Scientific Abstract Presentations: Breast Session 5 Friday, October 16 Fri, Oct 16 2:00-3:30 p.m. CDT

Purpose: Extensive literature describes increased morbidity associated with post-mastectomy radiotherapy (PMRT) in dual-stage implant-based breast reconstruction (IBBR), yet multi-institutional studies on the timing of tissue expander (TE)–to–implant exchange after completion of radiotherapy remains limited. (1, 2) Therefore, this study examined whether TE-to-implant exchange before 6 months of PMRT versus after 6 months influences post-implant complications.

Methods: A multi-institutional, breast-level cohort (2014–2025) included radiated breasts undergoing TE-to-implant exchange after PMRT completion. Exchange timing was categorized as early (≤183 days) versus delayed (>183 days). A 3:1 nearest-neighbor propensity score match (ATT estimand; 0.2 caliper; early exchange prioritized) balanced cohorts on age, smoking status, hypertension, chronic obstructive pulmonary disease, and acellular dermal matrix use. Outcomes were restricted to complications occurring after permanent implant placement. Weighted, patient-clustered logistic regression estimated odds of complications for early versus delayed exchange, adjusting for BMI and TE size.

Results: Among 1,842 radiated breasts, 349 underwent early exchange and 1,493 underwent delayed exchange. Matching yielded 808 breasts (345 early and 463 delayed). In the matched cohort, exchange before 6 months demonstrated higher crude rates of any complication (19.4% vs 12.3%), return to operating room (RTOR) (9.0% vs 3.7%), and implant exposure (4.1% vs 1.1%); infection rates were similar (9.7% vs 8.0%). In matched analyses, exchange after 6 months reduced odds of RTOR (OR 0.24, 95% CI 0.11–0.55; p<0.001) and showed a trend toward fewer overall complications (OR 0.59, 0.33–1.05; p=0.071). After adjustment for BMI and TE size, exchange after 6 months was associated with lower odds of RTOR (aOR 0.26, 0.11–0.60; p=0.002) and implant exposure (aOR 0.23, 0.066–0.835; p=0.026). Associations with infection and overall complications did not reach statistical significance.

Conclusion: Implant exchange after 6 months post-radiation therapy was associated with fewer reoperations and implant exposures. These findings support implant exchange timing as a practical and clinically significant component of peri-reconstructive planning. Patients considering early exchange may benefit from counseling that addresses the tradeoff between shorter TE burden with increased risk of reoperation and implant exposure. If early exchange is pursued, closer postoperative surveillance for complications may be warranted.

References: 1. Chang AE, Niu EF, Honig SE, Broach RB, Serletti JM, Azoury SC. Impact of Implant Exchange Timing after Postmastectomy Radiation in Immediate Tissue Expander Breast Reconstruction. Plast Reconstr Surg. 2025;155(1):9e-15e. 2. Shammas RL, Boe LA, Wagner BD, Chen J, Graziano FD, Stern CS, et al. Optimal Timing of Expander-to-Implant Exchange After Post-Mastectomy Radiation Therapy: 90-day Complications and Patient-Reported Outcomes. Plast Reconstr Surg. 2025.

Purpose: Breast reconstruction via procedures such as the deep inferior epigastric perforator (DIEP) flap reliably restores aesthetic form to the breast following mastectomy, but breast sensation is much more difficult to restore.(1) There are emerging strategies, such as nerve allografts, targeted muscle reinnervation (TMR), and nerve coaptation, that show great potential to enhance postoperative sensory outcomes, but they have yet to be comprehensively reviewed. (2) Therefore, the objective of this study was to systematically review and evaluate techniques for breast reinnervation following mastectomy and subsequent breast reconstruction.

Methods: A systematic review of publications in the PubMed database from 2010-2024 was conducted according to PRISMA guidelines. Exclusion criteria included animal studies and studies involving participants under 18 years of age. To minimize bias, only peer-reviewed journals were considered. Data were extracted on sensory outcomes, complications, and follow-up duration for each sensation-enhancing surgical technique.

