Scientific Abstract Presentations: Breast Session 2 Thursday, October 15 Thu, Oct 15 3:30-4:30 p.m. CDT

Background: Axillary lymph node dissection (ALND) is a known treatment-related risk factor for breast cancer-related lymphedema (BRCL) with reported prevalence rates up to 24.6% (1,2). Chronic BRCL has been associated with decreased psychological and physical functioning as well as up to $1 billion in healthcare costs over 5 years (3). Axillary reverse mapping (ARM) and immediate lymphatic reconstruction (ILR) are preventive surgical procedures at time of ALND but have yet to be compared in published literature. This systematic review and meta-analysis aims to summarize prospective studies of the efficacy of ARM and ILR in reducing lymphedema incidence.

Methods: A comprehensive literature search of PubMed, Scopus, Embase, and Web of Science was conducted in January 2026. Eligible studies were prospective studies of breast cancer patients (>18yrs) undergoing ALND with ARM or ILR procedures. Studies without an ALND-only comparator group, missing lymphedema data, or follow up < 12 months were excluded. All analyses used weighted mixed-effects models on summary data at the study level. Primary outcome reports the study-level risk ratios pooled based on reported lymphedema events for each procedure type with between-study variance (τ²) and heterogeneity (I²) estimations. Pooled proportions using mixed-effects models were calculated in studies with reported complications. Patient reported outcome measures were qualitatively assessed for trends.

Results: 230 studies were screened by two reviewers, and 12 studies (ARM n=7; ILR n=5) met the inclusion criteria. Bias assessment included ROB-2 and ROBINS-1 tools; all studies were evaluated as low or moderate risk. Mean follow up duration ranged from 14.8-44.6 months. There were no significant differences in weighted mean age, BMI, or number of excised nodes between ARM, ILR, and control groups. The pooled lymphedema risk ratios were 0.33 (95% CI [0.19-0.56]) for ARM and 0.43 (95% CI [0.30-0.62]) for ILR compared to control groups. There was low-to-moderate heterogeneity between studies (I2= 40.6%) overall. Of the four studies with patient-reported outcomes, trends suggested less functional impairment in ARM and ILR groups compared to control. Three ARM studies reported a 2.09% locoregional recurrence rate in the intervention group compared to 1.09% in controls (NS).

Conclusions: ILR and ARM demonstrated risk reduction of 57 and 67 percent in postoperative lymphedema incidence compared to standard axillary node dissection alone. Comparatively, ARM had the greater relative risk reduction but may be associated with postoperative recurrence. These findings provide additional data for preoperative patient counseling and risk stratification in selecting prophylactic surgical options.

References: 1. Ruffino, Amanda E, et al. "The Efficacy of Axillary Reverse Mapping for the Prevention of Lymphedema." Am Surg, vol. 90, no. 2, Feb. 2024, pp. 199–206, pubmed.ncbi.nlm.nih.gov/37619219/, https://doi.org/10.1177/00031348231198103 2. Che Bakri, Nur Amalina, et al. "Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients." Ann Surg, vol. 277, no. 4, 10 Aug. 2022, pp. 572–580, https://doi.org/10.1097/sla.0000000000005671. 3. Roberson ML, Strassle PD, Fasehun LK, Erim DO, Deune EG, Ogunleye AA. Financial burden of lymphedema hospitalizations in the United States. JAMA Oncol, 2021 Apr;7(4):630-2. https://doi:10.1001/jamaoncol.2020.7891

Purpose: Surgical site infections (SSIs) following oncologic breast surgery remain a significant cause of morbidity and reconstructive failure.(1,2) However, microbiologic patterns and antibiotic susceptibility based on prosthetic use are poorly defined. In this study, we aim to characterize the microbiologic spectrum and antibiotic susceptibility patterns of culture-positive infections following oncologic mastectomy, stratified by prosthetic use, to inform procedure-specific empiric antibiotic strategies.

