Scientific Abstract Presentations: Breast Session 6 Friday, October 16 Fri, Oct 16 5:00-6:00 p.m. CDT

Introduction: The Central Mound (CM) pedicle for breast reduction is established, but limited discussion exists for use in oncoplastic breast reduction (OBR). A single prior study showed favorable patient satisfaction in utilizing the CM for OBR (1). The aim of this study was to expand upon prior reports and include analysis of postoperative and oncologic outcomes compared to standard reduction mammaplasty (BBR) using the CM technique.

Methods: A retrospective review was conducted of 158 patients who underwent CM pedicle reductions from May 2020–2025 with either BBR (n=120) or OBR (n=38). Demographics, comorbidities (BMI, diabetes, hypertension, smoking), breast anthropometric measurements, operative time, and postoperative complications were collected with at least 6 months of follow up. Oncologic variables included cancer type, tumor grade, tumor stage, breast quadrant, margin status, re-excision, need for completion mastectomy, and time to adjuvant radiation (TTR).

Results: OBR patients were older (52.3±10.2 vs 37.0±14.0, p<0.001) and required longer operative times than BBR (121.1±47.9 min vs 104.2±23.8 min, p=0.013). All other demographics and comorbidities were not significantly different. Fat necrosis was more frequent in the OBR cohort (12% vs 2%, p=0.024). Rates of hematoma, seroma, infection, wound complications, rash, and contour deformity were not statistically different between cohorts. Invasive Ductal Carcinoma (IDC) was the predominant diagnosis (57.9%, n=22). Most tumors were high grade, with 44.7% (n=17) classified as Grade 3, 36.8% (n=14) as Grade 2, and 10.5% (n=4) as Grade 1. Positive margins were identified in 2.6% (n=1) of patients. There were no cases of re-excision, however, completion mastectomy was performed in 5.3% (n=2) of the cohort. Adjuvant radiation was indicated for 76.3% (n=29) of the cohort. The mean time from surgery to the initiation of adjuvant radiation was 9.71 ± 1.83 weeks.

Conclusion: This study highlights the central mound pedicle as a safe and reliable option for oncoplastic reductions. Although longer operative times and higher rates of fat necrosis were seen in the oncoplastic cohort, this may be explained by the greater surgical burden of oncoplastic surgery. Collectively, these findings demonstrate that the CM pedicle maintains timely continuity of adjuvant oncologic care. This is important because variable tumor location of breast cancer necessitates flexible approaches to resection; studies have shown improved outcomes in quadrant-based approaches (2,3). Inclusion of the CM pedicle in OBR will allow surgeons to respond to more diverse clinical scenarios. However, research in this area remains limited, and multi-institutional studies are warranted to further establish the role of the central mound pedicle in oncoplastic reduction.

Reference: 1. Stocco C, Cazzato V, Renzi N, et al. Central Mound Technique in Oncoplastic Surgery: A Valuable Technique to Save Your Bacon. Clin Breast Cancer. 2023;23(3):e77-e84. doi:10.1016/j.clbc.2023.01.004 2. Weber WP, Soysal SD, Fulco I, et al. Standardization of oncoplastic breast conserving surgery. Eur J Surg Oncol. 2017;43(7):1236-1243. doi:10.1016/j.ejso.2017.01.006 3. Clough KB, Ihrai T, Oden S, Kaufman G, Massey E, Nos C. Oncoplastic surgery for breast cancer based on tumour location and a quadrant-per-quadrant atlas. Br J Surg. 2012;99(10):1389-1395. doi:10.1002/bjs.8877

Purpose: Donor site selection in autologous fat grafting is often guided by availability and surgeon preference rather than biologic rationale. While prior studies have compared abdominal and thigh harvest sites, the impact of isolated versus combined donor-site harvest strategies remains unclear. We evaluated whether isolated flank harvest differs from combined or non-flank donor sites in volumetric fat graft retention following breast reconstruction using objective three-dimensional imaging.

Methods: A retrospective review was conducted of 51 patients who underwent autologous fat grafting following mastectomy and breast reconstruction between 2021 and 2024. Volumetric retention was quantified using preoperative and ≥3-month postoperative three-dimensional surface imaging, with volume change calculated in Autodesk Meshmixer. Donor site was categorized as isolated flank harvest versus combined or non-flank harvest (including flank combined with thigh or abdomen, and thigh-only harvest). Linear regression evaluated the association between donor site and retention, adjusting for processing technique.

Results: Among 51 patients (mean age 52.0 ± 10.4 years; BMI 26.4 ± 5.0 kg/m²), mean overall volumetric retention was 55.3 ± 29.8%. Donor site groups did not differ significantly in age (p = 0.449), BMI (p = 0.622), radiation history (p = 0.428), processing technique distribution (p = 0.584), or injected volume (p = 0.452). Isolated flank harvest (n=28) demonstrated higher mean retention compared with combined or non-flank sites (n=23; 65.3% vs 44.8%). In regression analysis adjusting for processing technique, isolated flank harvest was associated with a +20.7% increase in retention, though this did not reach statistical significance (p = 0.28).