Results: 500 articles were identified through the initial database search, of which 29 met the inclusion criteria after screening titles, abstracts, and full texts. A total of 3,929 participants were included across the 29 articles. Nerve coaptation during DIEP flap reconstruction improved nipple areolar sensation by 40–60% at 12 months compared with non-innervated flaps in two prospective cohorts.(3) They found that nerve coaptation was associated with significantly lower mean monofilament values in the breast (p < 0.001), whereas no significant differences were observed at the donor site (p = 0.161).(3) In adjusted comparisons, postoperative sensation improvements in innervated flaps remained statistically significant (p = 0.017) relative to baseline. The combination of nerve allografts with bioabsorbable conduits and enhanced neurotization demonstrated higher patient-reported satisfaction in a cohort of 50 patients. (4) Additionally, TMR, which transfers sensory nerves to motor branches, was associated with reduced neuropathic pain and faster post-operative recovery among the patient cohorts. (5)

Conclusion: This systematic review found that nerve coaptation during DIEP flap reconstruction significantly improved nipple–areolar sensation, while adjunctive techniques such as nerve allografts, bioabsorbable conduits, and targeted muscle reinnervation further enhanced sensory recovery, patient satisfaction, and postoperative outcomes. Establishing standardized protocols for breast reinnervation could not only advance surgical practice but also minimize patient burdens, such as repeated hospital visits, transportation challenges, and postoperative pain, while strengthening patient–provider relationships.

1) American Cancer Society. Breast Cancer Facts & Figures 2024-2025. Atlanta: American Cancer Society; 2024. 2) Garza R 3rd, Ochoa O, Chrysopoulo M. Post-mastectomy Breast Reconstruction with Autologous Tissue: Current Methods and Techniques. Plast Reconstr Surg Glob Open. 2021 Feb 18;9(2):e3433. doi: 10.1097/GOX.0000000000003433. PMID: 33680677; PMCID: PMC7929567. 3)Chou J, Hyland CJ, Kaufman Goldberg T, Broyles JM. Is nerve coaptation associated with improved sensation after microvascular breast reconstruction? A systematic review. Microsurgery. 2023;43(5):522–528. PMID: 36271757. 4) Santanelli F, Longo B, Angelini M, Laporta R, Paolini G. Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap. Plast Reconstr Surg. 2011 May;127(5):1790-1795. doi: 10.1097/PRS.0b013e31820cf1c6. PMID: 21532408. 5) Souza, J.M., Cheesborough, J.E., Ko, J.H., Cho, M.S., Kuiken, T.A. and Dumanian, G.A., 2014. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clinical Orthopaedics and Related Research®, 472(10), pp.2984-2990.

Introduction: While conventional nipple-sparing mastectomy (NSM) often disrupts native breast fascial support and neurovascular structures, the structure-preserving nipple-sparing mastectomy (s-NSM) preserves the circummammary ligament and associated perforators and nerves. Among patients undergoing direct-to-implant reconstruction (DTI), our institution's prior study found s-NSM was independently associated with reduced odds of acute complications, with lower rates of acellular dermal matrix use and increased nipple reinnervation rates compared to conventional nipple-sparing mastectomy (NSM). However, the impact of the s-NSM approach on patient-reported outcomes (PROs) is unknown. This study evaluates PROs associated with structural versus conventional NSM with DTI reconstruction.

Methods: A retrospective review of patients undergoing nipple-sparing mastectomy with DTI reconstruction at a single tertiary hospital was performed from November 2020 to August 2025. Patients at least 3 months after their most recent breast surgery were sent a survey that included the BREAST-Q reconstruction modules. Demographics, complications, and PROs were analyzed. s-NSM PROs were compared to our conventional NSM cohort, published BREAST-Q reconstruction normative scores, and the reported BREAST-Q reconstruction outcomes from the Mastectomy Reconstruction Outcomes Consortium (MROC) study of patients 1 year after DTI. Clinical significance was assessed using a minimal clinically important difference (MCID) of 4 points for BREAST-Q domains.

Results: A total of 61 patients completed the survey (response rate of 28.6%), with 35 (57.4%) patients having undergone s-NSM and 26 (42.6%) NSM. The s-NSM cohort had a shorter time to survey completion (10.0 [IQR: 10.7] vs 31.3 [13.2] months, p < 0.001). Compared to NSM, the s-NSM cohort had BREAST-Q scores greater than the MCID for breast satisfaction (67.5 ± 16.4 vs. 61.3 ± 19.2, p = 0.178), breast animation deformity (83.6 ± 17.5 vs. 78.5 ± 20.2, p = 0.292), sexual well-being (57.3 ± 20.4 vs. 51.5 ± 23.7, p = 0.342), breast sensation (52.3 ± 23.9 vs. 45.7 ± 22.9, p = 0.284), breast sensation quality of life (71.7 ± 15.2 vs. 65.9 ± 20.6, p = 0.207), impact on work (79.3 ± 25.2 vs. 67.9 ± 37.0, p = 0.169), and cancer worry (42.0 ± 16.9 vs. 52.6 ± 18.3, p = 0.025). Compared to reference normative values, the s-NSM had significantly greater breast satisfaction (67.5 ± 16.4 vs. 58 ± 18, p = 0.002) and significantly lower chest physical well-being (78.9 ± 13.7 vs. 93 ± 11, p < 0.001). Lastly, compared to the MROC DTI cohort at 1 year follow-up, the s-NSM had clinically greater psychosocial well-being (75.9 ± 17.1 vs. 71.8 ± 19.0, p = 0.162) and sexual well-being (57.3 ± 20.4 vs. 53.0 ± 21.1, p = 0.275) scores.