Methods: A retrospective review was conducted of oncologic breast procedures including mastectomies with or without immediate tissue expanders performed at a tertiary academic center from January 2017 to January 2024. Procedures were queried using Current Procedural Terminology (CPT) codes, and surgical site infections were defined by presence of intra-operative culture-positive specimen obtained from a postoperative wound, seroma, or abscess. Organism identification antimicrobial susceptibility testing were performed in accordance with Clinical and Laboratory Standards Institute (CLSI) guidelines. Comparative analyses evaluated infection incidence, timing, and microbiologic profiles across use of prosthetics.

Results: Among 1,534 oncologic breast operations, 74 (4.8%) resulted in a culture-positive infection. Prosthetic procedures demonstrated a higher infection rate than non-prosthetic procedures (5.8% vs 3.8%, p = 0.08). Infections in mastectomy patients without prosthetic devices were predominantly caused by Staphylococcus Aureus (25.1%), methicillin-resistant Staphylococcus aureus (MRSA, 17.6%), and Staphylococcus Epidermidis (5.9%), reflecting a predominance of gram-positive organisms. Infections in patients with TE placement exhibited a broader spectrum, including Pseudomonas Aeruginosa (31.5%), S. aureus (23.6%), and S. Epidermidis (12.5%). Per institutional antimicrobial data, empiric antibiotic coverage should be procedure-tailored. For non-prosthetic procedures (mastectomy-only), empiric coverage with cefazolin is warranted, given the predominance of S. aureus, with evidence that vancomycin can be reserved for patients at increased risk for MRSA or institutions with high MRSA prevalence. Dual coverage with vancomycin and a cephalosporin is the preferred empiric regimen for prosthetic based mastectomy.

Conclusions: Postoperative oncologic breast infections exhibit distinct microbiologic signatures based on prosthetic use. Non-prosthetic procedures are characterized by gram-positive pathogens, while prosthetic reconstructions favor gram-negative organisms. Recommended antibiotic coverage should be guided by institutional antibiograms to optimize outcomes and antibiotic stewardship.

References 1. Nguyen TJ, Costa MA, Vidar EN, et al. Effect of immediate reconstruction on postmastectomy surgical site infection. Ann Surg. 2012;256(2):326-333. doi:10.1097/SLA.0b013e3182602bb7 2. Pastoriza J, McNelis J, Parsikia A, et al. Predictive Factors for Surgical Site Infections in Patients Undergoing Surgery for Breast Carcinoma. Am Surg. 2021;87(1):68-76. doi:10.1177/0003134820949996

Background: Neurotization during DIEP flap breast reconstruction aims to restore sensory function through targeted nerve coaptation. While dual nerve coaptation has been associated with improved tactile recovery, its effect on thermal discrimination remains unclear.

Methods: In a single-institution prospective cohort (2022-present) of immediate DIEP flap reconstructions performed by one surgeon, breasts undergoing single neurotization (2022-2023) were compared with those undergoing dual neurotization (2024-present). Thermal discrimination was assessed using hot (52 °C) and cold (12 °C) pack testing at 3, 6, 9, and 12 months postoperatively. Accuracy was expressed as percent recovery relative to each breast's preoperative baseline. Between-group comparisons were performed at each timepoint with Holm correction. Paired testing evaluated recovery relative to baseline.

Results: Demographic and surgical characteristics were similar between cohorts (Dual: n = 49 breasts; Single: n = 44 breasts), including age (p = 0.977), BMI (p = 0.877), mastectomy weight (p = 0.660), and nipple-sparing mastectomy rate (p = 1.000).

For cold discrimination, composite recovery in the dual cohort progressed from 35.4% at 3 months (n = 32) to 42.3% at 6 months (n=19), 44.0% at 9 months (n=33), and 57.6% at 12 months (n = 12), compared with 40.7%, 59.3%, 39.5%, and 41.3% in the single cohort at the same intervals. Between-group differences were not statistically significant at any timepoint (12-month p = 0.914).

For hot discrimination, dual recovery increased from 54.4% at 3 months (n = 32) to 65.2% at 6 months (n = 19), 68.1% at 9 months (n = 33), and 76.3% at 12 months (n = 12), compared with 72.0%, 86.7%, 51.1%, and 60.0% in the single cohort, respectively (12-month p = 0.473).

