Scientific Abstract Presentations: Breast Session 4 Friday, October 16 Fri, Oct 16 8:00-9:30 a.m. CDT

Introduction: Postoperative infection in tissue expander (TE) based breast reconstruction remains a primary cause of reconstructive failure and increased morbidity. The management of these infections is particularly challenging due to the formation of bacterial biofilm on the implant surface, which can increase resistance to systemic therapy. While local drug-eluting delivery systems, such as polymethyl methacrylate (PMMA) antibiotic discs, have been shown to reduce infection rates, the microbial characteristics of breakthrough infections are poorly understood. Thus, this study aims to examine the microbial profiles and antibiotic susceptibilities associated with postoperative infection following TE-based breast reconstruction with and without antibiotic discs.

Methods: A retrospective review was conducted on patients undergoing post-mastectomy TE-based breast reconstruction performed by a single surgeon at a single institution between 2017 and 2024. Patients were stratified based on the use of tobramycin-vancomycin PMMA antibiotic discs (AD), started in 2021, versus no antibiotic discs (N-AD). 1:1 propensity score matching was performed, adjusting for age, BMI, smoking status, 5-item modified frailty index (mFI-5), neoadjuvant radiation therapy, and acellular dermal matrix use. Postoperative infection was defined by the presence of clinical symptoms (e.g., erythema, warmth, purulent drainage) and leukocytosis. When available, aerobic and anaerobic cultures were reviewed and microbial isolates and antibiotic susceptibilities were recorded. Microbial diversity and resistance patterns were compared between cohorts.

Results: 260 patients were included in our study (130 per matched cohort). 60-day acute postoperative infection rate was higher in the N-AD cohort than in the AD cohort (12% vs 3%, p = 0.04). Among infections with available cultures, 45% (n=5/11) in the N-AD cohort and 50% (n = 2/4) in the AD cohort demonstrated no growth. When evaluating all infections, not limited to the 60-day acute timeframe, median time to infection was significantly shorter in the N-AD group (45 vs 71 days, p = 0.02). Notably, the AD cohort demonstrated a greater number of unique microbial organisms, including atypical fungal (Candida parapsilosis) and acid-fast organisms (Mycobacterium fortuitum). All identified Staphylococcus aureus isolates demonstrated resistance to penicillin, but isolates in the AD cohort showed additional resistance patterns, with only 60-80% susceptibility to standard therapeutic agents (Clindamycin, Gentamicin, Erythromycin).

Conclusions: Culture-positive infections in TE-based reconstructions with antibiotic discs included atypical organisms and S. aureus isolates with resistance to multiple standard agents. All reconstructions were subject to levels of culture-negative growth, which may prompt further consideration of how biofilms or fastidious organisms may play a role in overall infection etiology. Although antibiotic discs are effective prophylactic mechanisms for acute infection, clinicians should be cognizant of how selective pressure may influence empirical antibiotic selection and potential resistance patterns.

Background: Patients undergoing mastectomy commonly pursue breast reconstruction, but the relative utilization of implant and autologous techniques remains poorly characterized. Previous studies faced notable data limitations, with minimal representation of delayed reconstructions and/or coverage of only a single patient setting (1,2). This study re-evaluates national breast reconstruction trends using a longitudinal study design with multi-setting representation. We hypothesize that from 2010 to 2020, implant-based techniques will constitute the majority of breast reconstructions but will not demonstrate further relative increases over autologous techniques.

Methods: A retrospective longitudinal cohort study was constructed from a national insurance claims dataset. Female patients were included if they were diagnosed with or at increased risk of breast cancer, underwent mastectomy between 2010 and 2020, and had at least 2 years of active database enrollment after mastectomy. Trends in the type of reconstruction (implant or autologous), timing of reconstruction (immediate, staged, or delayed), subtype of autologous surgery (i.e., flap donor site), and specialty of the operating surgeon (plastic or general surgeon) were assessed via linear regression.

Results: A total of 324,013 patients (median age, 58.0) were included. Among the 2020 mastectomy patients, 44.9% underwent reconstruction within two years – representing a 6.9% net increase from 2010 (β = 0.567%; p = 0.002). Implant and autologous reconstructions comprised 76% and 24% of identified reconstructions, respectively, and there were no significant trends in these proportions over the 2010-2020 period (p = 0.465). Concerning the timing of reconstruction, the relative proportion of immediate implant reconstructions increased from 16.7% to 31.4% over the 10-year period (β = 1.48%; p<.001). In parallel, the relative proportion of staged autologous reconstructions increased from 14.6% to 31.9% (β = 1.44%; p<.001). During 2010-2020, the DIEP flap became the predominant autologous subtype, increasing from 25.2% to 71.8% of inpatient autologous surgeries (β = 4.86%; p<.001). General surgeons performed a minority (2.7%-5.3%) of implant, tissue expander, and autologous reconstructions, with modestly increasing participation in implant (β = 0.098%; p = 0.006) and tissue expander reconstructions (β = 0.105%; p = 0.046).

