Scientific Abstract Presentations: Breast Session 7 Saturday, October 11 Sat, Oct 11 10:30 a.m.-12:30 p.m. CDT

Purpose: Prepectoral implant-based breast reconstruction (PP-IBR) is increasingly favored over subpectoral reconstruction (SP-IBR) to reduce animation deformity, yet data regarding its outcomes after post-mastectomy radiotherapy (PMRT) are limited. PMRT poses unique challenges, including progressive fibrosis and reconstruction compromise. This study aims to prospectively compare long-term outcomes of PP-IBR and SP-IBR following PMRT.

Methods: Data were obtained from the multicenter randomized trial, Study of Radiation Fractionation on Patient Outcomes After Breast Reconstruction (FABREC).1 Complications, aesthetic results, and patient-reported outcomes (PROs) were assessed between groups. Complications included infection, explantation, delayed healing, and unplanned reoperation. The FACT-B and Breast-Q Reconstruction Module were administered, and aesthetic outcomes were evaluated by blinded reviewers at 6 and 18 months following PMRT. Multivariable analysis was performed to evaluate whether PP-IBR vs. SP-IBR was associated with outcomes after controlling for other covariates.

Results: Among 380 patients, 224 underwent PP-IBR and 156 SP-IBR. Demographics were similar, except SP-IBR had a higher proportion of tissue expanders and lower body mass index (BMI). No significant differences were noted in patient reported outcomes for physical well being, social well being, emotional well being, and functional well being at both 6 and 18 months using the FACT-B survey. There were also no significant difference in satisfaction with breasts, psychosocial well being, sexual well being, and physical well being using the BREAST-Q questionnaire at both 6 and 18 months, but higher BMI correlated with lower sexual well-being scores at both 6 and18 months (Estimate -0.60, p=0.03). SP-IBR was associated with lower aesthetic score at 6 months compared to PP-IBR; however, only age remained significant at 18 months (Estimate -0.02, p=0.00).

Conclusion: In PMRT settings, both PP-IBR and SP-IBR exhibit comparable complication rates and long-term aesthetic and PRO outcomes. Patient factors, such as age and BMI, appear to play a more prominent role in overall outcomes.

References 1. Wong JS, Uno H, Tramontano AC, Fisher L, Pellegrini CV, Abel GA, Burstein HJ, Chun YS, King TA, Schrag D, Winer E, Bellon JR, Cheney MD, Hardenbergh P, Ho A, Horst KC, Kim JN, Leonard KL, Moran MS, Park CC, Recht A, Soto DE, Shiloh RY, Stinson SF, Snyder KM, Taghian AG, Warren LE, Wright JL, Punglia RS. Hypofractionated vs Conventionally Fractionated Postmastectomy Radiation After Implant-Based Reconstruction: A Randomized Clinical Trial. JAMA Oncol. 2024 Aug 8:e242652. doi: 10.1001/jamaoncol.2024.2652. Epub ahead of print. PMID: 39115975; PMCID: PMC11310844.

Background: For patients with high volume requirements for autologous breast reconstruction but limited abdominal tissue availability, alternative donor sites are required. While stacked four-flap reconstructions using two deep inferior epigastric perforator (DIEP) flaps and two profunda artery perforator (PAP) flaps have been used with good outcomes, bilateral lumbar artery perforator (LAP) flaps have become an increasingly popular alternative for these patients at our institution.

Methods: A retrospective review was conducted on 96 patients who underwent bilateral LAP flap reconstructions (192 flaps) and 85 who underwent bilateral stacked four-flap reconstructions (340 flaps) between December 2018 and December 2024. Demographics, surgical outcomes, complications, and BREAST-Q patient satisfaction scores were analyzed. Aesthetic outcomes were assessed via standardized postoperative images rated through a crowdsourcing platform.

Results: Institutional trends show a sharp increase in LAP flap cases since 2021, with a decline in four-flap reconstructions. Patients with bilateral LAP flaps had significantly fewer donor-site complications (27.1% vs. 49.4%, p = 0.002), specifically fewer donor-site wound complications (7.3% vs. 43.5%, p < 0.001), and donor site infections (2.1% vs. 12.9%, p = 0.02) and a reduced rate of fat necrosis (5.2% vs. 21.2%, p = 0.004) compared to patients with four flaps. Operative times were comparable (550.4 vs. 547.8 minutes, p = 0.9), and BREAST-Q scores showed no significant differences in patient satisfaction (85.3 ± 12.0 vs. 84.5 ± 9.7) between the groups.

Conclusion: Bilateral LAP flaps reduce complication rates compared to four flap reconstructions and lead to comparable aesthetic outcomes. While four flaps are still required for select patients, LAP flaps have largely replaced four-flap reconstructions at our institution and should be considered the preferred option for the majority of patients with high volume requirements and limited donor site availability.

Background: Immediate prepectoral implant-based breast reconstruction (IBBR) with tissue expanders is widely performed following mastectomy. Acellular dermal matrix (ADM) is often incorporated to enhance implant support and potentially improve aesthetic outcomes. However, the impact of ADM on postoperative complications remains a subject of ongoing debate (1). Leveraging data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Breast Reconstruction Pilot, this study examines the association between ADM use and clinical outcomes in patients undergoing immediate prepectoral IBBR with tissue expanders.

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 ADM use. The primary endpoints were 30-day deep/organ space surgical site infection (SSI), reoperation (overall and for tissue expander removal), and seroma. SSI and reoperation rates were assessed at the patient-level, while seroma incidence was evaluated for each reconstructed breast. Multivariable logistic regression adjusted for relevant patient- and procedure-related factors, and generalized estimating equations accounted for clustering at both patient and hospital levels.

Results: A total of 420 patients (255 with ADM and 155 without ADM) and 739 reconstructed breasts (441 with ADM and 298 without ADM) were analyzed. ADM use was not associated with higher odds of deep/organ space SSI (OR 0.66, 95% CI 0.18–2.27), reoperation (OR 0.67, 95% CI 0.31–1.42), or tissue expander removal (OR 0.90, 95% CI 0.26–3.20). However, seroma rates were significantly lower in the ADM group (7.7% vs. 22.5%), corresponding to a 71% reduction in the odds of seroma (OR 0.29, 95% CI 0.15–0.53; P<0.01).

Conclusion: In immediate prepectoral IBBR with tissue expanders, ADM use decreased the risk of seroma without increasing deep/organ space SSI or reoperation rates. These findings help alleviate concerns about ADM-related postoperative complications and underscore its value in optimizing surgical outcomes. Future research should explore long-term complications, patient-reported outcomes, and cost-effectiveness to further guide clinical decision-making.

References:

1. Cinquini M, Rocco N, Catanuto G, et al. Should Acellular Dermal Matrices Be Used for Implant-based Breast Reconstruction after Mastectomy? Clinical Recommendation Based on the GRADE Approach. Plast Reconstr Surg Glob Open. 2023;11(2):e4821. doi:https://doi.org/10.1097/gox.0000000000004821

Background Reduction mammaplasty (RM) for macromastia is one of the most performed procedures by plastic surgeons in the United States, demonstrating significant improvements in symptoms and quality of life. Despite this, RM is often not reimbursed by insurance, with high rates of preauthorization denials, and increasing denials over time. Many of the criteria for authorization or reimbursement include a minimum resection weight of tissue removed, often utilizing the Schnur Scale outside of its original intent. A single-institution study previously performed by our authors demonstrated that machine learning (ML) utilizing preoperative anthropometric variables was an accurate alternative to the Schnur Scale in predicting resection weights during RM. Based on these findings, we sought to evaluate ML and regression modeling in a heterogenous multi-institutional population for predicting RM resection weights with improved accuracy and generalizability.