On paired analysis within the dual cohort, select regions were no longer statistically different from baseline by 12 months. For cold, medial recovery reached 75% of baseline (p = 0.248). For hot, inferior, superior, and medial regions reached 83-92% of baseline (all paired p > 0.05).

Conclusions: These findings suggest that while dual coaptation may accelerate tactile recovery, thermal discrimination (i.e., protective sensation and burn risk) recovers gradually and appears less technique-dependent within the first year.

Background: Soft tissue irregularities can be a long-term source of aesthetic concerns after breast reconstruction. While several solutions exist to address contour deformities, persistent defects may remain even after adequate fat grafting techniques. Three-dimensional (3D) adipose grafting shows promise in fabricating patient-specific constructs to maintain volume stability with spatial accuracy. The technique has demonstrated efficacy in wound management, but evidence of its use in other areas of reconstructive surgery is limited (1). The aim of this study is to evaluate the feasibility of using a 3D-printed autologous minimally manipulated adipose graft to address residual defects after breast reconstruction in a series of three patients.

Methods: Three patients with residual lateral and inferior breast defects following breast reconstruction underwent elective structural fat grafting. Intraoperative imaging using the 3D printing application was used to measure and print a defect-specific biocompatible scaffold. After standard wet liposuction, processed lipoaspirate combined with thrombin was printed and integrated into the scaffold in sequence. The printed construct was allowed to polymerize while scar tissue within the defect was surgically released. The solidified bioprinted graft was then inserted and secured with 3-0 Monocryl sutures. Additional traditional lipofilling in 10 cc aliquots was performed around the scaffold to appropriately contour the area. Finally, skin was closed in standard fashion. Complications were assessed during the early postoperative period.

Results: Three patients aged 52, 56, and 57 years who had previously undergone oncoplastic reduction, implant-based reconstruction, and TRAM flap reconstruction, respectively, underwent 3D-printed fat grafting. A total of 150 – 300cc of autologous fat was harvested from the abdomen and thighs for each patient. The defects measured between 30 – 50 cm2. 3D-printed grafts composed of 5 – 40 cc of processed lipoaspirate were inserted into each defect. A total of 35 – 120 cc of additional processed lipoaspirate was used for supplementary contouring around the 3D grafts. The technique added an average of approximately 30 minutes to the operative time across the three cases. No complications were observed during the 30-day postoperative period. A biopsy of one patient's graft site was taken at 30 days which showed viable adipose tissue.

Conclusion: 3D-printed adipose grafting is a feasible method for addressing complex contour asymmetries that persist after breast reconstruction procedures. This novel technique provides the opportunity to achieve customizable projection and contour with standard internal architecture, mitigating technique-dependent variability that exists with traditional lipofilling. Future research is needed to examine the theoretical advantages in neovascularization and long-term retention rates among 3D-printed adipose grafts for breast defects.

1. Matsumura R, Matsumura H, Kawai Y, et al. Three-Dimensional Bioprinted Autologous Minimally Manipulated Homologous Adipose Tissue for Skin Defects After Wide Excision of Skin Cancer Provides Early Wound Closure and Good Esthetic Patient Satisfaction. J Clin Med. 2025;14(6):1795. Published 2025 Mar 7. doi:10.3390/jcm14061795

Introduction: Breast implant illness (BII) describes systemic symptoms reported by a subset of patients with breast implants. Prior database studies on BII are limited by inclusion of cancer populations receiving treatments causing systemic symptoms and lack of laboratory correlation (1). This study compares the incidence of patients seeking medical care for BII symptoms after breast implantation to case-matched controls and the proportion that result in explantation after symptom diagnosis as well as autoimmune laboratory data in a large, chemotherapy-excluded cohort.

Methods: The TriNetX US Collaborative Network database, comprising approximately 114 million patients across 67 healthcare organizations from 2007 to present, was queried to identify women with breast implants using CPT and ICD-10 codes. Patients with chemotherapy exposure were excluded. Implant patients were propensity-score matched to controls without implants based on age, body mass index, and thyroid disease. Patients who sought medical care for symptoms identified in the FDA Medical Device Report for BII, including fatigue, joint and muscle pain, cognitive dysfunction, headache, mood disorders, and hair loss, were compared. Explantation after symptom diagnosis and autoimmune laboratory abnormalities were evaluated.