Conclusion: Isolated flank harvest demonstrated higher volumetric retention compared with combined or non-flank donor sites, although this difference did not reach statistical significance. These findings suggest that harvest strategy may influence graft performance and warrant further investigation in larger, prospectively designed cohorts using objective three-dimensional volumetric assessment.

Purpose: Neoadjuvant therapy for breast cancer has expanded beyond traditional chemotherapy, with increasing incorporation of immunotherapy and targeted agents into contemporary treatment regimens. Programmed death-1 (PD-1) inhibitors block immune checkpoint signaling and restore T cell-mediated antitumor activity. Dual human epidermal growth factor receptor 2 (HER2) targeted therapy, trastuzumab/pertuzumab, blocks tumor cell HER2 receptors to inhibit growth. Although these agents improve oncologic response rates, their impact on breast reconstructive outcomes remains uncertain. This study evaluates the effect of neoadjuvant PD-1 inhibitor immunotherapy and dual HER2 blockade agents on postoperative outcomes after immediate implant-based reconstruction (IBR).

Methods: We performed a retrospective cohort study of patients undergoing immediate tissue-expander or direct-to-implant breast reconstruction from January 2019 to December 2024. Demographics, oncologic variables, surgical details, and postoperative complications were collected. Postoperative complications analyzed included unplanned reoperation, hematoma, seroma, infection, delayed wound healing, mastectomy skin flap necrosis (MSFN), nipple-areolar complex (NAC) necrosis, capsular contracture, malposition, fat necrosis, device failure (implant deflation or leakage), extrusion, unplanned exchange, and explant. Patients were first stratified by exposure to neoadjuvant chemotherapy (NACT). Within the NACT-exposed cohort, patients were stratified first by treatment with PD-1 inhibitors and then by treatment with dual HER2 blockade agents and compared to treatment with NACT alone. Patients were excluded if they received neoadjuvant endocrine therapy, or other targeted systemic agents.

Results: Of 617 patients (1,094 breasts), 195 (344 breasts) received NACT, and 422 (750 breasts) did not. NACT-exposed breasts demonstrated higher rates of overall infection (23.0% vs 17.6%, P=.038), infection requiring intravenous antibiotics (16.9% vs 10.7%, P=.004), and explantation (14.5% vs 6.9%, P<.001), but lower rates of MSFN (1.5% vs 5.1%, P=.004), NAC necrosis (3.8% vs 7.7%, P=.014), and unplanned exchange (3.2% vs 6.9%, P=.014). Among patients who received NACT, 48 patients (87 breasts) also received a PD-1 inhibitor, while 147 patients (257 breasts) received NACT alone. PD-1 inhibitor therapy was associated with higher rates of capsular contracture compared to NACT alone (23.6% vs 11.6%, P=.005). On multivariable logistic regression adjusting for covariates significant on univariable analysis, PD-1 inhibitor therapy remained the only independent predictor of capsular contracture (OR 2.53, 95% CI 1.26–5.08; P=.009). No significant differences were observed in other postoperative complications. Among patients who received NACT, 63 patients (113 breasts) also received a HER2 blockade targeted agent, while 132 patients (231 breasts) received NACT only. The addition of neoadjuvant dual HER2 blockade did not increase the risk of any individual breast complication (all P>.082).

Conclusion: NACT was associated with increased postoperative infection and explantation, yet decreased rates of MSFN and NAC necrosis following immediate IBR. Within the neoadjuvant cohort, PD-1 inhibitors independently predicted capsular contracture, whereas dual HER2 blockade did not increase reconstructive morbidity. As immunotherapy and targeted agents are increasingly incorporated in neoadjuvants regimens, they do not appear to broadly compromise IBR outcomes. The independent association between PD-1 inhibitors and capsular contracture highlights the need to better define how immune checkpoint modulation and treatment timing influence capsular fibrosis in this setting.

Background Postmastectomy breast reconstruction is a critical component of comprehensive breast cancer care and is associated with improved quality of life and psychosocial outcomes. Despite federal mandates and national efforts to improve access, reconstruction rates remain highly variable across geographic regions in the United States. The role of local plastic surgeon workforce availability as a structural determinant of reconstruction access has not been rigorously examined at a longitudinal, population level. We performed a county-level, 23-year analysis linking national cancer registry data with healthcare workforce data to evaluate whether plastic surgeon density is independently associated with postmastectomy breast reconstruction utilization.