Methods A multi-institutional retrospective study was performed including 635 patients from three institutions who underwent RM for macromastia between 2017 and 2022. Preoperative anthropometric variables included body surface area (BSA), body mass index (BMI), sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold (N-IMF) measurements. Demographics, comorbidities and surgical data were also collected. ML and regression models were evaluated for accuracy in predicting individual and total breast resection weights. The Schnur Scale estimates were calculated for comparison. After cross-validation, a final model for each method was trained utilizing a single institution dataset, then evaluated a single time on data from the two additional institutions. The mean absolute errors (MAE) were reported. Coefficients for the regression models were tested to determine the likelihood of association.

Results In our study population, the mean age at the time of RM was 38.5 years and 50.4% of patients were White. Mean BMI was 32.8 kg/m2, mean BSA was 2.0 m2, mean SN-N was 33.9 cm, and mean N-IMF was 15.3 cm. The demographics and comorbidities of the participating institutions varied greatly. Six of the seven models evaluated demonstrated lower MAEs than the Schnur Scale across individual and total predicted resection weights. Elastic Net regression had the lowest MAEs across individual right (164.2), left (163.8), and total breast resection weight predictions (310.5). This equated to a reduction of 39.1% for the right breast, 36.7% for the left breast, and 40.9% for total breast resection weights in the MAE from the Schnur Scale. Four shared covariates across both the left and right breasts demonstrated significance after multiple testing correction: preoperative BMI, SN-N, N-IMF, and race/ethnicity. BSA was found not to be a significant covariate for either the left (P= .16; [95% CI -18.4, 111.4]) or right (P= .22; [95% CI -23.8, 104.0]) breast.

Conclusions ML and regression modeling demonstrated improved accuracy in predicting resection weights for RM compared to the Schnur Scale in a heterogenous and multi-institutional population. Preoperative anthropometric measurements of BMI, sternal notch-to-nipple, and nipple-to-inframammary fold, in addition to race/ethnicity were found to be the covariates of greatest importance in predicting resection weights. BSA did not demonstrate significance as a covariate. This study provides further evidence of promising alternatives to the Schnur Scale.

Background: Acellular dermal matrix (ADM) is a widely utilized material in implant-based breast reconstruction due to its potential ability to provide structural support and enhance aesthetic outcomes. However, concern for infection risk persists. This study evaluates the effect of ADM on postoperative outcomes in implant-based reconstruction using a large, propensity-score matched analysis.

Methods: TriNetX, an online electronic health record database, was queried using ICD10 and CPT codes for breast implant and tissue expander reconstruction. Patients were stratified into two cohorts: those with ADM (CPT 15777) ("ADM") placed at reconstruction and those without ("non-ADM"). Propensity-score matching was performed on 76 characteristics, including age, demographics, BMI, breast cancer type and location, long-term drug therapy, chemotherapy, irradiation, cancer genomics and other comorbidities. CPT/ICD- Primary outcomes, identified by CPT/ICD10 codes, captured mechanical failures of the breast prosthesis or implant; infectious or inflammatory reactions related to internal prosthetic devices, implants, or grafts; other unclassified implant-related complications; postoperative surgical infections; postoperative complications of the skin and subcutaneous tissue, including cellulitis; peri-implant capsulectomy or removal of synthetic breast substitute; and postoperative wound dehiscence. Risk analysis compared postoperative outcomes for 6 months after surgery. Risk difference, risk ratio, and odds ratio were calculated to understand the independent effects of ADM.

Results: The query returned 23,656 patients with ADM and 39,482 without ADM. 15,469 patients matched to each cohort. After matching, the ADM cohort had significantly older age at surgery (50.8±11.6 years vs 46.5±13.5 years, p<0.001), higher prevalence of previous breast biopsy (23.8% vs 22.1%, p<0.001), and lower prevalence of previous mastectomy procedures (11.8% vs 12.7%; p=0.009); other variables were not significantly different, including BMI (27.4±6.1 vs 27.3 ± 6.2, p=0.293). Mean follow-up times were 172 ± 32 days for ADM and 169 ± 37 days for non-ADM. ADM use in implant-based breast reconstruction was associated with significantly higher risks of all studied outcomes in the 6-month postoperative period. Postoperative infections and wound dehiscence were respectively 1.585 and 1.419 times more likely to occur with ADM, and skin complications were more than twice as likely. Implant complications, such as capsular contracture and inflammation, were also more likely in the ADM group. Notably, the ADM group experienced breast implant explantation/capsulectomy 1.7x as often as the non-ADM group.

Conclusions: To our knowledge, this is the largest comparison of clinical outcomes using ADM in implant-based breast reconstruction to date. Our data suggest ADM placed at time of implant-based reconstruction is associated with significantly higher risk of infection, wound dehiscence, skin complications, and breast implant explantation within 6 months after surgery. This new information may shed more recent light on ADM's complication profile against potential aesthetic/structural benefits when choosing options in implant-based breast reconstruction.

Background: Implant-based reconstruction represents the most common method of breast reconstruction today. To preserve the viability and surface area of the skin envelope, immediate tissue expander placement is performed in two thirds of all patients undergoing breast reconstruction. Neoadjuvant chemotherapy is becoming more common and can have systemic effects that may place patients at risk for implant loss, infection, wound, and other complications.

Methods: We performed a retrospective review of all cases of implant-based breast reconstruction at a single institution between 2017 and 2024. A total of 210 patients met inclusion criteria of immediate tissue expander placement. 51% of cases were bilateral and 319 total breasts were reconstructed. 71 patients underwent neoadjuvant chemotherapy and 139 did not. Using regression analysis patients were matched for laterality, age, BMI, and ASA status. Patients were separated into neoadjuvant chemotherapy and non-neoadjuvant chemotherapy cohorts. Primary outcomes were all-cause implant loss, wound, infection, and seroma.

Results: The rate of tissue expander loss in patients who underwent neoadjuvant chemotherapy was 23% (24/105 breasts), and the rate of implant loss in patients who did not undergo neoadjuvant chemotherapy was 10.7% (23/214 breasts). On chi-square analysis and Fisher exact tests this difference was statistically significant (p=0.007). On regression analysis neoadjuvant chemotherapy increased risk of implant loss by 15% (p=0.039). There were no statistically significant differences in wound, seroma, and infection.

Conclusion: In this study neoadjuvant chemotherapy is an independent risk factor for implant loss after immediate tissue expander-based breast reconstruction. Further analysis of technique, implant factors, and specific chemotherapeutic agents are warranted.

Purpose: The choice between smooth tissue expanders (STEs) and textured tissue expanders (TTEs) in breast reconstruction has been a topic of discussion among many plastic surgeons with conflicting studies on their complication rates and the theoretical risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) with textured devices. The aim of this updated head-to-head meta-analysis is to provide a comparison of the complication profiles of STEs and TTEs to update the literature and help inform clinical decision-making.

Methods: PRISMA guidelines were followed. PubMed, Scopus, and Web of Science were searched for relevant studies in January 2025. All observational studies from inception to search date comparing TTEs with STEs and reported complications were included. Review Manager 5.4 was used to calculate the risk ratios (RR) and 95% confidence intervals (CI) using the Mantel-Haenszel method. Heterogeneity was assessed using I² statistics. In cases of significant heterogeneity, a random-effects model was applied followed by sensitivity analysis.