Conclusion: The s-NSM with DTI reconstruction is associated with clinically meaningful improvements across multiple BREAST-Q domains compared to conventional NSM, despite a shorter follow-up time after surgery. These findings suggest that preservation of native breast support structures translate into patient-centered benefits following DTI reconstruction, warranting further investigation in larger, longitudinal studies.

Background Over the past several decades, the Deep Inferior Epigastric Perforator (DIEP) flap has become the gold standard for autologous breast reconstruction. Extensive research has investigated complications after this surgery. However, fewer studies have focused on describing outcomes of donor site morbidities. This systematic review evaluates the common trends in donor site complications and patient-reported satisfaction of the abdomen after DIEP flap surgery.

Methods This systematic review was conducted in accordance with PRISMA guidelines. Articles were sourced from MEDLINE, Embase, Web of Science, and the Cochrane Central Register through February 2026. The primary outcomes were donor site complications and patient-reported satisfaction of the donor site using the BREAST-Q. Study quality was assessed using the NIH quality assessment tool. Comparative analyses were conducted when applicable, and single-arm random-effects meta-analyses of proportions were performed to estimate pooled donor-site complication rates.

Results A total of 1,819 titles and abstracts were screened, 274 full texts were assessed, and 94 studies were included. For analysis, the studies were stratified into two groups based on reported outcomes. Twenty-three studies (3,767 patients) reported BREAST-Q outcomes. Weighted mean age and BMI were 50.22 ± 2.51 years and 27.19 ± 1.29kg/m2, respectively. At a mean follow-up of 42 months, postoperative physical well-being of the abdomen averaged 75.26 ± 9.52. Eighty-seven studies reported donor-site morbidity (24,424 patients and 29,556 flaps). The mean age, BMI, length of stay, and follow-up were 50.78 (±1.92) years, 26.91 (±1.90)kg/m2, 7.24 (±2.15) days, and 32.91 (±81.87) months, respectively. Donor-site complications were reported in 13.5% of all patients. The most common donor-site complications reported were wound dehiscence (n=788), seroma (n=685), delayed wound healing (n=575), and infection (n=536). A total of 919 patients (3.8%) required a re-operation. In single-arm random-effects meta-analyses, the pooled overall donor-site complication rate was 20.0% (95% CI, 16.4-23.6%; I2=97.5%). ​​The pooled rate of hernia was <1% (95% CI, 0–1%; I² = 30.5%), that of umbilical necrosis was 2% (95% CI, 1–3%; I² = 80.4%), and that of wound dehiscence was 8% (95% CI, 6–11%; I² = 95.3%).

Conclusion This systematic review provides an updated overview of donor-site morbidity and patient satisfaction after DIEP flap. Overall, it can be concluded that donor-site complications are rare. Most complications were treated conservatively and were considered minor complications. These findings underscore the importance of donor-site monitoring post-operatively, not only during hospitalization but also during follow-up.

Background: Autologous breast reconstruction frequently relies on abdominal-based flaps, with the Deep Inferior Epigastric Perforator (DIEP) flap becoming the gold standard. However, alternative approaches that incorporate additional vascular territories have been utilized to improve aesthetic and operative outcomes. The superficial circumflex iliac perforator (SCIP) flap has emerged as an adjunct to augment volume, particularly in patients with higher body mass index (BMI). Yet the impact of adding a SCIP flap alongside a DIEP flap remains uncharacterized. Therefore, we evaluated the safety and efficacy of combined DIEP+SCIP flap breast reconstruction as a strategy to maximize autologous volume without compromising donor site morbidity compared to DIEP flap alone.

Methods: A retrospective review of 68 patients undergoing breast reconstruction with either DIEP or DIEP+SCIP flaps from 2022 to 2025 was conducted at a single academic center. Patient demographics, operative time, and postoperative complications were collected. Cohorts were compared using the Wilcoxon rank-sum and Fisher's exact tests. Logistic regression was performed to identify independent predictors of postoperative complications.