Methods Using the Surveillance, Epidemiology, and End Results Research Plus database (17 registries, 2000–2022) linked with the Area Health Resources File (2020-2022), we conducted a county-year–level analysis of female patients with primary breast cancer undergoing mastectomy. Immediate breast reconstruction was identified using registry procedural variables. County-level exposures included population-level plastic surgeon density (per 100,000 female residents), overall physician density, rurality, and state. Multivariable linear regression models assessed the association between plastic surgeon density and reconstruction percentage, adjusting for temporal trends and county-level healthcare characteristics. Reconstruction was analyzed overall and stratified by implant-based and autologous techniques.

Results The final cohort included 14,007 county-years across 11 states. The mean postmastectomy reconstruction rate was 21.1% (standard deviation 21.7), with substantial geographic heterogeneity. Over time, reconstruction utilization increased steadily, while mastectomy incidence declined modestly. In adjusted analyses, higher population-level plastic surgeon density was independently associated with higher reconstruction rates. Each additional plastic surgeon per 100,000 female residents was associated with a 0.7 percentage-point increase in overall reconstruction utilization (95% confidence interval 0.5–0.9, p<0.001). This association persisted for implant-based reconstruction (β 0.4, p<0.001) and autologous reconstruction (β 0.2, p<0.001) and was robust when workforce was alternatively defined as plastic surgeons per 1,000 physicians. In contrast, overall physician density was not independently associated with reconstruction rates. Rurality was inversely associated with reconstruction utilization (β −0.09 per percentage-point increase in rural population, p<0.001). State-level differences remained pronounced, with median county reconstruction rates ranging from 10.2% in Louisiana to 37.6% in New Jersey. When county-years were stratified by plastic surgeon density, reconstruction rates increased stepwise across density categories, with the lowest rates observed in counties without plastic surgeons.

Conclusions In this large, longitudinal county-level analysis, plastic surgeon workforce distribution was strongly and independently associated with immediate postmastectomy breast reconstruction utilization. Counties with greater plastic surgeon density consistently demonstrated higher rates of both implant-based and autologous reconstruction, whereas rurality was associated with lower utilization. These findings suggest that reconstructive access is shaped not only by patient-level factors but also by structural workforce distribution. Policy strategies aimed at reducing disparities in breast reconstruction following mastectomy may require addressing geographic maldistribution of plastic surgeons and strengthening regional reconstructive capacity.

Background: Body mass index (BMI) is a critical determinant in autologous breast reconstruction. Although low BMI is commonly perceived as a limitation for autologous reconstruction, patients in this cohort demonstrated greater satisfaction with autologous reconstruction compared with implant-based reconstruction (1). Conversely, patients with higher BMI typically have adequate abdominal tissue; however, these procedures require a long transverse abdominal incision that may introduce donor-site morbidity. Because higher BMI is independently associated with wound healing complications, minimizing abdominal incision burden may be particularly advantageous in this population (2). The omental fat-augmented free flap (O-FAFF), harvested laparoscopically through small port sites, may expand autologous options at both ends of the BMI spectrum. We compared O-FAFF outcomes among low (<18.5), normal (18.5–24.9), and high (≥25) BMI patients. Methods: A retrospective review was performed of consecutive O-FAFF breast reconstructions by a single surgeon. Outcomes included major and minor complications, abdominal donor-site morbidity, and revision procedures. Fisher's exact test was used for unadjusted analyses, and logistic regression models adjusted for preoperative radiotherapy. Results: Seventy-seven O-FAFF reconstructions were analyzed (12 low BMI, 51 normal BMI, 14 high BMI). Overall complication rates were 25.0% (4/12), 11.8% (6/51), and 21.4% (3/14), respectively, with no significant difference between cohorts (global Fisher p=0.4028). Major complications were rare: 8.3% (1/12) in low BMI (seroma requiring drainage), 7.1% (1/14) in high BMI (debridement), and 0% in normal BMI (p=0.1111). Delayed wound healing occurred more frequently in low BMI patients (16.7% vs 0% in normal and high BMI; global p=0.0226), though this did not remain significant after adjustment for radiation. Importantly, there were no abdominal donor-site complications of any kind in high BMI patients (0/14), including infection, wound dehiscence, delayed healing, or hypertrophic scarring. Revision procedures were common across cohorts as part of staged reconstructive refinement: 87% in low BMI, 64% in normal BMI, and 59% in high BMI patients. There was no significant difference in overall revision patterns between BMI groups. However, high BMI patients more frequently underwent implant placement at the time of revision (20% vs 0% in low BMI and 13% in normal BMI) (Figure 1). Notably, the combined weight of transferred omentum and supplemental fat grafting approximated mastectomy specimen weight across all BMI categories (Figure 2). Conclusion: O-FAFF demonstrates comparable minor and major complication rates across BMI categories, supporting its safety across a broad body habitus spectrum. For low-BMI patients, O-FAFF expands autologous options beyond implants. For higher-BMI patients, laparoscopic harvest with minimal abdominal incision burden may mitigate donor-site morbidity in a population predisposed to wound complications.