Results: Nine studies (7738 tissue expanders: 3487 STEs and 4251 TTEs) were included in the meta-analysis. STEs were associated with a significantly higher risk of malposition (RR = 1.65, 95% CI = 1.23 to 2.20, p = 0.0007) and explantation (RR = 1.33, 95% CI = 1.05 to 1.67, p = 0.02) compared to TTEs. Nonetheless, STEs had a lower risk of capsular contracture (RR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and mastectomy skin flap necrosis (RR = 0.82, 95% CI = 0.69 to 0.98, p = 0.03). There were no statistically significant differences in rates of seroma, hematoma, wound infection, and wound dehiscence. Across all 9 included studies, BIA-ALCL was not reported in both arms.

Conclusion: This head-to-head meta-analysis indicates that although STEs may increase the risk of malposition and explantation, they may have a lower risk of capsular contracture and mastectomy skin flap necrosis compared to TTEs. Further comparative studies are necessary to confirm these findings, particularly comparing rates of capsular contracture due to the small number of studies that reported this outcome and the contradicting notion that smooth implants are more likely to result in capsular contracture. Studies with longer follow ups are necessary to assess the risk of BIA-ALCL.

Purpose: The choice between smooth tissue expanders (STEs) and textured tissue expanders (TTEs) in breast reconstruction has been a topic of discussion among many plastic surgeons with conflicting studies on their complication rates and the theoretical risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) with textured devices. The aim of this updated head-to-head meta-analysis is to provide a comparison of the complication profiles of STEs and TTEs to update the literature and help inform clinical decision-making.

Methods: PRISMA guidelines were followed. PubMed, Scopus, and Web of Science were searched for relevant studies in January 2025. All observational studies from inception to search date comparing TTEs with STEs and reported complications were included. Review Manager 5.4 was used to calculate the risk ratios (RR) and 95% confidence intervals (CI) using the Mantel-Haenszel method. Heterogeneity was assessed using I² statistics. In cases of significant heterogeneity, a random-effects model was applied followed by sensitivity analysis.

Results: Nine studies (7738 tissue expanders: 3487 STEs and 4251 TTEs) were included in the meta-analysis. STEs were associated with a significantly higher risk of malposition (RR = 1.65, 95% CI = 1.23 to 2.20, p = 0.0007) and explantation (RR = 1.33, 95% CI = 1.05 to 1.67, p = 0.02) compared to TTEs. Nonetheless, STEs had a lower risk of capsular contracture (RR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and mastectomy skin flap necrosis (RR = 0.82, 95% CI = 0.69 to 0.98, p = 0.03). There were no statistically significant differences in rates of seroma, hematoma, wound infection, and wound dehiscence. Across all 9 included studies, BIA-ALCL was not reported in both arms.

Conclusion: This head-to-head meta-analysis indicates that although STEs may increase the risk of malposition and explantation, they may have a lower risk of capsular contracture and mastectomy skin flap necrosis compared to TTEs. Further comparative studies are necessary to confirm these findings, particularly comparing rates of capsular contracture due to the small number of studies that reported this outcome and the contradicting notion that smooth implants are more likely to result in capsular contracture. Studies with longer follow ups are necessary to assess the risk of BIA-ALCL.

Purpose: The choice between smooth tissue expanders (STEs) and textured tissue expanders (TTEs) in breast reconstruction has been a topic of discussion among many plastic surgeons with conflicting studies on their complication rates and the theoretical risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) with textured devices. The aim of this updated head-to-head meta-analysis is to provide a comparison of the complication profiles of STEs and TTEs to update the literature and help inform clinical decision-making.

Methods: PRISMA guidelines were followed. PubMed, Scopus, and Web of Science were searched for relevant studies in January 2025. All observational studies from inception to search date comparing TTEs with STEs and reported complications were included. Review Manager 5.4 was used to calculate the risk ratios (RR) and 95% confidence intervals (CI) using the Mantel-Haenszel method. Heterogeneity was assessed using I² statistics. In cases of significant heterogeneity, a random-effects model was applied followed by sensitivity analysis.

Results: Nine studies (7738 tissue expanders: 3487 STEs and 4251 TTEs) were included in the meta-analysis. STEs were associated with a significantly higher risk of malposition (RR = 1.65, 95% CI = 1.23 to 2.20, p = 0.0007) and explantation (RR = 1.33, 95% CI = 1.05 to 1.67, p = 0.02) compared to TTEs. Nonetheless, STEs had a lower risk of capsular contracture (RR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and mastectomy skin flap necrosis (RR = 0.82, 95% CI = 0.69 to 0.98, p = 0.03). There were no statistically significant differences in rates of seroma, hematoma, wound infection, and wound dehiscence. Across all 9 included studies, BIA-ALCL was not reported in both arms.

Conclusion: This head-to-head meta-analysis indicates that although STEs may increase the risk of malposition and explantation, they may have a lower risk of capsular contracture and mastectomy skin flap necrosis compared to TTEs. Further comparative studies are necessary to confirm these findings, particularly comparing rates of capsular contracture due to the small number of studies that reported this outcome and the contradicting notion that smooth implants are more likely to result in capsular contracture. Studies with longer follow ups are necessary to assess the risk of BIA-ALCL.

Purpose: The choice between smooth tissue expanders (STEs) and textured tissue expanders (TTEs) in breast reconstruction has been a topic of discussion among many plastic surgeons with conflicting studies on their complication rates and the theoretical risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) with textured devices. The aim of this updated head-to-head meta-analysis is to provide a comparison of the complication profiles of STEs and TTEs to update the literature and help inform clinical decision-making.

Methods: PRISMA guidelines were followed. PubMed, Scopus, and Web of Science were searched for relevant studies in January 2025. All observational studies from inception to search date comparing TTEs with STEs and reported complications were included. Review Manager 5.4 was used to calculate the risk ratios (RR) and 95% confidence intervals (CI) using the Mantel-Haenszel method. Heterogeneity was assessed using I² statistics. In cases of significant heterogeneity, a random-effects model was applied followed by sensitivity analysis.

Results: Nine studies (7738 tissue expanders: 3487 STEs and 4251 TTEs) were included in the meta-analysis. STEs were associated with a significantly higher risk of malposition (RR = 1.65, 95% CI = 1.23 to 2.20, p = 0.0007) and explantation (RR = 1.33, 95% CI = 1.05 to 1.67, p = 0.02) compared to TTEs. Nonetheless, STEs had a lower risk of capsular contracture (RR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and mastectomy skin flap necrosis (RR = 0.82, 95% CI = 0.69 to 0.98, p = 0.03). There were no statistically significant differences in rates of seroma, hematoma, wound infection, and wound dehiscence. Across all 9 included studies, BIA-ALCL was not reported in both arms.

Conclusion: This head-to-head meta-analysis indicates that although STEs may increase the risk of malposition and explantation, they may have a lower risk of capsular contracture and mastectomy skin flap necrosis compared to TTEs. Further comparative studies are necessary to confirm these findings, particularly comparing rates of capsular contracture due to the small number of studies that reported this outcome and the contradicting notion that smooth implants are more likely to result in capsular contracture. Studies with longer follow ups are necessary to assess the risk of BIA-ALCL.