Conclusions: As overall reconstruction rates rose by 6.9% during the 2010-2020 period, the ratio of implant-to-autologous surgeries remained stable at approximately 3:1. This finding diverges from previous reports of increasing implant proportions, which could represent a true shift in reconstructive patterns or may reflect improvements in fundamental study design. While implant-to-autologous proportions remained stable, shifts in the timing of reconstruction were highly dynamic, with a doubling in the relative rates of both immediate implant and staged autologous reconstructions.

References: 1. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15-23. doi:10.1097/PRS.0b013e3182729cde 2. Wong SM, Chun YS, Sagara Y, Golshan M, Erdmann-Sager J. National Patterns of Breast Reconstruction and Nipple-Sparing Mastectomy for Breast Cancer, 2005-2015. Ann Surg Oncol. 2019;26(10):3194-3203. doi:10.1245/s10434-019-07554-x

Purpose: Stage IV breast cancer patients have been historically considered ineligible for reconstruction following mastectomy. Recent literature, however, has begun to show comparable surgical outcomes and improved quality of life following reconstruction, regardless of tumor staging, but face limitations in the small sample sizes of stage IV reconstructive patients (1-4). Using a decade of NSQIP data, this retrospective study aims to clarify the profile and surgical outcomes of stage IV patients undergoing immediate free flap breast reconstruction.

Methods: Ten years of NSQIP participant user file (PUF) data from January 2015 to December 2024 were filtered to include mastectomy using current procedural terminology (CPT) codes 19301-19307 with concurrent reconstructive code 19364 (breast reconstruction with free flap) to capture immediate free flap reconstruction. To minimize confounding, cases with concurrent surgical procedures unrelated to breast reconstruction, active infection, contaminated or dirty wounds, male sex, and emergent/non-elective surgery were excluded. Statistical analysis was performed using Chi-square and/or independent t-tests in STATA 15 with significance at alpha < 0.05.

Results: Among 6,177 patients undergoing immediate breast reconstruction post-mastectomy with free flap reconstruction, 6,109 stage 0-III and 69 stage IV cases were identified. Demographics and preoperative risk factors were similar between groups, except for steroid therapy, which was more common among the stage IV population (12%, n=8; p<0.001). Additionally, stage IV patients more frequently received unilateral surgery (88%, n=61) than stage 0-III patients (54%, n=3,313; p<0.001). Finally, no significant differences were observed in 30-day surgical outcomes between the two groups, including unplanned reoperation, unplanned readmission, surgical site infection, and dehiscence.

Conclusions: Breast reconstruction enhances quality of life for all breast cancer patients following mastectomy; however, patients with stage IV disease have been historically denied breast reconstruction due to perceived surgical risk (1, 4).This ten-year retrospective analysis of free flap reconstruction reinforces findings of prior literature on a larger scale: eligible stage IV breast cancer patients do not exhibit different 30-day outcomes than other tumor stages following immediate breast reconstruction.

References: 1. Asaad M, Meaike J, Yonkus J, et al. Breast Reconstruction in the Setting of Stage 4 Breast Cancer: Is It Worthwhile? Ann Surg Oncol. 2020;27(12):4730-4739. doi:10.1245/s10434-020-08879-8 2. Weiss A, Chu CK, Lin H, et al. Reconstruction in the Metastatic Breast Cancer Patient: Results from the National Cancer Database. Ann Surg Oncol. 2018;25(11):3125-3133. doi:10.1245/s10434-018-6693-1 3. Talwar AA, Mazzaferro D, Morris MP, et al. The Impact of Breast Cancer Type, Staging, and Treatment on Vascular Complications of Immediate Free-Flap Breast Reconstruction. Ann Plast Surg. 2023;90(6S):S556-S562. doi:10.1097/SAP.0000000000003411 4. Hespe GE, Matusko N, Hamill JB, Kozlow JH, Pusic AL, Wilkins EG. Outcomes of breast reconstruction in patients with stage IV breast cancer. J Plast Reconstr Aesthet Surg. 2023;83:51-56. doi:10.1016/j.bjps.2023.04.032

Purpose: Targeted nipple reinnervation (TNR) at implant exchange may enhance sensory recovery in implant-based breast reconstruction. We evaluated composite and regional tactile outcomes following T3/T4 coaptation to the nipple dermis.

Methods: A retrospective cohort of patients undergoing tissue expander-to-implant exchange (December 2023-2025) was identified. TNR breasts underwent T3 or T4 coaptation to the nipple dermis at the time of exchange. Non-TNR breasts underwent implant exchange alone. Breast-level analysis was performed using pressure-specified sensory device measurements (g/mm2), transformed into a sensation score where higher values reflect greater sensitivity (0-100). Composite scores reflect the mean of nine tested regions. Outcomes were assessed at 0-3, 4-7, and 8-14 months following implant exchange. Welch t-tests were used for between-group comparisons.

Results: Twenty-nine patients (57 breasts; 13 TNR, 16 non-TNR) met inclusion criteria. TNR patients were younger at implant exchange (41.0 ± 9.9 vs 48.3 ± 10.1 years; p = 0.009). BMI, smoking, diabetes, radiation exposure, plane, implant material, acellular dermal matrix use, implant size, and mastectomy-to-implant interval (5.46 ± 3.12 vs 5.23 ± 2.97 months; p = 0.72) were similar.