Results: After matching, 91,613 patients were included per cohort. Breast implants were associated with slightly higher rates of fatigue (11.0% vs. 10.4%, p=0.0003), brain fog (0.90% vs. 0.73%, p<0.0001), mood disorders (14.1% vs. 13.1%, p<0.0001), and hair loss (2.49% vs. 1.86%, p<0.0001), but lower rates of joint and muscle pain (17.0% vs. 19.2%, p<0.0001) and headache (10.5% vs. 11.9%, p<0.0001). Overall symptom incidence was slightly lower in implant patients (27.6% vs. 28.5%, p=0.001). The median time from breast implantation to presentation of any BII symptom was 2.9 years. Patients with breast implants and BII symptoms had a relatively higher explantation rate compared to those without BII symptoms (12.3% vs 11.1%, p=0.020). Autoimmune laboratory results (ESR, CRP, and ANA) were not elevated among implant patients with BII symptoms.

Conclusion: While certain individual symptoms, including fatigue, cognitive dysfunction, mood disorders, and hair loss, were slightly more common in women with breast implants, there was no consistent pattern of systemic symptoms. Autoimmune laboratory abnormalities were uncommon. Explant rates were slightly increased in patients with implants and BII symptoms. These findings do not support the presence of a clinically meaningful systemic symptom syndrome associated with breast implants and provide important context to the ongoing clinical discussion of breast implant illness.

References: 1: Hemal K, Kabir R, Stanton E, et al. Breast Implant Illness (BII) As a Clinical Entity: A Systematic Review of the Literature. Aesthet Surg J Open Forum. 2024;6(Suppl 1):ojae007.073. Published 2024 Apr 12. doi:10.1093/asjof/ojae007.073

PURPOSE: Engineering patient-derived, three-dimensional (3D) in vitro breast cancer models holds significant potential for improving our understanding of cancer invasion within the native breast microenvironment. Our laboratory developed a tissue-engineered biomimetic breast platform incorporating patient-derived breast tissue components within a collagen matrix to recapitulate key elements of the native breast milieu. Now, we investigate tumor cell proliferation and migration behavior in plain collagen versus biomimetic (cell-containing) constructs, with specific focus on long-distance invasive behavior in two distinct breast cancer subtypes.

METHODS: Breast tissue from healthy patients undergoing reduction mammoplasty (n=6; mean age 34.5 years; mean BMI 33.99 kg/m²) was processed to isolate mature adipocytes, stromal vascular fraction, and ductal organoids, which were suspended in 0.3% type I collagen. Tri-layer 3D constructs (~50 µL total volume) were fabricated in 96-well plates and consisted of: 1) a base layer containing either triple-negative (MDA-MB-231) or estrogen receptor-positive (MCF-7) breast cancer cells tagged to red fluorescent protein, 2) a middle layer composed of either collagen alone ("Collagen") or collagen containing patient-derived breast tissue components ("Biomimetic"), and 3) a top layer containing human umbilical vascular endothelial cells. Constructs were imaged using fluorescent confocal microscopy on Day 1 to establish baseline tumor position, and again on Day 4; tumor cell counts were normalized to baseline (Day 4 / Day 1). Vertical migration was quantified using an Imaris™ machine-learning algorithm that reconstructed a regression plane and defined "migratory" cells as those located one standard deviation above or below the tumor layer's mean z-position. "Long-distance" migratory cells were defined as those traveling >100 µm above this plane. Mean migration distance among migratory cells was also calculated.

RESULTS: On Day 4, normalized tumor cell counts were comparable between Collagen and Biomimetic constructs for both MDA-MB-231 and MCF-7 cells. The overall percentage of migratory cells did not differ significantly between matrices for either subtype. In contrast, Biomimetic constructs were associated with greater invasion distance. For MDA-MB-231 cells, mean migration distance was increased (p<0.01), and the proportion of "long-distance" migratory cells (>100 µm) was significantly higher (p<0.05) in Biomimetic constructs compared with Collagen alone. For MCF-7 cells, Biomimetic constructs similarly exhibited greater mean migration distance (p<0.05) relative to Collagen controls.