Introduction: DIEP flaps are regarded as the gold standard in breast reconstruction. Abdominally-based breast reconstruction historically required the use of abdominal drains in the donor site to reduce the rate of abdominal seroma. Recently, authors have found that abdominal drains may not reduce abdominal complications and may cause discomfort. Use of progressive tension sutures in abdominoplasty has challenged the need for drains. A retrospective study was performed to compare abdominal complications in patients who have undergone DIEP flap breast reconstruction both with and without abdominal drains with progressive tension sutures over a two year period at our institution. We also sought to determine the effect of abdominal drains on the patient experience using triage nurse calls and number of RN visits required for drain management as a proxy.

Methods: A retrospective chart review was performed from 2021-2023 of all patients who underwent abdominally-based breast reconstruction at our institution. Demographics, perioperative data, and outcomes were recorded. The data were analyzed for statistical significance.

Results: A total of 174 consecutive patients treated by 3 surgeons met criteria. 103 patients were in the drain-free cohort and 61 patients were in the drain cohort. The average age of the drain-free and drain cohorts were 50.7 and 48.4, respectively (range 26-77). The average BMI of the drain-free and drain cohorts were 30.0 and 31.6, respectively (range 19.5-45.2). The rate of abdominal seroma in the drain-free cohort and drain cohort was not significantly different at 7.8% and 14.8%, respectively (p=0.1956). The rate of abdominal hematoma was not significantly different in the drain-free cohort and drain cohort at 0.0% and 1.7%, respectively (p=0.1938). Compared to the drain cohort, the drain-free cohort had a similar rate of triage calls regarding drains (drain-free cohort =1.4 calls per patient, drain cohort = 1.3 calls per patient, p = 0.6994). The drain-free cohort had significantly fewer RN visits for drain issues (drain-free cohort = 1.3 visits in 90 days, drain cohort = 1.6 visits in 90 days, p = 0.0357).

Conclusion: This study shows with significance that patients undergoing abdominally-based breast reconstruction without abdominal drains have the same rate of abdominal complications as those with drains, suggesting that the use of the abdominal drain is not necessary. Furthermore, patients without drains had fewer nurse drain visits. Our study is unique as it includes a large cohort with a high average BMI for a study of this kind.

Background: Sarcopenia, characterized by progressive loss of skeletal muscle mass and strength, has been linked to higher rates of postoperative complications across various surgical disciplines. However, its effect on autologous breast reconstruction has not been described. This study aims to evaluate the association between preoperative sarcopenia and surgical outcomes in patients undergoing DIEP flap breast reconstruction.

Methods: This retrospective cohort study included all patients who underwent DIEP flap breast reconstruction at a single academic institution between June 2017 and September 2024. Preoperative computed tomography angiography (CTA) was routinely obtained for surgical planning unless contraindicated; therefore, only patients with CTA were included. Sarcopenia was defined using the psoas muscle mass index (L3-PMI, cm²/m²) at the L3 vertebra, calculated as the cross-sectional area of the psoas muscles normalized to height. The threshold for sarcopenia was determined using receiver operating characteristic (ROC) analysis. Propensity score matching (PSM) was performed (1:1 nearest-neighbor matching) for age, BMI, comorbidities, reconstruction laterality, timing, and adjuvant treatments. Balance was assessed using standardized mean differences (SMDs < 0.1). Post-matching, logistic regression was used to evaluate associations between sarcopenia and postoperative complications. Statistical significance was set at p < 0.05.

Results: 203 patients with mean age 51.7 years, (range 27–77) were included. 64 (31.5%) were sarcopenic and 139 (68.5%) were non-sarcopenic. Sarcopenic patients were older (69.76 vs. 71.6 years, p = 0.01) but had no significant differences in BMI, comorbidities, reconstruction laterality, timing, or adjuvant treatments. After PSM, sarcopenia remained associated with higher rates of breast revision (p = 0.026), donor site infection (p = 0.0109), recipient site wounds requiring intervention (p = 0.015), and hematoma (p = 0.027).

Conclusions: Preoperative sarcopenia is independently associated with increased postoperative morbidity following autologous breast reconstruction. These findings highlight the need for preoperative risk stratification and optimization strategies in sarcopenic patients.

Background: Sarcopenia, characterized by progressive loss of skeletal muscle mass and strength, has been linked to higher rates of postoperative complications across various surgical disciplines. However, its effect on autologous breast reconstruction has not been described. This study aims to evaluate the association between preoperative sarcopenia and surgical outcomes in patients undergoing DIEP flap breast reconstruction.

Methods: This retrospective cohort study included all patients who underwent DIEP flap breast reconstruction at a single academic institution between June 2017 and September 2024. Preoperative computed tomography angiography (CTA) was routinely obtained for surgical planning unless contraindicated; therefore, only patients with CTA were included. Sarcopenia was defined using the psoas muscle mass index (L3-PMI, cm²/m²) at the L3 vertebra, calculated as the cross-sectional area of the psoas muscles normalized to height. The threshold for sarcopenia was determined using receiver operating characteristic (ROC) analysis. Propensity score matching (PSM) was performed (1:1 nearest-neighbor matching) for age, BMI, comorbidities, reconstruction laterality, timing, and adjuvant treatments. Balance was assessed using standardized mean differences (SMDs < 0.1). Post-matching, logistic regression was used to evaluate associations between sarcopenia and postoperative complications. Statistical significance was set at p < 0.05.

Results: 203 patients with mean age 51.7 years, (range 27–77) were included. 64 (31.5%) were sarcopenic and 139 (68.5%) were non-sarcopenic. Sarcopenic patients were older (69.76 vs. 71.6 years, p = 0.01) but had no significant differences in BMI, comorbidities, reconstruction laterality, timing, or adjuvant treatments. After PSM, sarcopenia remained associated with higher rates of breast revision (p = 0.026), donor site infection (p = 0.0109), recipient site wounds requiring intervention (p = 0.015), and hematoma (p = 0.027).

Conclusions: Preoperative sarcopenia is independently associated with increased postoperative morbidity following autologous breast reconstruction. These findings highlight the need for preoperative risk stratification and optimization strategies in sarcopenic patients.

Introduction

The rate of implant-based breast reconstruction following mastectomy has been steadily increasing(1) . However, one of the most detrimental complications is surgical site infection, with reported rates in the literature reaching up to 30% (2). Perioperative antibiotic protocols vary, with some surgeons prescribing antibiotic prophylaxis until drain removal, while others adhere to guidelines from the CDC and the Surgical Care Improvement Project, administering only a preoperative dose. Extended antibiotic therapy may contribute to the development of drug-resistant infections and other adverse effects(1). Most existing literature is retrospective, with some studies reporting no significant reduction in infection rates with extended antibiotic use, while others suggest an increase in postoperative infections(3). This randomized controlled study aims to examine whether there is a difference in infection rates or bacterial growth on drain cultures between patients receiving a single preoperative dose of antibiotics and those following an extended antibiotic protocol until drain removal.

Methods

A single-center, prospective randomized controlled trial. Patients undergoing breast reconstruction were randomized into two groups: one group received a single dose of antibiotics prior to surgery, while the second group received antibiotics until drain removal. Drains were cultured to assess bacterial growth. Data on patient demographics, surgical details, clinical outcomes, and drain culture results were collected and subsequently analyzed.