Baseline composite tactile scores were similar between groups (p = 0.89). At 0-3 months, composite tactile scores were 36.7 ± 23.7 in TNR and 34.9 ± 21.8 in non-TNR breasts (p = 0.85). At 4-7 months, TNR scores were 34.1 ± 22.6 versus non-TNR 37.6 ± 16.6 (p = 0.86). At 8-14 months, composite scores favored TNR (56.4 ± 10.5) compared to non-TNR (43.0 ± 17.9), demonstrating a 13-point difference (p = 0.10). NAC sensation at 0-3 months was 30.7 ± 34.3 in TNR versus 15.1 ± 25.6 in non-TNR breasts (p = 0.23). At 8-14 months, NAC scores were 45.4 ± 29.6 versus 35.8 ± 28.8 (p = 0.60).

Prospective BREAST-Q Sensation module data collection is ongoing and will allow correlation of objective tactile recovery with patient-reported sensory outcomes as follow-up matures.

Conclusions: In this early cohort, TNR was associated with numerically higher composite tactile recovery at 8-14 months and earlier improvement in NAC sensation. Larger cohorts with longer follow-up are required to determine whether these trends represent durable sensory benefit.

Purpose Obesity is a well-established risk factor for postoperative complications in breast reconstruction, typically defined using a body mass index (BMI) threshold of ≥30 kg/m². However, it remains unclear whether complication risk increases earlier along the BMI spectrum in contemporary reconstructive populations. We evaluated whether a data-driven BMI threshold more precisely identifies patients at increased risk of postoperative morbidity following breast reconstruction.

Methods We performed a retrospective cohort study of post-mastectomy breast reconstructions performed within a single hospital network from January 2020 to January 2026. Receiver operating characteristic (ROC) analysis was used to evaluate the discriminative ability of BMI for major postoperative complications. The optimal BMI threshold was identified using Youden's index. Complication rates were compared using chi-square testing. Multivariable logistic regression assessed independent association after adjustment for reconstruction type, comorbidity burden, and nutritional risk score. Stratified analyses evaluated whether BMI-associated risk varied by comorbidity burden (<3 vs ≥3 conditions).

Experience One hundred consecutive breast reconstructions were analyzed, including 63 implant-based and 37 autologous procedures. Mean age was 57.43 ± 11.99 years. Median BMI was 27.45 kg/m² (IQR 17.00). Postoperative complications occurred in 58% of patients, and reconstruction failure occurred in 11%.

Results BMI alone demonstrated modest discriminatory ability for major complications (AUC 0.587). However, ROC analysis identified an optimal BMI threshold of 26.65 kg/m² (Youden index 0.274). Patients with BMI ≥26.65 kg/m² experienced significantly higher complication rates compared with those below this threshold (70.4% vs 43.5%; χ²=7.37, p=0.007), representing a 62% relative increase in risk. In multivariable logistic regression adjusting for reconstruction type, comorbidity burden, and nutritional risk score, BMI ≥26.65 kg/m² remained independently associated with major complications (OR 4.67, 95% CI 1.62–13.46, p=0.004). No independent associations were observed for reconstruction type, comorbidity burden, or nutritional risk score. Stratified analysis demonstrated that the BMI threshold significantly predicted complications among patients with lower comorbidity burden (<3 conditions; p=0.016) but not among those with higher comorbidity burden (≥3 conditions; p=0.145).

Conclusions A data-driven BMI threshold in the overweight range independently predicted postoperative complications following breast reconstruction, with risk elevation below the traditional obesity cutoff. This directly challenges recent findings that suggest BMI alone is not predictive below 35 kg/m² [1,2]. BMI-associated risk appears most pronounced among patients with lower baseline comorbidity burden, indicating body habitus may be a particularly important determinant of outcomes in otherwise medically stable patients.

References Yamin M, Puducheri S, Colarusso B, et al. Defining a safe body mass index threshold in plastic surgery: an NSQIP analysis of BMI, comorbidities, and complication risk in plastic surgery patients. Ann Plast Surg. 2026 Feb 13. doi:10.1097/SAP.0000000000004687 Tobin MJ, Mustoe AK, Ahn S, et al. Body mass index, comorbidities, and the new Lancet obesity definition: implications for risk analysis in plastic and reconstructive surgery. Plast Reconstr Surg. 2026 Jan 21. doi:10.1097/PRS.0000000000012830

Purpose: Autologous breast reconstruction with a deep inferior epigastric perforator (DIEP) flap has high success rates; however, venous congestion can compromise flap viability. The benefit of routinely performing a second venous anastomosis remains uncertain.

Methods: We conducted a retrospective cohort study of DIEP flap breast reconstructions performed at a single academic center between 2015 and 2023. Flaps were categorized by venous configuration (single vs dual venous anastomoses). The primary outcome was total flap loss. Secondary outcomes included partial flap loss, venous complications, fat necrosis, hematoma, infection, wound dehiscence, take-back surgery, and at least one postoperative complication. Multivariable logistic regression explored factors associated with postoperative morbidity.