Results: A total of 78 flaps were performed, including 34 DIEP alone and 34 DIEP+SCIP. The mean patient age was 51 ± 9 years in the DIEP group and 49 ± 9 years in the DIEP+SCIP group (p = 0.417). The average BMI was 26.9 kg/m² vs 29.2 kg/m² (p = 0.045) for the DIEP vs DIEP+SCIP cohorts respectively. Most of the cases in both groups were bilateral (91% DIEP vs 94% DIEP+SCIP). Prior radiation was present in 26% DIEP and 32% DIEP+SCIP groups (p = 0.595). Mean combined flap weight was significantly greater in the DIEP+SCIP group (523 ± 284 g vs 760 ± 378 g, p < 0.005). Average operative time was significantly longer in the DIEP+SCIP group (583 ± 111 minutes vs 638 ± 88 minutes, p < 0.001). There were no significant differences among donor site complications, fat necrosis, and asymmetry between the two groups. On multivariable logistic regression, the addition of a SCIP flap was not an independent predictor of postoperative complication (OR 0.39, 95% CI 0.05-2.14, p = 0.297).

Conclusion: The combined DIEP+SCIP approach achieves significantly greater flap volume, yielding in this study 45% greater volume of harvested tissue, than DIEP flap alone without significantly increasing complication risk. SCIP flap harvest does not require disruption of muscle or fascia, thereby preserving donor site integrity. The added SCIP territory allows effective use of a single perforator for the DIEP flap. Although operative time is longer, it is justified by the meaningful gain in autologous volume, especially in higher BMI cases. This combined approach represents a valuable and safe evolution in autologous breast reconstruction.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RA) are being increasingly used for weight loss. Emerging literature examining perioperative outcomes among GLP-1RA users suggests the medication may affect post-surgical wound healing. Data specific to breast reconstruction outcomes remains poorly characterized. Our study sought to examine the association between preoperative GLP-1 usage and tissue expander (TE) breast reconstruction outcomes.

METHODOLOGY: The TriNetX database (TriNetX LLC, Cambridge, MA), a global federated health research network providing access to geographically aggregated and de-identified electronic medical records from large healthcare organizations, was queried (2015-2025) to identify patients ≥ 18 undergoing TE breast reconstruction. Patients were grouped into two cohorts: those who used GLP-1RAs within 12 months prior to surgery (Cohort 1) and those who never used GLP-1RAs prior to surgery (Cohort 2). Propensity matching was performed for patient demographics, comorbidities, and oncologic treatments. Outcomes of interest at 90-days post-operatively included wound dehiscence, seroma/hematoma, surgical site infection (SSI), overall wound complications, and tissue expander explantation. Kaplan-Meier analysis evaluated time to explantation. Odds ratios with confidence intervals (95%) were examined.

RESULTS: A total of 23,129 patients were identified (Cohort 1: 544; Cohort 2: 22,585). After propensity matching, each cohort included 543 patients. Preoperative GLP-1RA therapy was associated with higher odds of wound dehiscence (OR 1.86, 95% CI 1.11-3.11; p=0.017). Overall wound complications were increased in the GLP-1RA cohort (OR 1.49, 95% CI 1.06-2.10; p=0.020). There was no significant difference in odds of surgical site infection (OR 1.26, 95% CI 0.73-2.16; p=0.410) or seroma/hematoma (OR 1.60, 95% CI 0.99-2.60; p=0.054) between cohorts. Odds for tissue expander explantation were not statistically significant (OR 1.30, 95% CI 0.92-1.85; p=0.134) with similar explant-free duration on Kaplan-Meier analysis (hazard ratio 1.29; p=0.126).

CONCLUSION: Preoperative GLP-1RA therapy was associated with increased early wound complications following tissue expander breast reconstruction. These findings suggest that perioperative optimization including directed patient counseling and medication management strategies may be warranted in patients receiving GLP-1RA undergoing TE reconstruction.

Purpose: Mastectomy skin flap necrosis is a relatively common postoperative complication. Our prior studies have demonstrated topical tacrolimus improves skin flap survival in a rodent model. Given the rapid onset vasodilatory effects of nitroglycerin and more gradual onset of tacrolimus, early nitroglycerin pretreatment may provide an additional improvement in skin flap survival by acting in the early ischemic period. This study compared nitroglycerin pretreatment followed by tacrolimus versus tacrolimus alone.

Methods: A 3x10 cm cranially based dorsal skin flap was raised and re-inset on 22 Sprague-Dawley rats. Rats were randomized to receive one of two treatments regimens (n=11 in each group). (1) Topical tacrolimus twice daily for seven days. (2) Topical nitroglycerin twice daily for one day followed by topical tacrolimus twice daily for six days. Rats were euthanized on postoperative day seven and the flaps were harvested for analysis. ImageJ software was used to measure the percent surface area of tissue that was healthy (H), ischemic (I), and necrotic (N) by gross observation. Groups were compared using the Mann-Whitney U test. Two reviewers blinded to treatment group evaluated each flap independently. Inter-rater reliability was assessed using intraclass correlation coefficients (ICC) and Bland-Altman analysis.