Results

Data from 63 breasts were collected and analyzed. Results revealed no significant difference in postoperative infection rates between the group receiving a single dose of antibiotics and the group receiving antibiotics until drain removal (16.1% vs 12.5%, respectively; p = 0.73). However, the extended antibiotic treatment group demonstrated significantly less bacterial growth on drain cultures compared to the single-dose group (40.6% vs 71%, respectively; p = 0.015). Pathogen distribution varied, with mixed gram-positive organisms being the most common in the extended antibiotic group, while Cons was the predominant pathogen in the single-dose group

Discussion

Interestingly, our findings suggest that extended antibiotic treatment significantly reduced bacterial growth on drains, indicating a potential decrease in bacterial presence within the breast pocket. However, despite this reduction, extended antibiotic therapy did not lead to a statistically significant decrease in postoperative infection rates. These findings are important, as they may encourage surgeons to discontinue prolonged prophylaxis, thereby reducing the risk of drug-resistant bacteria, and contribute to the standardization of antibiotic therapy protocols. In conclusion, our results indicate that extended therapy does not reduce postoperative infections and is not warranted in breast reconstruction.

1. Sergesketter AR, Langdell HC, Shammas RL, et al. Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis. Plast Reconstr Surg. 2024;153(3):496E-504E. doi:10.1097/PRS.0000000000010825
2. Sisco M, Kuchta K, Alva D, Seth AK. Oral Antibiotics Do Not Prevent Infection or Implant Loss after Immediate Prosthetic Breast Reconstruction. In: Plastic and Reconstructive Surgery. Vol 151. Lippincott Williams and Wilkins; 2023:730E-738E. doi:10.1097/PRS.0000000000010073
3. Clayton JL, Bazakas A, Lee CN, Scott Hultman C, Halvorson EG. Once is not enough: Withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg. 2012;130(3):495-502. doi:10.1097/PRS.0b013e31825dbefe

Purpose: Autologous breast reconstruction with free tissue transfer is an integral component of treatment for breast cancer patients. Although these procedures are commonly performed by plastic surgeons, they are by nature highly complex, lengthy, and require close postoperative monitoring. Utilizing agents such as vasopressors for hemodynamic management remains controversial, as vasopressors induce vasoconstriction, which could decrease tissue perfusion and threaten the viability of the flap (1). However, the true effects of vasopressor use on free flap outcomes are unknown and existing literature has found mixed results (2, 3). Therefore, our study aims to analyze the outcomes of free flap breast reconstruction in the setting of perioperative vasopressor use.

Methods: The TriNetX LLC. National Health Research database was utilized to identify patients who had a breast cancer diagnosis and underwent free flap reconstruction between 2004-2024. The database was further queried for those who did and did not receive vasopressors within 5 days of surgery and the two cohorts were subsequently matched for their demographics and comorbidities. Then, common procedural terminology (CPT) codes were used to assess for procedures related to flap complications. These included revision of the microvascular anastomosis, flap debridement, hematoma evacuation, and blood vessel repair within 7 days postoperatively. Diagnoses such as venous thromboembolism (VTE) and sepsis were also included as postoperative complications.

Results: Of the 17,151 patients who underwent free flap breast reconstruction, a total of 7,309 patients were associated with vasopressor use and 6,842 were not. When the two groups were matched for their demographics and comorbidities, 5,909 patients were identified in each cohort. There was no significant difference in the rate of free flap complication rates among those who did (16.5%) and did not (17.5%) receive vasopressors perioperatively (p=0.1349).

Conclusion: Our study demonstrates that perioperative vasopressor use does not significantly impact the complication rate associated with free flap breast reconstruction. Patients who received vasopressors did not experience a higher rate of postoperative complications, including those requiring return to the operating room, within the first 7 days after the index surgery. Therefore, these results imply that vasopressor use is safe when clinically indicated without an increased risk of complications.

1. Larcher Q, Mernier T, Feigna M, Pozzo V, Lantieri L. Impact of Norepinephrine Use on Free Flap Survival in Breast Reconstructive Microsurgery. Microsurgery. 2025 Jan;45(1):e70026. doi: 10.1002/micr.70026. PMID: 39865374.
2. Goh CSL, Ng MJM, Song DH, Ooi ASH. Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis. J Reconstr Microsurg. 2019 Sep;35(7):529-540. doi: 10.1055/s-0039-1687914. Epub 2019 May 1. PMID: 31042803.
3. Michelle L, Bitner BF, Pang JC, Berger MH, Haidar YM, Rajan GR, Tjoa T. Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta-analysis. Head Neck. 2023 Mar;45(3):721-732. doi: 10.1002/hed.27289. Epub 2023 Jan 8. PMID: 36618003.

Purpose: Artificial intelligence (AI) has emerged as a powerful tool in predictive analytics, offering the potential to enhance clinical decision-making and optimize patient outcomes. In the field of reconstructive surgery, particularly autologous breast reconstruction, accurately predicting postoperative complications remains a critical challenge. Recent advancements in AI, including machine learning (ML) models, have demonstrated superior performance in risk stratification and outcome prediction across various surgical specialties. By leveraging large datasets and non-linear relationships, AI models have the potential to refine risk assessment, personalize perioperative care, and ultimately improve reconstructive surgery outcomes. This study evaluates the predictive performance of different ML models in forecasting postoperative complications following autologous breast reconstruction.

Methods: The American College of Surgery National Surgical Quality Improvement Program (NSQIP) database (2009–2022) was queried for patients undergoing free flap breast reconstruction. Predictive models were trained using demographics, comorbidities, preoperative labs, surgical details, and ACS risk assessments. We employed logistic regression, k-nearest neighbors (KNN), random forest, XGBoost, an artificial neural network (ANN), and an ensemble model (VOTE). To address class imbalance, Synthetic Minority Oversampling Technique (SMOTE) was applied [1]. Hyperparameters were optimized using grid search with cross-validation, and model performance was evaluated using accuracy, sensitivity, specificity, and AUROC. All models were trained and evaluated in Python 3.11 (Python Software Foundation. Wilmington, DE.).

Results: We identified 33,282 patients who had breast free flap reconstruction in our cohort, and the rate of SSI was 6.4% and unplanned reoperation was 10.2%. When predicting SSI, ANN demonstrated the highest accuracy (0.671, CI [0.660, 0.680]) and specificity (0.691, CI [0.681, 0.703]), but had the lowest sensitivity (0.367, CI [0.322, 0.401]). KNN exhibited the highest sensitivity (0.585, CI [0.577, 0.615]). When predicting unplanned reoperation, ANN again achieved the highest accuracy (0.699, CI [0.693, 0.705]) and specificity (0.746, CI [0.740, 0.755]), while KNN had the highest sensitivity (0.553, 95% [0.529, 0.580]). Random forest provided balanced performance across both outcomes, with AUROC values of 0.581 for SSI and 0.574 for reoperation.

Discussion: The ANN yielded the greatest accuracy in predicting both SSI (67.1%) and unplanned reoperation (69.9%). Achieving high sensitivity and specificity remains a challenge in predicting rare events, even when employing a bootstrapping approach to address imbalanced outcomes. These findings suggest that the ANN may be optimal for ruling out complications due to its high specificity, whereas the KNN may be more useful for identifying high-risk patients due to its superior sensitivity. Nevertheless, these results demonstrate the potential for such models to be used in clinical practice to predict complications of free flap surgery.

1. Yap B, Rani KA, Rahman HA, Fong S, Khairudin Z, AbdullahNN. An application of oversampling, undersampling, bagging and boosting in handling imbalanced datasets. Paper presented at: DaEng2013.