CONCLUSIONS: Incorporation of patient-derived breast tissue components into this 3D platform alters breast cancer cell migration behavior. Although cell proliferation and overall proportion of migratory cells were comparable between Collagen and Biomimetic constructs, tumor cells within Biomimetic matrices exhibited a shift toward greater long-distance migratory behavior. This effect is observed not only in the highly aggressive triple-negative MDA-MB-231 breast cancer cell line but also in estrogen receptor-positive MCF-7 cells, which are traditionally considered to possess more limited invasive potential. These findings suggest that the biochemical composition of breast-derived microenvironmental components supports sustained and efficient long-distance migration, potentially uncovering invasive phenotypes not apparent in 2D or even 3D plain collagen models. Together, these data highlight the importance of incorporating patient-derived breast tissue elements into 3D culture platforms to better model clinically relevant breast cancer invasion.

Introduction: Modifier 22 was introduced to increase reimbursement for procedures requiring substantially greater work than typically expected. Prior analysis of modifier 22 has shown limited financial benefit, as potential payment increases are offset by increased denial. Plastic surgery is a particularly informative context in which to evaluate modifier 22, as it has among the lowest relative hourly compensation. This study evaluated modifier 22 utilization and reimbursement effects in microsurgical breast reconstruction and examined interactions with other commonly applied modifiers.

Methods: A retrospective analysis of the Physician/Supplier Procedure Summary dataset was performed. Autologous breast reconstruction billing units, defined by CPT 19364, were included in this cohort. Mixed-effects regression was employed to model mean payments and the probability of zero payment. Modifiers 50 (bilateral procedure) and 62 (dual surgeons) were included as covariates.

Results: A total of 4,239 billing units met inclusion criteria; 29.7% contained modifier 22, 28.3% modifier 50, and 29.1% modifier 62. Modifier 22 was not associated with a significant change in mean payment or the probability of nonpayment. Modifier 50 was associated with higher payments, whereas modifier 62 was associated with lower payments. Inflation-adjusted payments declined by 1.1% per year.

Conclusions: Modifier 22 is frequently used in autologous breast reconstruction but does not meaningfully affect Medicare reimbursement. High utilization despite limited financial benefit may reflect perceived procedural complexity in microsurgical reconstruction. Concurrent declines in inflation-adjusted reimbursement further exacerbate inadequate complexity adjustment within current payment models, which may discourage treatment of higher-complexity patients and worsen inequities in access to autologous breast reconstruction.

Oncoplastic reduction mammaplasty and mastopexy procedures are often utilized to remedy breast conservation therapy-related asymmetries (1). Immediate oncoplastic procedures have been shown to be significantly lower risk than delayed reduction mammaplasty or mastopexy procedures performed after partial mastectomies and adjuvant irradiation (2). Unfortunately, patients that present with delayed macromastia, ptosis, and/or asymmetry after breast irradiation may be denied these procedures due to a perception of excessive risks. We hypothesized that the risks of delayed reduction mammaplasty or mastopexy procedures in previously irradiated breasts are acceptable and should be offered to appropriate patients.

We performed a retrospective cohort review of all patients who underwent delayed reduction mammaplasty or mastopexy after prior partial mastectomy and irradiation of breasts at our institution between 2015-2025. Outcome measures were major and minor surgical complications, including reoperation, readmission, hematoma, seroma, infection, wound complications, and fat necrosis of ipsilateral (irradiated) or contralateral (non-irradiated) breast. Major complications were defined as any complication requiring reoperation or readmission or any wound complication that needed greater than six weeks to heal. Minor complications were any complications necessitating minimal to no outpatient management, fat necrosis, and wound complications that healed in six weeks or less. The difference in complication rates between irradiated vs non-irradiated breasts was evaluated using logistic regression models. All tests were two-sided with p value <0.05 considered to be statistically significant.