Results: In the treatment group that received seven days of topical tacrolimus, the median tissue areas were 47.1% H, 20.8% I, 32.1% N. In the treatment group that was treated with one day of nitroglycerin followed by six days of tacrolimus, the median tissue areas were 58.9% H, 8.2% I, 31.1% N. Nitroglycerin pretreatment was associated with a higher percentage of healthy tissue (p=0.019) and lower percentage of ischemic tissue (p=0.023). Differences in necrotic area did not reach statistical significance (p=0.401). Inter-rater agreement was excellent for all tissue zones ICC(2,1)>0.90, with narrow limits of agreement on Bland-Altman analysis.

Conclusion: Short term nitroglycerin pretreatment followed by topical tacrolimus was associated with an additional improvement in tissue composition compared with tacrolimus alone, increasing healthy tissue and decreasing ischemic tissue in a rat skin flap model.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become among the most widely prescribed medications in the United States, with rapidly expanding use for type 2 diabetes and obesity.¹ As their use becomes increasingly prevalent in surgical patients, concerns have emerged regarding their potential effects on wound healing and post-operative recovery. These concerns are particularly relevant in breast reconstruction, where complications such as surgical site infections and flap necrosis can significantly affect both reconstructive and oncologic outcomes. Despite this, the impact of GLP-1 RA use on breast surgical outcomes remains poorly understood. This study intends to use a national cohort to evaluate the association between pre-operative GLP-1 RA usage and post-operative complications in patients undergoing breast reconstruction surgery. Methods: A retrospective cohort study was performed using the Merative MarketScan database to identify female patients 18 years and older who underwent breast reconstruction surgery between 2007 – 2023. These patients were stratified by GLP-1 RA usage, with the GLP-1 RA cohort defined as patients with active prescriptions for at least three months prior to surgery. Propensity score matching was performed to balance cohorts on age, body mass index, smoking status, congestive heart failure, diabetes, COPD/pneumonia, hypertension, and functional status. Primary outcomes included post-operative infection, hematoma/seroma, delayed wound healing, implant or flap complications, and reoperation. Adjusted multivariable logistic regression was used to compare outcomes between the two cohorts. Subgroup analyses were performed to evaluate whether the effect of GLP-1 RA usage on complications differed by metabolic status, comparing GLP-1 RA users to non-users within four strata: obesity with diabetes, obesity only, diabetes only, and neither condition. Results: Following propensity score matching, 5,425 female patients were included (1,085 GLP-1 RA users; 4,340 controls). Groups were well-balanced on baseline characteristics. After multivariable adjustment, GLP-1 RA usage was not significantly associated with any post-operative complication: hematoma/seroma, infection, implant/flap complication, reoperation or delayed healing (p>0.1). Subgroup analysis stratifying by metabolic status demonstrated among patients with obesity and diabetes, GLP-1 RA users had significantly lower odds of reoperation compared to non-users (OR 0.76, 95% CI 0.58–0.99, p=0.04). No other significant differences were observed across metabolic subgroups. Conclusions: In this large, propensity score-matched analysis, pre-operative GLP-1 RA usage was not associated with increased risk of post-operative complications following breast reconstruction surgery. Subgroup analysis suggested potential protective effects against reoperation among patients with combined obesity and diabetes, though this isolated finding should be interpreted with caution given the multiple comparisons performed. As a retrospective claims-based study, these findings are limited by inability to verify medication adherence and potential for residual confounding. Nonetheless, these results provide reassuring evidence for surgeons managing the growing population of patients presenting on GLP-1 RAs and suggest GLP-1 RA use alone should not be considered a risk to breast reconstruction outcomes. Further prospective investigation is warranted to confirm these findings and explore mechanism-specific effects of GLP-1 RAs on surgical wound healing.

1. Li P, et al. Prescribing Trends of Glucagon-Like Peptide 1 Receptor Agonists for Type 2 Diabetes or Obesity. JAMA Netw Open. 2025;8(10):e2540890. doi:10.1001/jamanetworkopen.2025.40890

Background Regional anesthesia can improve postoperative pain control in breast reconstruction, yet direct comparisons of block techniques remain limited. This study compares the erector spinae plane (ESP), pectoralis and serratus (PECS I/II), and paravertebral (PVB) blocks in immediate tissue-expander breast reconstruction.