Aim. To explore the outcomes and transformative potential of a novel mastopexy approach utilizing advanced autoaugmentation techniques. This innovative method achieves upper pole fullness and breast rejuvenation exclusively using native tissue, offering a groundbreaking alternative to traditional techniques reliant on implants. Methods and Materials. A prospective study was conducted in years 2019-2025, involving patients undergoing mastopexy with autoaugmentation at a single center. All procedures were performed using a standardized protocol, focusing on tissue preservation and redistribution to enhance breast aesthetics. Patient outcomes were assessed preoperatively and postoperatively using standardized measurements and patient-reported outcome tools. Diverse clinical presentations and anatomical variations were included to the study. All procedures were performed by a single surgeon with extensive experience in breast aesthetics. Follow-up periods ranged from 12 to 72 months. Results. The autoaugmentation mastopexy approach demonstrated significant improvements in breast projection, upper pole fullness, and overall aesthetic harmony. Patients reported high satisfaction rates. Objective measurements confirmed long-term maintenance of upper pole volume and cleavage definition. Minimal postoperative complications, including delayed wound healing, occurred in fewer than 1% of cases. Conclusions. This study highlights the pioneering role of implant-free autoaugmentation techniques in redefining mastopexy possibilities. The approach ensures natural, long-lasting aesthetic results and eliminates implant-associated risks. These findings suggest a paradigm shift in breast surgery, emphasizing patient-centric, sustainable, and innovative methods to achieve optimal outcomes.

Background Staging tissue expander (TE) placement before deep inferior epigastric perforator (DIEP) flap reconstruction offers patients flexibility in choosing between autologous and implant-based breast reconstruction (1). From a technical standpoint, TE placement before DIEP flap reconstruction helps preserve the breast pocket, potentially enhancing final aesthetic outcomes and reducing the need for revision surgery (2). However, staging with a TE introduces an additional phase of treatment with associated risks. This study evaluates the impact of staged TE to DIEP flap reconstruction on revision surgery rates and postoperative complications.

Methods A retrospective review was conducted on patients who underwent DIEP flap reconstruction at two institutions between 2020 and 2022. Patient demographics, medical history, operative course, post-operative complications, and revision surgery rates were analyzed. Major complications were defined as those requiring reoperation. Patients were categorized into four groups: (1) immediate to DIEP, (2) delayed to DIEP, (3) TE to DIEP, or (4) implant to DIEP.

Results A total of 439 patients were included, with 64 in the immediate DIEP group, 149 in the delayed to DIEP group, 166 in the TE to DIEP group, and 60 in the implant to DIEP group. Revision rates following DIEP flap reconstruction did not differ significantly between groups (p=0.663). Among patients undergoing tissue expansion, the major complication rate was 35%, with 14% requiring unplanned hospital admission.

Conclusion Staging DIEP flap reconstruction with a TE does not significantly impact revision surgery rates. However, this approach carries inherent risks, as demonstrated by the major complication rate during expansion. These findings highlight the importance of careful patient selection and thorough counseling on potential complications. Further research is needed to assess patient-reported outcomes and long-term aesthetic results in staged TE to DIEP flap reconstruction.

[1] Pittelkow E, DeBrock W, Christopher L, Mercho R, Suh LJ, Fisher CS, Hartman B, Lester M, Hassanein AH. Advantages of the Delayed-Immediate Microsurgical Breast Reconstruction: Extending the Choice. J Reconstr Microsurg. 2022 Sep;38(7):579-584. doi: 10.1055/s-0041-1742240. Epub 2022 Feb 8. PMID: 35135030.

[2] Lee KR, Clavin N. Bridging autologous reconstruction with pre-pectoral tissue expanders. Gland Surg. 2019 Feb;8(1):90-94. doi: 10.21037/gs.2018.11.07. PMID: 30842933; PMCID: PMC6378259.

Background: Nipple sparing mastectomy (NSM) improves patient quality of life and self-image but has traditionally been limited to patients with minimal or no ptosis due to the difficulty in manipulating the skin envelope. The Goldilocks technique, however, allows preservation of the nipple-areolar complex (NAC) in larger, ptotic breasts by utilizing an autologous dermal flap. This study aimed to assess the viability of NSM utilizing a goldilocks technique.

Methods: A retrospective review compared patients that underwent NSM with Goldilocks technique (NSM Goldilocks) to the traditional NSM with an inframammary fold incision (NSM IMF). The NAC is maintained on the distal aspect of the goldilocks flap and closed with Wise pattern incisions (Figure 1).

Results: A total of 39 patients (66 breasts) were included in this study. Between 2019 and 2025, five patients (10 breasts) underwent NSM goldilocks (figure 2) and 34 patients (66 breasts) underwent NSM IMF. The average age was 50 ± 10 years and mean BMI was 24.8 ± 4.2. The nipple to IMF distance of NSM Goldilocks (10.2 ± 2.3cm) was significantly larger than in NSM IMF (7.8 ± 1.7cm), p < 0.01. NSM goldilocks had similar odds of overall complications as NSM IMF (OR 1.97 (0.31–12.76), p = 0.48).

Conclusion: While NSM remains the gold standard for ideal candidates with minimal ptosis, the Goldilocks technique provides a viable alternative for larger, ptotic breasts, expanding the eligibility for NAC preservation. Further studies are needed to validate its safety and efficacy.

Purpose Infection requiring implant removal after immediate alloplastic breast reconstruction continues to be a vexing problem for the reconstructive surgeon and patient. While most patients go on to compete the reconstructive process, there is little data regarding the optimal management of these patients. This study examines reconstructive options and outcomes after alloplastic reconstructive failure due to infection.

Methods A retrospective study was conducted with patients from a single institution undergoing immediate alloplastic reconstruction complicated by infection requiring removal of the implant. Patients undergoing delayed reconstruction or immediate autologous reconstruction were excluded. SPSS software was used to compare continuous variables via independent t-test and categorical variables compared by Chi-square.

Results 71 patients (78 breasts) were included in the study with an average age of 50.8 years and average BMI of 29.6 kg/m2. The majority of breasts underwent tissue-expander reconstruction (n=60, 76.9%) with the remainder undergoing direct-to-implant reconstruction (n=18, 23.1%) ; explantation occurred a median of 28 days (range 8-355) after reconstruction. The majority of infections were due to Staphylococcus Aureus (n=32, 45.1%) and Pseudomonas Aeruginosa (n=19, 26.8%). 54 patients (76.1%) and 58 breasts (74.4%) of the original cohort underwent secondary reconstruction. Secondary reconstruction was done with tissue-expanders (n=35, 60.3%), silicone implants (n=9, 15.6%), DIEP or msTRAM flaps (n=8,13.8%), and latissimus flaps with tissue-expanders (n=6, 10.3%). Recurrent infections occurred in ten breasts (17.2%), eight of which had been secondarily reconstructed with tissue-expanders and two with implants. Of these, two were successfully treated with IV antibiotics and 8 required repeat explantation. Of the eight breasts that required a second explant, six went on to complete reconstruction successfully. The most common organism responsible for recurrent infection was Staphylococcus aureus (n=3, 30%). No patients who underwent secondary reconstruction with autologous tissue developed recurrent infection.

Conclusion The majority of patients who develop an infection requiring explant are able to complete reconstruction successfully. However, these patients are at a higher-than-average risk for recurrent infection. Conversion to autologous reconstruction may increase the likelihood of success.

Purpose: The optimal plane of tissue expander (TE) and prosthetic device placement in breast reconstruction is still debatable among surgeons, with conflicting studies on subpectoral versus prepectoral techniques regarding their complication profiles. The aim of this meta-analysis is to compare the outcomes of TE placement in the subpectoral vs. prepectoral planes in terms of postoperative complications and patient-reported satisfaction.