122 patients underwent reduction mammaplasty or mastopexy to 42 irradiated and 113 non-irradiated breasts. Overall complication rates for the irradiated breasts were higher than the nonirradiated group (38% vs 24%; OR, 2.3; p = .005). Major complication rates for the irradiated group were higher than the nonirradiated group (19% vs 9.7%; OR, 2.0; p = .029). Interestingly, the irradiated breasts had less minor wound complications noted than the non-irradiated breasts (7.1% vs. 16.0%); however, fat necrosis was significantly higher in the irradiated breasts compared to the non-irradiated breasts (21.4% vs. 3.5%).

Our results are consistent with prior studies that reported higher complication rates from delayed reduction mammoplasty or mastopexy procedures after irradiation when compared to immediate oncoplastic procedures. However, our results indicate that these delayed procedures are still relatively safe. Furthermore, complications such as fat necrosis may be partially attributed to the known risks of fat necrosis due to irradiation, independent of oncoplastic procedures (3). Nonetheless, delayed reduction mammoplasty or mastopexy procedures to the previously irradiated breast are safe and should be offered to the appropriate patient when indicated.

1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Version 1.2026. Published January 16, 2026. Accessed February 9, 2026.

2. Egro FM, Pinell-White X, Hart AM, Losken A. The use of reduction mammaplasty with breast conservation therapy: an analysis of timing and outcomes. Plast Reconstr Surg. 2015;135(6):963e-971e. doi:10.1097/PRS.0000000000001274

3. Nyirády LE, Czébely-Lénárt A, Hoferica J, et al. Evaluating oncoplastic breast-conserving surgery: oncological safety, risks, and satisfaction-a systematic review and meta-analysis. Sci Rep. 2025;16(1):444. Published 2025 Dec 2. doi:10.1038/s41598-025-30062-w

Background: Enhanced Recovery After Surgery (ERAS) protocols are increasingly utilized to optimize outcomes in microvascular breast reconstruction. Single-dose intraoperative methadone has demonstrated reductions in opioid requirements within ERAS pathways (1). Intrathecal morphine (ITM) has also emerged as a promising alternative for abdominally based free flap breast reconstruction (2). However, no prior study has directly compared intraoperative methadone and ITM within an ERAS framework. This study evaluates the impact of a single intraoperative methadone dose versus ITM on perioperative opioid use and hospital length of stay (LOS) in patients undergoing autologous breast reconstruction.

Methods: A retrospective review was conducted of patients undergoing abdominally based free flap breast reconstruction between January and June 2025. Patients who received a single weight-based intraoperative dose of methadone (n = 34) were compared to patients who received a single preoperative dose of intrathecal morphine (n = 50). All patients were managed within an ERAS protocol. Primary outcomes included intraoperative, postoperative, and total opioid consumption, reported in morphine milligram equivalents (MME). The secondary outcome was postoperative length of stay (LOS). Comparisons were performed using independent t-tests.

Results: Demographics and baseline clinical variables were comparable between groups. Intraoperative opioid use did not differ significantly between the methadone and ITM groups (14.6 vs 16.2 MME, p = 0.24). Postoperative opioid use was significantly lower in the methadone group (15.0 vs 31.4 MME, p = 0.0059), as was total opioid consumption (29.6 vs 47.6 MME, p = 0.0056). Length of stay was slightly longer in the methadone group (1.94 vs 1.48 days, p = 0.0005). No methadone or ITM-related adverse events were observed.

Conclusions: In this study, methadone significantly reduced postoperative and total opioid consumption compared to ITM, with a modest increase in length of stay that may not be clinically meaningful. While ITM is effective, its use often depends on the availability and efficiency of a regional anesthesia team, which may delay case start times and may complicate workflow. In contrast, intraoperative methadone is easily administered by the anesthesia team, requiring no additional coordination. Both methadone and intrathecal morphine offer substantial benefits and should be considered permanent components of the ERAS analgesic armamentarium for autologous breast reconstruction, tailored to institutional resources and workflow.