Methods A retrospective review of patients undergoing immediate tissue-expander reconstruction from 2017-2023 at a single institution was performed. Outcomes included morphine milligram equivalents (MME), length of stay (LOS), and pain scores 4–48 hours postoperatively. Patients were grouped by block type and stratified by laterality. Cohort differences were assessed using ANOVA, Fisher's exact, and Chi-square tests. Multivariable regression controlled for anesthetic solution, operative, and demographic covariates.

Results A total of 175 patients were included: 84 unilateral (47.6% ESP, 11.9% PECS I/II, 40.5% PVB) and 91 bilateral blocks (37.4% ESP, 30.8% PECS I/II, 31.9% PVB). Mean LOS was 1.0 day, daily MME 59.8, and total MME 66.7, with no significant differences across block types (p>0.05). Despite variation in anesthetic agent and concentration (p<0.001), block type was not independently associated with opioid use or LOS. Axillary dissection modestly increased LOS in unilateral cases (β=0.255 days, p=0.031). Bilateral ESP blocks showed slightly higher 4-hour pain scores (p=0.028), though differences were <2 points and not sustained.

Conclusion ESP, PECS I/II, and PVB blocks demonstrate comparable clinical performance in immediate tissue-expander breast reconstruction. Flexibility in block selection may allow surgeons and anesthesiologists to prioritize efficiency, cost, and institutional workflow without compromising analgesic outcomes.

Purpose: Suzetrigine, a novel non-opioid peripheral sodium channel inhibitor that selectively targets Nav1.8 channels, has shown to be highly efficacious in managing postoperative pain in Phase II and III clinical trials1,2. The effectiveness of Suzetrigine in controlling post-operative pain after breast surgery has not been explored. This study sought to evaluate the effect of peri-operative Suzetrigine on post-operative opioid use in patients who underwent various breast surgeries.

Methods: This retrospective review of the TriNetX Analytics Network queried the Global Collaborative Network with over 170 million patients to identify patients undergoing various breast surgeries including mastectomy, breast reconstruction, breast reduction, and breast augmentation who received Suzetrigine either on the day of surgery or up to one day post-operatively. Patients who received Suzetrigine were compared to patients undergoing the same procedures who did not receive Suzetrigine. Patients were identified using diagnosis and procedure codes. Post-operative opioid consumption within 72 hours after surgery were compared between 1:1 propensity score matched cohorts. Patients were matched for age, BMI, gender, race, opioid abuse, anxiety, and affective mood disorders. Risk ratios and T-tests were used to compare outcomes.

Results: A total of 161 patients undergoing breast surgery who received Suzetrigine within 1-day post-op were matched to 161 patients who did not receive Suzetrigine from an original pool of 489, 038. Up to 72 hours post-op, patients who received Suzetrigine used significantly less intravenous opioids (p<0.0001). Patients used similar amounts of non-opioid medications up to one-week post-op (p>0.05). Patients who received Suzetrigine were not at increased risk of nausea (p>0.05), vomiting (p>0.05), or liver injury (p>0.05).

Conclusions: Patients undergoing various breast surgeries including mastectomy, breast reconstruction, breast reduction, and breast augmentation who received Suzetrigine either on the day of surgery or up to one day post-operatively were associated with significantly less intravenous opioid analgesic use up to 72-hours post-op without an increased risk of nausea, vomiting, or liver injury. This study establishes the role of newer selective sodium channel blockade such as Suzetrigine as an adjuvant to a multimodal analgesia strategy to decrease postoperative intravenous opioid analgesic use in patients undergoing various breast surgeries. This decreased need for IV analgesics could translate to faster IV discontinuation and decreased length of hospital stay after breast procedures. Plastic surgeons may consider utilizing Suzetrigine as an adjunct to a multimodal analgesia strategy to decrease post-op IV opioid use.

Background Breast reconstruction rates in the US are increasing for both implant-based and autologous procedures. Over 90% of new breast cancer diagnoses occur in women over 45, most of whom are peri- or postmenopausal. Low estrogen in postmenopausal women has been recognized to contribute to declines in skin function and delayed wound healing (1). However, despite the relevance of menopause to wound healing and plastic surgery, there is a paucity of literature describing postoperative outcomes in this population. Estrogen hormone replacement therapy (HRT) can alleviate symptoms of menopause and may promote wound healing; however, its prothrombotic properties introduce potential implications for postoperative complications (1,2). We investigate breast reconstruction outcomes among postmenopausal patients on HRTs compared to those without HRT use.