Methods: PubMed, Scopus, and Web of Science were screened. PRISMA guidelines were followed. Observational studies were included if they compared the two TE placements and had reported at least one of the primary outcomes (surgical complications). Secondary outcomes were BREAST-Q scores, length of hospital stay, time to completion of expansion, and time to drain removal. 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) with their respective CI using the inverse variance method. Heterogeneity was assessed using I² statistics. A random-effects model was applied when significant heterogeneity was found. This was followed by sensitivity analysis.

Results: 23 studies (10,476 tissue expanders) met the inclusion criteria and were included in the meta-analysis. Subpectoral TE was associated with a significantly lower risk of seroma (RR = 0.67, 95% CI = 0.53 to 0.85, p = 0.0009), wound dehiscence (RR = 0.74, 95% CI = 0.56 to 0.97, p = 0.03), longer length of hospital stay in days (MD = 0.08, 95% CI = 0.05 to 0.12, p < 0.00001), and longer time to completion of expansion in days (MD = 24.66, 95% CI = 15.39 to 33.92, p < 0.00001) compared to prepectoral TE placement. Nonetheless, no statistically significant differences were observed between the two planes regarding rates of hematoma, infection, skin flap necrosis, nipple necrosis, TE loss, readmission, TE exposure, malposition, capsular contracture, reoperation, BREAST-Q scores, and time to drain removal. A meta-analysis could not be performed for pain scores due to the heterogeneity in the pain scoring assessment across the 3 studies that reported it; however, all 3 studies that assessed pain reported lower scores with prepectoral TE placement.

Conclusion: This head-to-head meta-analysis shows that while TE placement in the subpectoral plane may pose a lower risk of seroma formation and wound dehiscence compared to the prepectoral plane, both approaches demonstrate comparable outcomes for most postoperative complications and patient satisfaction; however, prepectoral TE placement may result in shorter time to complete expansion, shorter length of stay, and less pain.

Purpose: The optimal plane of tissue expander (TE) and prosthetic device placement in breast reconstruction is still debatable among surgeons, with conflicting studies on subpectoral versus prepectoral techniques regarding their complication profiles. The aim of this meta-analysis is to compare the outcomes of TE placement in the subpectoral vs. prepectoral planes in terms of postoperative complications and patient-reported satisfaction.

Methods: PubMed, Scopus, and Web of Science were screened. PRISMA guidelines were followed. Observational studies were included if they compared the two TE placements and had reported at least one of the primary outcomes (surgical complications). Secondary outcomes were BREAST-Q scores, length of hospital stay, time to completion of expansion, and time to drain removal. 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) with their respective CI using the inverse variance method. Heterogeneity was assessed using I² statistics. A random-effects model was applied when significant heterogeneity was found. This was followed by sensitivity analysis.

Results: 23 studies (10,476 tissue expanders) met the inclusion criteria and were included in the meta-analysis. Subpectoral TE was associated with a significantly lower risk of seroma (RR = 0.67, 95% CI = 0.53 to 0.85, p = 0.0009), wound dehiscence (RR = 0.74, 95% CI = 0.56 to 0.97, p = 0.03), longer length of hospital stay in days (MD = 0.08, 95% CI = 0.05 to 0.12, p < 0.00001), and longer time to completion of expansion in days (MD = 24.66, 95% CI = 15.39 to 33.92, p < 0.00001) compared to prepectoral TE placement. Nonetheless, no statistically significant differences were observed between the two planes regarding rates of hematoma, infection, skin flap necrosis, nipple necrosis, TE loss, readmission, TE exposure, malposition, capsular contracture, reoperation, BREAST-Q scores, and time to drain removal. A meta-analysis could not be performed for pain scores due to the heterogeneity in the pain scoring assessment across the 3 studies that reported it; however, all 3 studies that assessed pain reported lower scores with prepectoral TE placement.

Conclusion: This head-to-head meta-analysis shows that while TE placement in the subpectoral plane may pose a lower risk of seroma formation and wound dehiscence compared to the prepectoral plane, both approaches demonstrate comparable outcomes for most postoperative complications and patient satisfaction; however, prepectoral TE placement may result in shorter time to complete expansion, shorter length of stay, and less pain.

Purpose: The optimal plane of tissue expander (TE) and prosthetic device placement in breast reconstruction is still debatable among surgeons, with conflicting studies on subpectoral versus prepectoral techniques regarding their complication profiles. The aim of this meta-analysis is to compare the outcomes of TE placement in the subpectoral vs. prepectoral planes in terms of postoperative complications and patient-reported satisfaction.

Methods: PubMed, Scopus, and Web of Science were screened. PRISMA guidelines were followed. Observational studies were included if they compared the two TE placements and had reported at least one of the primary outcomes (surgical complications). Secondary outcomes were BREAST-Q scores, length of hospital stay, time to completion of expansion, and time to drain removal. 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) with their respective CI using the inverse variance method. Heterogeneity was assessed using I² statistics. A random-effects model was applied when significant heterogeneity was found. This was followed by sensitivity analysis.

Results: 23 studies (10,476 tissue expanders) met the inclusion criteria and were included in the meta-analysis. Subpectoral TE was associated with a significantly lower risk of seroma (RR = 0.67, 95% CI = 0.53 to 0.85, p = 0.0009), wound dehiscence (RR = 0.74, 95% CI = 0.56 to 0.97, p = 0.03), longer length of hospital stay in days (MD = 0.08, 95% CI = 0.05 to 0.12, p < 0.00001), and longer time to completion of expansion in days (MD = 24.66, 95% CI = 15.39 to 33.92, p < 0.00001) compared to prepectoral TE placement. Nonetheless, no statistically significant differences were observed between the two planes regarding rates of hematoma, infection, skin flap necrosis, nipple necrosis, TE loss, readmission, TE exposure, malposition, capsular contracture, reoperation, BREAST-Q scores, and time to drain removal. A meta-analysis could not be performed for pain scores due to the heterogeneity in the pain scoring assessment across the 3 studies that reported it; however, all 3 studies that assessed pain reported lower scores with prepectoral TE placement.

Conclusion: This head-to-head meta-analysis shows that while TE placement in the subpectoral plane may pose a lower risk of seroma formation and wound dehiscence compared to the prepectoral plane, both approaches demonstrate comparable outcomes for most postoperative complications and patient satisfaction; however, prepectoral TE placement may result in shorter time to complete expansion, shorter length of stay, and less pain.

Purpose: The optimal plane of tissue expander (TE) and prosthetic device placement in breast reconstruction is still debatable among surgeons, with conflicting studies on subpectoral versus prepectoral techniques regarding their complication profiles. The aim of this meta-analysis is to compare the outcomes of TE placement in the subpectoral vs. prepectoral planes in terms of postoperative complications and patient-reported satisfaction.

Methods: PubMed, Scopus, and Web of Science were screened. PRISMA guidelines were followed. Observational studies were included if they compared the two TE placements and had reported at least one of the primary outcomes (surgical complications). Secondary outcomes were BREAST-Q scores, length of hospital stay, time to completion of expansion, and time to drain removal. 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) with their respective CI using the inverse variance method. Heterogeneity was assessed using I² statistics. A random-effects model was applied when significant heterogeneity was found. This was followed by sensitivity analysis.