Reference: 1. Bernstein JL, Lu Wang M, Huang H, Otterburn DM. Intra-operative Methadone Decreases Post-operative Pain and Opioid Use in DIEP Flap Breast Patients: A New ERAS Protocol. Plast Reconstr Surg Glob Open. 2022;10(10 Suppl):92. doi:10.1097/01.GOX.0000898792.35273.f6 2. Swisher MW, Nguyen AT, Becker M, et al. Intrathecal Morphine vs Paravertebral Nerve Blocks for Analgesia After Breast Reconstruction With Abdominally Based Free Flaps. Aesthet Surg J. 2025;45(6):605-610. doi:10.1093/asj/sjaf043

Purpose:

Prophylactic mastectomy with immediate autologous- or implant-based reconstruction reduces breast cancer risk by up to 95% in high-risk patients.[1] Although disparities in prophylactic mastectomy utilization using race or insurance status have been described, composite, community-level measures of social vulnerability have not been evaluated as predictors for access to risk-reducing surgery. The CDC Social Vulnerability Index (SVI) quantifies deprivation across socioeconomic, household composition, minority status, and housing domains at the ZIP-code level.[2] The present study sought to evaluate the association between SVI and rates of prophylactic mastectomy within a breast reconstruction cohort.

Methods:

A retrospective analysis was performed of 1,059 patients who had undergone implant- or autologous-based breast reconstruction at a single academic institution between 2019 and 2023. Demographics, comorbidities, operative characteristics, and postoperative outcomes were collected. SVI was assigned by residential ZIP code and stratified into quartiles (Q1 = lowest vulnerability; Q4 = highest vulnerability). Prophylactic mastectomy utilization was compared across quartiles using chi-square analysis. Logistic regression models were constructed to evaluate the association between SVI and prophylactic mastectomy utilization, adjusting for age, BMI, race, and insurance status. To assess potential mediation by insurance type, preliminary and fully adjusted SVI odds ratios were compared. Findings were cross-validated using the Area Deprivation Index (ADI), an independent measure of neighborhood disadvantage.

Results:

Increasing social vulnerability was associated with a significant decline in prophylactic mastectomy utilization: Q1=10.2%, Q2=5.7%, Q3=3.0%, Q4=1.9% (p=0.0001). Patients within the lowest social vulnerability quartile (Q1) were more than five times as likely to undergo prophylactic mastectomy compared with those in the highest social vulnerability quartile (Q4). In univariate logistic regression, higher SVI was strongly associated with decreased odds of prophylactic mastectomy (OR=0.086, 95% CI 0.030–0.251, p<0.001). In multivariate analysis, SVI remained an independent inverse predictor (OR=0.20, 95% CI 0.06–0.65, p=0.008). Younger age (OR=0.96 per year increase, p<0.001) and lower BMI (OR=0.93 per unit increase, p=0.02) were also independently associated with increased utilization. Adjustment for insurance type attenuated the SVI effect size by 13%, suggesting that insurance status accounts for only a modest portion of the observed disparity. All four SVI subdomains were independently associated with reduced utilization (all p<0.005). Cross-validation using ADI demonstrated a similar inverse association (ADI Q1=7.4% vs. ADI Q4=3.4%; r=−0.078, p=0.017).

Conclusions:

Prophylactic mastectomy utilization demonstrates a marked inverse association with increasing social vulnerability, independent of demographic and insurance factors. These findings suggest that barriers to risk-reducing care extend beyond race and insurance inequities. Broader dimensions of social vulnerability – including structural access to genetic counseling, health literacy, and care navigation – may contribute to inequities in prophylactic care. Surgeons, clinicians, and healthcare systems should prioritize equitable access to genetic risk assessment and prophylactic counseling in socially vulnerable communities.

References [1] Surgery to Reduce the Risk of Breast Cancer - NCI. July 3, 2024. Accessed February 23, 2026. https://www.cancer.gov/types/breast/causes-risk-factors/prevention/preventive-breast-surgery [2] Flanagan BE, Gregory EW, Hallisey EJ, Heitgerd JL, Lewis B. A Social Vulnerability Index for Disaster Management. J Homel Secur Emerg Manag. 2011;8(1):0000102202154773551792. doi:10.2202/1547-7355.1792