Results: A total of 349 DIEP flaps were analyzed (288 single-vein; 61 dual-vein). Total flap loss was rare (0.9%) and did not differ between groups (1/61 vs 2/288, p=0.439). At least one complication occurred in 30% of flaps, with no significant difference between venous configurations (80/288 vs 24/61, p=0.073). Rates of venous events, fat necrosis, infection, hematoma, wound dehiscence, and take-back surgery were comparable. Partial flap loss was more frequent in dual-vein reconstructions (28/288 vs 12/61, p=0.027), likely reflecting greater case complexity. Operative time was also longer in this group (597.0 [533.0–684.0] vs 502.0 [454.0–582.5] minutes, p<0.001). On multivariable analysis, hypertension was independently associated with at least one complication (adjusted OR 2.40, 95% CI 1.27–4.40, p=0.007), whereas venous configuration was not.

Conclusion: In routine practice, dual venous anastomosis was preferentially used in more complex DIEP flap reconstructions and was not associated with lower rates of flap loss or overall complications.

Purpose: Submuscular implant-based breast reconstruction remains a dependable technique following mastectomy but is associated with persistent complications including animation deformity, implant malposition, and muscle-related pain, leading to aesthetic distortion and reduced patient satisfaction. Conversion to a prepectoral implant pocket has gained acceptance as a corrective option, offering improved contour and restoration of natural breast dynamics. Although primary prepectoral reconstruction is well established, evidence regarding its role as a secondary conversion strategy remains limited. The expander-to-implant exchange or revision setting provides an opportunity to address these complications once mastectomy flaps have matured and adequate soft-tissue coverage has developed. This study evaluates the indications, surgical technique, and clinical outcomes of submuscular-to-prepectoral implant conversion with selective fat grafting.

Methods: A two-year retrospective review was conducted of all patients who underwent pocket conversion from submuscular to prepectoral implant placement at a single institution between January 2023 and October 2025. The study population included patients undergoing expander-to-implant exchange in whom animation deformity, implant displacement, or rippling was identified, as well as patients with prior submuscular reconstructions performed elsewhere who presented for revision.

All procedures were completed under general anesthesia without the use of ADM. The previous incision, most commonly inframammary or periareolar, was reopened and the capsule entered. The existing implant or tissue expander was removed, and the pectoralis major muscle was released from its inferior and lateral attachments. A new prepectoral pocket was then developed superficial to the pectoralis while maintaining flap thickness and vascularity. The pectoralis muscle was secured to the chest wall with absorbable sutures to restore its anatomic position and eliminate animation deformity. When capsular contracture or adherence was present, selective capsulotomy or limited capsulectomy was performed to improve implant positioning and contour. Fat grafting was added in select patients to enhance upper pole coverage or correct contour irregularities. Smooth, round silicone implants were inserted using a Keller funnel and a no-touch technique. Drains were not routinely required, and patients were placed in supportive garments after surgery. Collected data included patient demographics, surgical indications, operative details, use of fat grafting, and postoperative outcomes.

Results: Twenty-six patients (50 breasts) underwent pocket conversion. Mean age was 47.2 years and mean BMI was 24.6 kg/m². Fat grafting was performed in 34.6% of patients. The most common indication was animation deformity (50%), followed by implant malposition, displacement, rippling, contour distortion, and deformity related to prior capsular contracture. Seven postoperative complications occurred. Four patients developed capsular contracture, three with a prior history. One hematoma occurred in a previously radiated patient. One hypertrophic scar and one case of persistent inferior implant migration requiring revision were observed. No infections, seromas, or implant losses occurred. Resolution of the presenting deformity was achieved in all remaining cases, with high patient satisfaction.

Conclusion: Prepectoral pocket conversion is a reliable solution for correcting functional and aesthetic complications of submuscular breast reconstruction. Most adverse events occurred in patients with prior capsular contracture or radiation exposure. This technique effectively resolves implant-related deformities while maintaining low complication rates and providing durable, reproducible aesthetic improvement.

Introduction Surgical site infections (SSI) following implant-based breast reconstruction (IBBR) can lead to implant removal in some cases. Patients are often discharged with extended courses of prophylactic oral antibiotics in an effort to prevent these complications, though it has been shown that prolonged antibiotic use can sometimes lead to an increased risk of adverse events and resistance. Thus, there is no consensus on whether antibiotics should be prescribed at discharge in these patients. Therefore, the objective of this study was to evaluate whether postdischarge prophylactic oral antibiotics following IBBR reduced the risk of SSI or implant removal due to infection and influenced time to SSI.

Methods All female patients who had undergone IBBR at a single academic center between 2014 and 2023 were included. Patients were stratified into groups based on duration of postdischarge: none (inpatient antibiotics only), 1-7 days postdischarge, or ≥8 days postdischarge. Demographics, comorbidities, and operative details were collected. The primary outcomes were SSI and implant removal due to infection. Outcomes were compared with Pearson chi-square or Fischer's exact test for categorical variables, and Mann–Whitney U for continuous variables. Kaplan-Meier analysis evaluated time to SSI. As a proxy for SSI severity, treatment type (oral, intravenous, or both) was collected. Multivariable logistic regression was utilized to adjust for confounders. Significance was set at p<0.05.