Results: 23 studies (10,476 tissue expanders) met the inclusion criteria and were included in the meta-analysis. Subpectoral TE was associated with a significantly lower risk of seroma (RR = 0.67, 95% CI = 0.53 to 0.85, p = 0.0009), wound dehiscence (RR = 0.74, 95% CI = 0.56 to 0.97, p = 0.03), longer length of hospital stay in days (MD = 0.08, 95% CI = 0.05 to 0.12, p < 0.00001), and longer time to completion of expansion in days (MD = 24.66, 95% CI = 15.39 to 33.92, p < 0.00001) compared to prepectoral TE placement. Nonetheless, no statistically significant differences were observed between the two planes regarding rates of hematoma, infection, skin flap necrosis, nipple necrosis, TE loss, readmission, TE exposure, malposition, capsular contracture, reoperation, BREAST-Q scores, and time to drain removal. A meta-analysis could not be performed for pain scores due to the heterogeneity in the pain scoring assessment across the 3 studies that reported it; however, all 3 studies that assessed pain reported lower scores with prepectoral TE placement.

Conclusion: This head-to-head meta-analysis shows that while TE placement in the subpectoral plane may pose a lower risk of seroma formation and wound dehiscence compared to the prepectoral plane, both approaches demonstrate comparable outcomes for most postoperative complications and patient satisfaction; however, prepectoral TE placement may result in shorter time to complete expansion, shorter length of stay, and less pain.

BACKGROUND: Insurance coverage for reduction mammaplasty is currently dictated by a sliding scale based on body surface area. However, the correlation between musculoskeletal symptoms and physical examination measurements to these estimated resection weights has not been elucidated. The purpose of this study was to determine whether morphometric parameters of patients with insurance coverage from breast reduction are correlated to ultimate resection weights.

METHODS: Retrospective cohort study was conducted across seven academic institutions of patients undergone insurance-covered reduction mammaplasty from 2010-2019 to analyze pre-operative symptomatology, clinical measurements, and BMI as they relate to resection weights.

RESULTS: During the study interval, 2500 patients underwent reduction mammaplasty, of which 46% of patients were white, and 80% of patients were between the ages of 20-59. All but 10% of patients were overweight or obese. Pre-operatively, 91% of patients endorsed upper back pain and 81% endorsed neck pain, while 6% had no musculoskeletal symptoms. 65% of patients had a nipple to inframammary fold distance of 13-18cm, and 40% had a sternal notch to nipple distance of 30-34 cm. Pre-operative neck pain, BMI (Pearson correlation r=0.63), sternal notch to nipple distance (r=0.71), and nipple to inframammary fold (NIMF) distance (r=0.62) all correlated with resected weight. Regression analysis demonstrated increasing age and BMI as independent risk factors for overall complications. BMI alone independently predicted nipple necrosis (p=0.002) and fat necrosis (p<0.001).

CONCLUSIONS: Patients achieving insurance approval for reduction mammaplasty in the southeast were overweight or obese with pre-operative MSK symptoms. There was a strong positive correlation between neck pain, BMI, SNN, and NIMF distance versus resected weights, suggesting that symptoms and physical examination measurements may be similarly important to BMI in predicting medically necessary resection weights for reduction mammaplasty.

Purpose ChatGPT is an artificial intelligence (AI) platform with over 100 million users, serving as a key resource that has proven to be useful in clinical settings. There is a strong emphasis on the ease and readability of informative education materials provided to patients. With regards to breast implants, the FDA recommends all patients who are to undergo breast implant placement to review and sign a checklist delineating the risks, indications, and monitoring guidelines of breast implants during the pre-operative visit. These forms are standardized nationally and provided by the three major leading companies: Allergan, Sientra, and Mentor. However, the readability of the forms and patient's complete comprehension of details, risks, and complications is difficult to assess. Therefore, this study aims to evaluate the readability of the existing breast implant consultation forms and how the use of ChatGPT can improve readability and facilitate patient's comprehension of their procedures.

Methods Breast implant checklists available online from Allergan, Sientra, and Mentor's official websites were obtained. ChatGPT was queried to convert and create documents for the same procedures at a 6th grade reading level, which is the official grade level recommended by the American Medical Association in regards to patient information materials. Readability was assessed using the Flesch Reading Ease score and Flesch-Kincaid Reading level before and after AI-conversion. These are metric systems commonly used to assess and provide a numeric gauge of comprehension difficulty that readers experience when reading a text. Content reliability and accuracy of the AI materials were assessed by three physicians utilizing the Global Quality Scale.

Results The mean Flesch Reading Ease scores for Allergan, Sientra, and Mentor's consultation forms before and after ChatGPT conversion were 29.43 and 67.4, (p = 0.003) and the Flesch-Kincaid grade levels were 16.1 and 6, (p = 0.001), both showing statistical significant difference. The word count was found to have an 84.6% reduction in length after conversion (Table 1).

Conclusion The Breast implant checklist provided by three major companies in America, Allergan, Menton, and Sientra are at a reading level higher than recommended for the general public. We used ChatGPT to convert these documents into a language more accessible to patients with a significant improvement in readability as demonstrated by Flesch Reading Ease andFlesh-Kincaid grade level. This study shows the potential role AI can play in empowering patient understanding and facilitating communication between patients and treating physicians with regards to the details, risks, benefits, and complications of undergoing breast implant based procedures.

Introduction The preservation of the breast skin envelope in autologous breast reconstruction offers significant benefits, including maintaining the initial breast skin color tone, sensation, footprint, projection, and patient's sense of self. Two-stage reconstruction involving the initial placement of tissue expanders immediately after nipple-sparing mastectomy (NSM) followed by autologous DIEP flap reconstruction offers a lower risk of mastectomy skin flap necrosis and better overall definition. Despite these benefits, tissue expander loss due to infection can result in contracture of the skin envelope on the chest wall. This can severely impact the final aesthetic outcome and create esthetic asymmetry with the contralateral intact skin envelope in bilateral cases.

Methods: This study investigates a series of 68 patients (120 breasts) who underwent two-stage autologous breast reconstruction from November 2021 to June 2024 with the initial reconstruction involving NSM and pre-pectoral tissue expander placement. We identified 10 patients (15 breasts) who required removal of their tissue expander due to infection or wound complications and underwent re-elevation of their mastectomy skin flap during autologous reconstruction to preserve their entire skin envelope. We analyzed complication rates and the ability to regain the initial NSM characteristics from the initial tissue expander-based reconstruction.

Results Patients were followed to assess the impact of well-vascularized tissue on the improvement of skin envelope dermal scarring and rippling after capsulotomy and capsulectomy. We compared the number of revisions required to achieve the final aesthetic outcome between patients who underwent two-stage reconstruction with and without tissue expander loss. There were no significant differences in revision rates or the number of revisions between the control group (no tissue expander loss) and the group with tissue expander loss and re-elevation of the NSM skin envelope. The complication rates in the re-elevation group were identical to those in the control group. The interval time from tissue expander loss to autologous reconstruction was approximately 4 months.

Conclusion Aggressive capsulectomy and capsulotomy in the setting of a previously lost tissue expander after NSM are powerful tools in preserving the aesthetic characteristics of the initial mastectomy. Our findings suggest that re-elevation with aggressive capsulotomy and capsulectomy offers a significant aesthetic advantage and should be strongly considered in autologous reconstruction following tissue expander loss. This approach improves the vascularity and softening of irregularities over time. Additionally, the revision rates following tissue expander loss were similar to those in the control group, confirming the effectiveness of this technique.