0.03); subgroup analysis with ADM rendered this difference statistically insignificant (RR = 0.79, 95% CI = 0.56 to 1.12, P = 0.19). SP DTI also showed a significantly higher risk of animation deformity (RR = 8.02, 95% CI = 3.72 to 17.33, P < 0.00001), higher risk of malposition (RR = 6.88, 95% CI = 1.66 to 28.46, P = 0.008), higher pain scores (SMD = 0.31, 95% CI = 0.14 to 0.48, P = 0.0005), lower BREAST-Q breast satisfaction (SMD = -1.44, 95% CI = -2.26 to -0.61, P = 0.0006), lower physical wellbeing (SMD = -0.27, 95% CI = -0.52 to -0.02, P = 0.04), and longer length of stay in days (MD = 0.69, 95% CI = 0.26 to 1.12, P = 0.002). Nonetheless, no statistically significant differences were found between the two techniques (even after subgroup analysis) for rates of seroma, hematoma, infection, skin flap necrosis, nipple necrosis, dehiscence, implant exchange, reoperation, and capsular contracture rates.

Conclusion: Although both planes in DTI reconstruction appear to result in similar postoperative complications, PP DTI seems to result in higher patient satisfaction, lower risk of animation deformity, malposition, and shorter length of hospital stay. This meta-analysis suggests that PP DTI may be a better choice depending on patient-specific factors and surgeon preference.

PURPOSE: Cannabis use has increased drastically since recreational cannabis was legalized in New York in 2021. This study evaluates how cannabis use affects postoperative opioid consumption and pain scores in patients undergoing mastectomy and alloplastic reconstruction.

METHODS: Patients who underwent mastectomy with immediate tissue expander (TE) reconstruction between 2019 and 2024 were identified and classified as either cannabis users or non-users. Postoperative opioid consumption, acetaminophen use, and pain scores were assessed in 12-hour increments. Discharge opioid quantities and refill rates were also evaluated. Linear regression analysis was performed to identify risk factors for increased opioid consumption.

RESULTS: The study included 40 cannabis users and 197 non-users. Alcohol use (62.5% vs. 43.15%, p = 0.036) and tobacco use (20.0% vs. 5.08%, p = 0.004) were significantly more common among cannabis users. They were also more likely to be black (12.5% vs. 4.57%, p = 0.066), approaching significance. Age, body mass index, cup size, comorbidities, and intra-operative factors (TE plane placement, axillary biopsy/dissection, mastectomy type) were otherwise comparable. Postoperative length of stay was comparable between groups (1.33 days for cannabis users vs. 1.28 days for non-users, p = 0.49), as were complication rates, including takebacks (2.5% vs. 0%, p = 0.17) and readmissions within 30 days (0% vs. 5.08%, p = 0.376). Postoperative pain scores were significantly higher among cannabis users at 0–12 hours (4.42 vs. 3.68, p = 0.018), 12–24 hours (4.53 vs. 3.36, p = 0.004), and throughout hospitalization (4.46 vs. 3.53, p = 0.002). Similarly, opioid consumption was significantly higher in cannabis users at 0–12 hours (29.55 vs. 19.73 MME, p = 0.001), 12–24 hours (20.69 vs. 15.35 MME, p = 0.038), and in total throughout hospitalization (67.40 vs. 44.38 MME, p = 0.010). While acetaminophen consumption was lower in cannabis users across all postoperative time points, the differences were not statistically significant. Univariable and multivariable linear regression identified younger age (β = -0.56, p < 0.001), cannabis use (β = 16.56, p = 0.008), active smoking (β = 18.93, p = 0.032), and longer hospitalization (β = 2.53, p < 0.001) as significant predictors of increased opioid consumption (R² = 0.72). Although discharge opioid quantities were comparable, cannabis users were significantly more likely to request refills (42.5% vs. 22.8%, p = 0.02). Additional regression analysis further identified cannabis use (β = 39.44, p < 0.001), younger age (β = -0.71, p = 0.010), and larger breast cup size (β = 8.25, p = 0.002) as significant predictors of requesting opioid refills (R² = 0.28).

Conclusion: Our findings suggest that perioperative cannabis use may be associated with higher pain scores and increased opioid consumption in both inpatient and outpatient settings following mastectomy and TE reconstruction. These results highlight the need for tailored pain management strategies to optimize postoperative analgesia in cannabis-using patients.

Background Implant-based breast reconstruction (IBBR) commonly uses saline to inflate tissue expanders. Air inflation has been proposed as an alternative to potentially improve early postoperative outcomes, but evidence comparing complication rates between the two approaches remains limited (1). Leveraging data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Breast Reconstruction Pilot, this study examines postoperative outcomes following immediate prepectoral IBBR with air versus saline inflation.

Methods A retrospective analysis of the ACS NSQIP Breast Reconstruction Pilot dataset was conducted. Patients who underwent immediate prepectoral IBBR with tissue expanders from June 2024 to January 2025 were stratified by fill type (air vs. saline). The primary endpoints were rates of mastectomy skin flap necrosis (MSFN), hematoma, and seroma. Multivariable logistic regression models adjusted for relevant patient- and procedure-specific variables, and generalized estimating equations accounted for clustering at the patient and hospital levels.

Results A total of 711 breast reconstructions from 422 patients were included (35.7% air-filled and 64.3% saline-filled). Although MSFN (5.5% vs. 2.8%) and hematoma (3.2% vs. 1.3%) were more frequent in the air-filled group, these differences did not reach statistical significance. By contrast, seroma was significantly more common with air inflation (22.4% vs. 8.5%), corresponding to an odds ratio of 3.09 (95% CI, 1.81–5.29; P<0.01). Sensitivity analysis revealed a significant unadjusted association between fill type and mesh use, indicating that no-mesh procedures with air inflation were linked to the highest seroma rates.

Conclusion Air inflation for immediate prepectoral IBBR with tissue expanders does not provide a clear early postoperative advantage over saline-filled procedures. The significantly higher seroma rate with air inflation highlights the need for additional strategies to minimize this complication and optimize patient outcomes. Further studies clarifying patient risk profiles may help clinicians tailor the choice of air versus saline fill to individual patients.

References:

1. Kim EJ, Friedman R, Nickman S, et al. Air Versus Saline in Tissue Expanders: A Systematic Review of the Literature. J Reconstr Microsurg. 2024;40(06):458-465. doi:https://doi.org/10.1055/s-0044-1782208