Results Among 527 who underwent IBBR, 10.4% (n=55) received inpatient antibiotics only, 63.6% (n=335) received 1-7 days of postdischarge antibiotics, and 25.8% (n=136) received ≥8 days. There were no differences observed between groups in rates of postoperative SSI (3.6% inpatient only vs 9.2% 1-7 days vs 5.1% ≥8 days; p = 0.160) or implant removal due to infection (3.6% inpatient only vs 2.7% 1-7 days vs 0.7% ≥8 days; p = 0.341). Kaplan-Meier analysis demonstrated no difference in time to SSI based on antibiotic duration (p=0.163). Additionally, SSI treatment type did not differ between antibiotic duration groups (p=0.765).

Conclusion Postdischarge prophylactic oral antibiotics may not decrease the risk of surgical site infection or need for implant removal following implant-based breast reconstruction. Additionally, the timing to SSI diagnosis and severity of infection did not differ with postdischarge prophylactic antibiotics. Therefore, surgeons should consider avoiding extended courses of prophylactic antibiotics following implant-based breast reconstruction.

Background: Breast cancer is the most commonly diagnosed cancer among women in the United States, excluding non-melanoma skin cancers, and ranks as the second leading cause of cancer related deaths.1 Surgical intervention may involve various techniques, including tissue expander (TE) and implant-based reconstruction which is estimated to constitute nearly 65% of all breast reconstructions procedures performed in the United States.2 While autologous breast reconstructions have advantages in aesthetic outcomes, long-term satisfaction, and the ability to avoid future implant replacement and specific complications associated with their placement, TE-based reconstructions have the advantages of shorter operative time, faster recovery, and avoidance of donor site morbidity.2–5

Operative duration has been associated with increased risk of postoperative complications in various surgical disciplines. However, its relationship with adverse outcomes in tissue expander–based (TE) breast reconstruction remains underexplored.

Methods: We conducted a retrospective cohort analysis of 1,874 patients (633 unilateral, 1,241 bilateral) undergoing TE–based breast reconstruction. We evaluated the association between operative time and 30-day postoperative outcomes including hematoma, seroma, mastectomy skin flap necrosis (MSFN), unplanned readmission, surgical site infection (SSI), and unplanned reoperation. Logistic regression models were used to estimate odds ratios (OR) for each outcome per 10-minute increase in operative duration for unilateral and bilateral cases, respectively. Both unadjusted and hierarchical adjusted models were constructed.

Results: Among unilateral cases, a 10-minute increase in operation duration was significantly associated with higher odds of MSFN (aOR: 1.04; 95% CI, 1.01-1.07) and unplanned reoperation (aOR: 1.04; 95% CI, 1.01-1.06). In bilateral cases, operative duration per 10-minute increase demonstrated similar results with statistically significant increases in MSFN (OR: 1.03; 95% CI, 1.00-1.05), unplanned readmission (aOR: 1.02; 95% CI, 1.00-1.04), and SSI (OR: 1.02; 95% CI, 1.00-1.03).

Conclusions: Longer operative time was consistently associated with increased odds of MSFN in both unilateral and bilateral TE–based breast reconstructions. These findings suggest that operative duration may serve as a modifiable risk factor or marker of case complexity. Further investigation is warranted to determine causal mechanisms and whether reducing operative time may mitigate risk.

References CDC. Breast Cancer Statistics. Breast Cancer. June 10, 2025. Accessed August 7, 2025. https://www.cdc.gov/breast-cancer/statistics/index.html 2. Bertozzi N, Pesce M, Santi P, Raposio E. Tissue expansion for breast reconstruction: Methods and techniques. Ann Med Surg. 2017;21:34-44. doi:10.1016/j.amsu.2017.07.048 3. Sungkar A, Yarso KY, Nugroho DF, Wahid DI, Permatasari CA. Patients' Satisfaction After Breast Reconstruction Surgery Using Autologous versus Implants: A Meta-Analysis. Asian Pac J Cancer Prev APJCP. 2024;25(4):1205-1212. doi:10.31557/APJCP.2024.25.4.1205 4. Stefura T, Rusinek J, Wątor J, et al. Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients. J Plast Reconstr Aesthetic Surg JPRAS. 2023;77:346-358. doi:10.1016/j.bjps.2022.11.044 5. Alsubhi FS, Alothman MA, Alhadlaq AI. The International Awareness of Breast Reconstruction. Plast Reconstr Surg Glob Open. 2023;11(11):e5417. doi:10.1097/GOX.0000000000005417