Methods The TriNetX database, a multi-institutional data analytics platform including almost 1000 healthcare organizations, was queried to compare patients with and without a history of HRT use within 1 year preceding breast reconstruction. Breast reconstruction procedures were identified using CPT codes and included tissue expander placement, implant-based, and autologous reconstruction. HRT use was identified using ICD-10 diagnosis codes and RxNorm codes within TriNetX. The two cohorts were propensity-matched with respect to demographics such as age and body mass index (BMI) and medical comorbidities associated with surgical outcomes, including hypertension and diabetes. Risk differences with 95% confidence intervals were calculated for endpoints relating to specific surgical complications within 90 days of operation. All statistical analyses were performed within the TriNetX platform, and a p-value of 0.05 was used to determine statistical significance.

Results Two cohorts were generated, with 1440 in the HRT+ group and 22699 in the HRT- group. After propensity matching, two similar cohorts of 1437 patients each were created. While the HRT+ cohort trended towards a lower risk of hematoma and seroma, after propensity adjustment, there was no significant association between postoperative outcomes and HRT use prior to breast reconstruction. The risk of mortality, deep vein thrombosis and pulmonary embolism, and wound healing complications was comparably low across both cohorts.

Conclusion Systemic hormone replacement therapy was not associated with an increased risk of postoperative complications after breast reconstruction, including mortality, thrombosis, infection and wound dehiscence in a peri- and postmenopausal population. Further prospective studies stratified by reconstructive modality and across surgical populations are needed to validate these findings.

References 1. Horng HC, Chang WH, Yeh CC, et al. Estrogen effects on wound healing. Int J Mol Sci. 2017;18(11):2325. doi:10.3390/ijms18112325. 2. Campbell L, Emmerson E, Davies F, Gilliver SC, Hardman MJ, Ashcroft GS. Estrogen promotes cutaneous wound healing via estrogen receptor β independent of its antiinflammatory activities. J Exp Med. 2010;207(9):1825-1833. doi:10.1084/jem.20100500

Purpose: Enhanced Recovery After Surgery (ERAS) protocols aim to minimize opioid use in microsurgical breast reconstruction. Additionally, these protocols emphasize the importance of decreasing hospital length of stay and the overall cost of care (Bajaj et al.). Although liposomal bupivacaine is commonly used for transversus abdominis plane (TAP) blocks, its high cost may hinder implementation. This study compares postoperative outcomes in patients who received a low-cost multimodal analgesic cocktail to liposomal bupivacaine and no TAP block in DIEP and msTRAM flap procedures.

Materials and Methods: A retrospective review was conducted on 104 women undergoing DIEP or msTRAM reconstruction between January 2021 and December 2024. Patients were divided into three groups: A (no TAP block), B (TAP block with liposomal bupivacaine), and C (TAP block with a cocktail of 50 mL 0.25% bupivacaine, 50 mcg dexmedetomidine, 12 mg dexamethasone, and 30 mg ketorolac). Primary outcomes included opioid use in oral morphine equivalents (OME), length of hospital stay, pain scores, and postoperative complications.

Results: Group C had the lowest inpatient opioid use (135 OMEs) compared to Group A (278) and Group B (240) (p<0.001). Daily OME use was halved in Group C (29 vs. 58 and 57; p<0.001). Postoperative nausea and antiemetic use were also reduced in Group C. Although LOS trended shorter in Group C (4.2 days), differences were not statistically significant (p=0.1). Pain scores and complications were comparable.

Conclusions: A low-cost (~$45 per patient) multimodal analgesic cocktail for TAP blocks significantly reduces opioid use and improves recovery in abdominally based breast reconstruction. This strategy offers a cost-effective, scalable solution for ERAS implementation in microsurgical practice.

References: 1. Bajaj, Anitesh BS; Sarkar, Prottusha BA; Yau, Alice BS; Lentskevich, Marina A. BS; Huffman, Kristin N. BS; Williams, Tokoya MD; Galiano, Robert D. MD, FACS; Teven, Chad M. MD, MBA, FACS. The Cost-effectiveness of Enhanced Recovery after Surgery Protocols in Abdominally Based Autologous Breast Reconstruction. Plastic & Reconstructive Surgery-Global Open 12(5):p e5793, May 2024.

Purpose: Intraoperative device volume selection is a modifiable surgical decision that influences outcomes of immediate implant-based breast reconstruction (IBR). Prior studies have associated higher tissue expander (TE) fill volumes and ischemic complications, typically quantifying fill as an absolute value or percentage of device capacity. However, because mastectomy weight varies substantially across patients, these approaches may not fully account for differences in breast size. Normalizing device volume to specimen weight has therefore been proposed as an alternative metric. Despite this rationale, limited data have examined TE fill relative to mastectomy weight, and no study has examined implant volume-to-mastectomy weight ratio in direct-to-implant (DTI) reconstruction. This study evaluated absolute device volume and volume-to-mastectomy weight ratio across TE and DTI reconstruction to determine their relative ability to predict postoperative complications.