Background: The Goldilocks mastectomy provides autologous breast mound reconstruction using redundant mastectomy skin flaps and offers a simplified reconstructive option for patients with obesity, diabetes, and other medical comorbidities (1-3). Increasingly, this technique is combined with nipple–areolar complex (NAC) preservation and/or immediate tissue expander placement (4). However, complication profiles and patient-specific risk factors in these modified approaches remain incompletely defined. This study evaluates outcomes and predictors of complications following Goldilocks mastectomy with and without NAC preservation and immediate tissue expander placement. Methods: A single-institution retrospective cohort study was conducted of patients undergoing Goldilocks mastectomy by a single surgeon from August 2021 to June 2024. Procedures were categorized as Goldilocks alone, NAC-sparing Goldilocks, Goldilocks with immediate tissue expander placement, and NAC-sparing Goldilocks with immediate tissue expander placement. All expanders were placed in the prepectoral plane without acellular dermal matrix. Primary outcomes included postoperative complications. Statistical analysis assessed associations between patient factors and complications. Results: Twenty-six patients (41 breasts) were included, with a median age of 56 years (IQR 49–63.8) and median body mass index (BMI) of 33.8 kg/m² (IQR 30.3–40.4). Mean follow-up was 6 months. Hypertension, hyperlipidemia, and diabetes were the most common comorbidities. Overall complications occurred in 12 breasts (29.3%). Major complications occurred in 19.5% (n=8), including infection (n=5), mastectomy skin flap necrosis (n=2), and wound dehiscence (n=1). These events resulted in seven tissue expander removals across four patients. Minor complications occurred in 9.8% (n=4). Complication rates varied by reconstructive strategy. Goldilocks alone demonstrated a 16.7% complication rate. Goldilocks with immediate tissue expander placement demonstrated a 22% complication rate, while NAC-sparing Goldilocks with immediate tissue expander placement demonstrated a 66.7% complication rate. NAC-sparing Goldilocks without expander placement demonstrated a 9.1% complication rate. Diabetes was significantly associated with mastectomy skin flap necrosis (p=0.0092). Trends toward increased infection and reoperation were observed in patients with advanced age, hypertension, and elevated BMI. Eleven breasts underwent staged autologous reconstruction following Goldilocks mastectomy, including lateral intercostal artery perforator (LICAP) or deep inferior epigastric perforator (DIEP) flaps. In 36% of these cases, DIEP reconstruction was used to salvage prior expander loss. Conclusions: Goldilocks mastectomy remains a valuable reconstructive option for high-risk patients. However, combining NAC preservation and immediate prepectoral tissue expander placement substantially increases complication rates, particularly in patients with diabetes. These findings support careful patient selection and favor a staged reconstructive approach in medically complex individuals. References: 1. Richardson H, Ma G. The Goldilocks mastectomy. Int J Surg Lond Engl 2012;10(9):522-526. 2. Oliver JD, Chaudhry A, Vyas KS, Manrique OJ, Martinez-Jorge J. Aesthetic Goldilocks mastectomy and breast reconstruction: promoting its use in the ideal candidate. Gland Surg 2018;7(5):493-495. 3. Chaudhry A, Oliver JD, Vyas KS, Alsubaie SA, Manrique OJ, Martinez-Jorge J. Outcomes analysis of Goldilocks mastectomy and breast reconstruction: A single institution experience of 96 cases. J Surg Oncol 2019;119(8):1047-1052. 4. Setit A, Bela K, Khater A, Elzahaby I, Hossam A, Hamed E. Nipple sparing Goldilocks mastectomy, a new modification of the original technique. Eur J Breast Health 2023;19(2):172-176.

Purpose: Patients who elect to undergo post-mastectomy breast reconstruction (PMBR) have multiple surgical options to choose from, each with a different surgical timeline. Patients who opt to undergo immediate PMBR at the time of mastectomy have the option of choosing between a staged approach involving tissue expanders (tissue expander-based reconstruction, or TE-BR), or a one-step approach involving immediate implant placement at the time of mastectomy (direct-to-implant reconstruction, or DTI). Literature surrounding the relative risks and benefits of these two approaches is heterogenous; while some studies have reported fewer postoperative complications among DTI patients, others have reported higher complication rates among DTI patients, or no difference at all. To contribute to this discussion, we utilized a large nation-wide database to compare postoperative complication rates among immediate TE-BR and DTI patients.

Methods: We conducted a retrospective cohort study using the TriNetX Research Network-a global federated database of de-identified electronic health records. Adult female patients (≥18 years) who underwent immediate PMBR between 2006 and 2026 were isolated and stratified into two cohorts-those who underwent TE-BR, and those who underwent DTI. These cohorts underwent 1:1 propensity score matching for age and obesity. Postoperative outcomes of interest included surgical site infection (SSI), thromboembolic events (DVT/PE), bleeding/hematoma, seroma, wound dehiscence, fat necrosis, surgical revision, prosthetic removal, and overall postoperative complication rate. These outcomes were analyzed in the first 30, 60, and 90 days after mastectomy date.

Results: A total of 48,960 patients who underwent immediate PMBR were identified in the TriNetX Research Network-30,910 who underwent TE-BR at the time of mastectomy, and 18,050 who underwent DTI. Propensity score matching yielded 17,546 matched pairs that were used for subsequent analyses. The overall rate of complications was comparable between the two cohorts in the first 30 days but were significantly higher in the TE-BR cohort at 60 days (19.2% vs.15.7%, p<0.001) and at 90 days (22.4% vs. 17.3%, p<0.001). SSI risk was significantly higher in the TE-BR cohort across all timepoints (p<0.001), as was the risk of DVT/PE (p≤0.019), bleeding or hematoma formation (p<0.001), seroma formation (p<0.001), wound dehiscence (p≤0.01), and fat necrosis (p≤0.001). The risk of requiring prosthetic removal was also significantly higher in the TE-BR cohort across all timepoints (p<0.001). Surgical revision rate was higher in the TE-BR cohort, but only reached significance for the 60-day and 90-day timepoints (p≤0.001).

Conclusion: In the context of immediate PMBR, TE-BR was associated with a significantly higher risk of postoperative complications across multiple timepoints after mastectomy. Specifically, it was associated with a higher risk of DVT/PE, bleeding/hematoma formation, seroma formation, wound dehiscence, fat necrosis, surgical revision, and need for prosthetic removal. To our knowledge, this represents the largest study to-date comparing early postoperative risks between TE-BR and DTI. These findings could play an important role in the preoperative patient education process when comparing the surgical options available for patients who opt to undergo immediate PMBR. Future prospective observational studies are warranted to further validate these conclusions.

Purpose Recovery of breast sensation after mastectomy and reconstruction is critical for quality of life and protection from thermal injury. However, patterns of sensory recovery over time remain poorly characterized. We aimed to characterize the timeline and pattern of sensory return following conventional, non-neurotized breast reconstruction.

Methods Post-mastectomy patients were assessed from June 2025 to January 2026. Light touch was measured using Semmes-Weinstein monofilaments (SWMF) across nine regions per breast; temperature sensation (hot/cold) was evaluated in five regions. Outcomes included minimal monofilament threshold per breast, temperature return, and mislocalization. Results were summarized by postoperative interval: Early (<6 mo), Intermediate (6-12 mo), 1 year, 2-5 years, 5+ years. Statistical analyses included ANOVA, linear regression, t-tests, chi-square tests, and logistic regression.

Results A total of 235 patients (407 breasts) were included (mean age 56.0 ± 11.6 years; mean follow-up 43.8 ± 59.6 months). The cohort included 389 post-mastectomy breasts (329 alloplastic, 45 autologous, 5 combination, 6 explant, and 4 flat closure) and 18 native breasts as controls.

Light touch recovery: 20.6% of post-mastectomy breasts demonstrated normal touch in at least one region; 50.9% had protective sensation. Light touch threshold significantly improved over time (ANOVA p <0.001). Early breasts (<6 mo) had worse protective sensation than 1-year breasts (difference 0.49, p = 0.003). No significant differences were observed beyond 1 year, suggesting a plateau, although continuous analysis showed gradual improvement over time (β = -0.00175 per month, p<0.01). No differences were seen between autologous and alloplastic reconstruction (p = 0.16).

Temperature recovery: Temperature recovery increased with time and correlated strongly with light touch return (p < 0.001). Cold detection increased significantly from Early to 1-year breasts (54% to 86%, p < 0.001), whereas hot detection trended toward improvement (63% to 74%, p = 0.245). Early breasts had significantly lower odds of cold return compared with 1-year breasts (OR = 0.19, p = 0.0003).

Localization: Mislocalizations occurred most frequently to non-breast sites. Breasts with ≥50% light touch detection had lower mislocalization rates (17.8% vs 33.1%, p < 0.001). Lower SWMF thresholds predicted increased mislocalization (p = 0.003), independent of postoperative interval.

Conclusions Breast sensation improves spontaneously after mastectomy, with the greatest gains within the first postoperative year. Cold recovery occurs earlier and more consistently than hot, which is slower and more variable. These data provide the first quantitative, time-resolved benchmarks for sensory recovery, informing patient counseling and guiding development of future sensory-optimizing reconstruction techniques.

Background: Obstructive sleep apnea (OSA) is a chronic upper airway condition often resulting in intermittent nocturnal hypoxic events leading to cardiovascular, metabolic, and cognitive complications. Additionally, OSA has been associated with increased perioperative morbidity across a variety of surgical specialties. However, its effects among patients undergoing reduction mammoplasty remain poorly understood. As there exists a high prevalence of obesity and OSA among patients undergoing breast reduction, understanding the effects of OSA on postoperative outcomes is critical to optimizing patient selection and understanding postoperative risk.

Methods: A retrospective cohort study was performed using TriNetX, a large, federated healthcare database. Patients (18-80 years old) undergoing reduction mammoplasty were identified using CPT codes. Patients with previous breast surgery or chronic lower respiratory diseases were then identified excluded. The remaining patient cohort was stratified by diagnosis of OSA (ICD-10) prior to surgery. 1:1 propensity score matching was performed for age, body mass index (BMI), diabetes, and race/ethnicity. Primary outcomes included postoperative infection, wound dehiscence, re-operation, and venous thromboembolism (PE/DVT). Analysis was performed at 1 month and 3 months. Subgroup analyses was then performed based on BMI (>25 kg/m², >30 kg/m², and >35 kg/m²) at the same postoperative timepoints.

Results: A total of 1,914 patients were identified and included in the matched full cohort analysis which demonstrated OSA was associated significant increases in postoperative dehiscence (1 month 2.19% vs 1.36%, p=0.05; 3 months 3.87% vs 2.30%, p=0.005) and re-operation rates (1 month 2.25% vs 1.10%, p=0.006; 3 months 2.82% vs 1.67%, p=0.016). In contrast, no significant differences in the infection rate or PE/DVT rate was observed between groups. In patients with BMI >25 kg/m² (n=1,794), OSA was associated with a significantly increased rate of infection at 3 months (3.01% vs 1.95%, p=0.041) and an increased rate dehiscence at 3 months (4.13% vs 2.68%, p=0.016). In patients with a BMI >30 kg/m² (n=1,484), the observed findings association was more pronounced with significantly higher rates of infection (1 month 2.49% vs 1.35%, p=0.023; 3 months 3.44% vs 2.16%, p=0.034), dehiscence (1 month 2.83% vs 1.28%, p=0.003; 3 months 4.65% vs 2.49%, p=0.0016), and re-operation (1 month 2.56% vs 1.35%, p=0.017; 3 months 3.17% vs 2.02%, p=0.0497). In patients with a BMI >35 kg/m² (n=986) no statistically significant differences in postoperative outcomes were observed at either 1 or 3 months.