Methods: We retrospectively reviewed consecutive patients undergoing immediate TE or DTI breast reconstruction (January 2019–December 2024), analyzing TE and DTI cohorts independently. TE initial fill volume and fill ratio (initial fill/mastectomy weight) as well as DTI implant size and implant ratio (implant volume/mastectomy weight) were evaluated. Postoperative complications included unplanned re-operation, hematoma, seroma, infection, delayed wound healing, mastectomy skin flap necrosis (MSFN), nipple-areolar complex (NAC) necrosis, malposition, fat necrosis, device failure, extrusion, unplanned exchange, and explantation. Multivariable logistic regression assessed associations between device volume metrics and postoperative complications, adjusting for relevant demographic, oncologic and operative covariates.

Results: A total of 1,030 breasts underwent immediate IBR, including 832 TE and 198 DTI reconstructions. In the TE cohort, mean initial fill was 113.03 ± 78.12 cc, mean mastectomy weight was 439.63 ± 263.94 grams, and mean TE fill ratio was 0.31 ± 0.34. Higher absolute initial fill, per 10 cc increase, was independently associated with any major complication (OR 1.03, CI 95% 1.00–1.05; P=.023), unplanned reoperation (OR 1.04, CI 95% 1.02–1.07; P<.001), delayed wound healing (OR 1.04, CI 95% 1.01–1.07; P=.003), MSFN (OR 1.06, CI 95% 1.01–1.12; P=.010), NAC necrosis (OR 1.05, CI 95% 1.01–1.09; P=.008), and malposition (OR 1.05, CI 95% 1.02–1.09; P=.004). In contrast, TE fill ratio demonstrated limited predictive value, with a borderline association with NAC necrosis (OR 1.81, CI 95% 0.98–3.34; P=.057) and no consistent association across other outcomes. In the DTI cohort, mean implant size was 280.03 ± 107.05 cc, mean mastectomy weight was 251.56 ± 137.88 grams, and mean implant ratio was 1.33 ± 0.78. Greater implant size, per 10 cc increase, was independently associated with seroma (OR 1.10, CI 95% 1.01–1.22; P=.031) and unplanned exchange (OR 1.06, CI 95%1.01–1.13; P=.016). Implant volume-to-mastectomy weight ratio was not significantly associated with postoperative complications. Across reconstruction types, absolute device volume demonstrated more consistent associations with adverse outcomes than ratio-based metrics.

Conclusion: In immediate IBR, absolute intraoperative device volume was more consistently predictive of postoperative complications than volume-to-mastectomy weight ratio in both TE and DTI reconstruction. These findings suggest that absolute volumetric thresholds may offer more clinically actionable guidance for intraoperative decision making than normalization to mastectomy weight alone.

Background: Enhanced Recovery After Surgery (ERAS) protocols are now widely adopted to optimize outcomes in microvascular breast reconstruction. A recent study demonstrated that single-dose intraoperative methadone, when used in conjunction with ERAS pathways, significantly reduced opioid requirements but did not reduce hospital length of stay compared to patients without ERAS or methadone (1). To date, no study has directly compared the addition of methadone to a standard ERAS protocol. This study evaluates the impact of a single intraoperative dose of methadone on perioperative opioid use and hospital length of stay in patients undergoing abdominally based autologous breast reconstruction, compared to ERAS alone. Methods: A retrospective review was conducted of patients undergoing DIEP or muscle-sparing TRAM flap reconstruction between January and June 2025. Patients who received a single weight-based intraoperative dose of methadone within an ERAS protocol (n=34) were compared to a historical cohort who underwent the same procedures using ERAS alone (n=34). 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. Methadone-ERAS patients had significantly lower opioid requirements intraoperatively (14.6 vs 40.3 MME), postoperatively (15.0 vs 132.2 MME), and in total (29.6 vs 172.5 MME; all p < 0.001). Length of stay was also significantly shorter in the methadone group (1.94 vs 3.62 days, p < 0.001). No methadone-related adverse events were observed. Conclusions: Compared to ERAS alone, the addition of a single intraoperative methadone dose significantly reduced opioid consumption and shortened length of stay following autologous breast reconstruction. These findings suggest that methadone-enhanced ERAS may further optimize recovery, beyond what standard ERAS achieves. Prospective studies are underway to validate these findings and support broader protocol implementation. References: 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