Conclusions: The results of this study suggest OSA is associated with an increased rate of postoperative wound dehiscence and re-operation following reduction mammoplasty. Among patients with a BMI >30 kg/m² these findings predominated while in patients with a BMI >35 outcomes may be primarily driven by obesity. These findings suggest that OSA functions as an independent risk factor for wound complications in moderately obese patients and highlight the importance of preoperative risk stratification and postoperative monitoring.

Introduction: Breast cancer–related lymphedema (BCRL) is a chronic, progressive debilitating complication of breast cancer treatment that impairs function and quality of life. Despite rising breast cancer rates and the role of radiotherapy, BCRL still remains underdiagnosed and undertreated, exacerbating inequities in survivorship care. Emerging evidence demonstrates racial and ethnic disparities in BCRL prevalence, with Black and Hispanic patients at higher risk than Caucasian patients (1-3). Treatment involves conservative and sometimes combined with surgical intervention. Patterns of recognition, referral and BRCL management remain poorly characterized. This study aimed to evaluate surgical and conservative management of BCRL in women to identify potential disparities in treatment delivery and access.

Methods: A retrospective cohort study was conducted using the TriNetX database utilizing the US Collaborative Network (4). Adult female patients with a history of breast cancer and mastectomy who subsequently developed lymphedema were identified using ICD-10 and CPT codes. Patients with primary lymphedema or prophylactic surgical procedures were excluded. To reliably capture microsurgical techniques for lymphedema from relevant CPT codes, only patients treated from 2016 onward were included. Two cohorts were defined: (1) patients managed conservatively with compression and therapy-based treatment only and (2) patients who also underwent surgical intervention for lymphedema treatment. Baseline demographics and comorbid conditions were compared between groups. Statistical analyses were conducted using the native TriNetX analytical tools, which apply chi-square testing for categorical variables and t-tests for continuous variables.

Results: A total of 303 surgically treated patients and 16,046 conservatively treated patients were included in the analysis. Patients undergoing surgical management were significantly younger than those receiving only conservative treatment (58.2 ± 12.0 vs 63.8 ± 12.4 years; p < 0.001). Racial distribution differed significantly between the surgically and conservatively managed cohorts, with the surgical cohort comprising 82% White patients versus 75% in the conservatively managed cohort (p = 0.014). Additionally, Black patients were significantly underrepresented in the surgical cohort (9% vs 15%, p = 0.006). There was no significant difference between the two cohorts when comparing patients that identified as Hispanic or Latino (5% vs 4%). Furthermore, comorbidities were more prevalent in the non-surgical cohort, including heart failure (p < 0.001), hypertensive heart disease (p = 0.001), chronic obstructive pulmonary disease (p = 0.002), and type 2 diabetes mellitus (p = 0.012).

Conclusions: These findings highlight measurable differences in the populations receiving both conservative and operative care for lymphedema which raises important questions regarding access, referral patterns, and candidacy for surgical management of BCRL. Further investigation is warranted to better understand factors influencing awareness and equitable delivery of lymphedema treatment.

1) Hassan AM, Hajj JP, Lewis JP, Fisher CS, Imeokparia FO, Ludwig KK, Danforth RM, VonDerHaar RJ, Bamba R, Lester ME, Hassanein AH. Socioeconomic and ethnic disparities in breast cancer-related lymphedema and quality-of-life after immediate lymphatic reconstruction. Breast Cancer Res Treat. 2025 Nov 20;215(1):1. doi: 10.1007/s10549-025-07829-w. PMID: 41264041; PMCID: PMC12634788.

2) Mattia, Alexzandra BS; Hadzimustafic, Nina MD†; Rivero, Rachel MD‡; Oh, SeungJu Jackie MD; Bach, Karen MD; Brown, Stav MD; Haykal, Siba MD, PhD*. Disparities in Breast Cancer–related Lymphedema: A Systematic Review of Inequities and Barriers in Care. Plastic & Reconstructive Surgery-Global Open 13(7):p e6935, July 2025. | DOI: 10.1097/GOX.0000000000006935

3) Montagna G, Zhang J, Sevilimedu V, et al. Risk Factors and Racial and Ethnic Disparities in Patients With Breast Cancer–Related Lymphedema. JAMA Oncol. 2022;8(8):1195–1200. doi:10.1001/jamaoncol.2022.1628

4) Ludwig RJ, Anson M, Zirpel H, Thaci D, Olbrich H, Bieber K, Kridin K, Dempfle A, Curman P, Zhao SS, Alam U. A comprehensive review of methodologies and application to use the real-world data and analytics platform TriNetX. Front Pharmacol. 2025 Mar 10;16:1516126. doi: 10.3389/fphar.2025.1516126. PMID: 40129946; PMCID: PMC11931024.