1. Weichman KE, Broer PN, Thanik VD, et al. Patient-Reported Satisfaction and Quality of Life following Breast Reconstruction in Thin Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients. Plast Reconstr Surg. 2015;136(2):213-220. doi:10.1097/PRS.0000000000001418
2. Barnes LL, Lem M, Patterson A, et al. Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction. Plast Reconstr Surg. 2024;153(3):553-566. doi:10.1097/PRS.0000000000010621

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 are limited by the small sample sizes of the stage IV patients undergoing reconstruction (1–3). Using a decade of NSQIP data, this retrospective study aims to clarify the profile and surgical outcomes of stage IV patients undergoing immediate breast reconstruction with implant or tissue expander placement.

Methods: Ten years of NSQIP participant user file (PUF) data from 2015 to 2024 were filtered to include mastectomy with current procedural terminology (CPT) codes 19301-19307 with concurrent reconstructive codes 19340 (immediate implant placement) and 19342 (tissue expander placement) to capture immediate prosthetic 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, Fisher's exact, and/or independent t-tests in STATA 15 with significance at alpha < 0.05.

Results: Among 22,990 patients undergoing immediate breast reconstruction post-mastectomy, 22,822 stage 0-III and 138 stage IV cases were identified. No significant differences in demographic information or preoperative risk factors were observed between cohorts except higher rates of steroid therapy in the stage IV group (10%, n=17; p<0.001). Additionally, stage IV patients more frequently experienced unilateral surgery (77%, n=183) than stage 0-III patients (56%, n=16,289; p<0.001). Additionally, inpatient hospitalization was more likely to occur among stage IV patients (59%, n=139) while this occurred in 39% (n=11,320) of cases without dissemination (p<0.001). No significant difference in 30-day surgical outcomes of unplanned reoperation, surgical site infection, or dehiscence were observed. However, the stage IV group demonstrated significantly higher rates of unplanned readmission (9%, n=15 ; p=0.003).

Conclusions: Historically, stage IV patients have been excluded from breast reconstruction due to perceived risk. Growing evidence, however, suggests that candidates eligible for reconstruction tolerate the procedure and experience improved quality of life postoperatively (3). The results of this ten-year retrospective analysis support on a larger scale that this stage IV population, although more likely to receive conservative management with increased readmission rates, does not exhibit different 30-day surgical outcomes than other cancer stages following immediate prosthetic 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. 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: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is a common autologous technique using abdominal skin and fat to create a breast mound. Proton pump inhibitors (PPIs), widely prescribed for gastrointestinal disorders, have been linked to impaired wound healing and increased infection risk. Their effect on postoperative outcomes in DIEP flap reconstruction remains unclear. This retrospective cohort study evaluates the association between preoperative PPI use and postoperative complications in patients undergoing DIEP flap reconstruction.

Methods and Materials: Female patients aged 18 years and older who underwent DIEP flap breast reconstruction between 2016 and 2024 were identified in the TriNetX Research Network using ICD-10 codes. Chronic PPI use, defined as three or more prescriptions within one year prior to surgery, was compared with no documented PPI use. Primary outcomes included postoperative infection, wound disruption, skin flap necrosis, breast fat necrosis, seroma, hematoma, sepsis, cellulitis, and postprocedural pain. Propensity score matching controlled for age, race, ethnicity, BMI, substance use, major comorbidities, chemotherapy, radiotherapy, and GERD/peptic ulcer disease. Multivariable Cox proportional hazards regression estimated hazard ratios (HRs) with 95% confidence intervals at 60 days postoperatively.

Results: After matching, each cohort included 648 patients. At 60 days, infection occurred in 7.66% of PPI users and 4.71% of non-users. PPI use was associated with significantly increased hazard of postoperative infection (HR 1.65, 95% CI 1.04–2.63; p = 0.03). No significant differences were found in wound disruption, skin flap necrosis, breast fat necrosis, seroma, hematoma, sepsis, cellulitis, or postprocedural pain.

Conclusion: Preoperative PPI use is associated with increased postoperative infection risk following DIEP flap breast reconstruction. These findings highlight the importance of reviewing PPI therapy before elective reconstructive procedures.

Background Patients with physical and intellectual disabilities are underrepresented in plastic surgery research (1). Although breast reconstruction (BR) improves quality of life after mastectomy, patients with disabilities face significant barriers to care (2,3,4). To date, BR utilization and complication rates in this population remain unstudied.

Methods We performed a retrospective cohort study in the TriNetX global collaboration network. Adults with breast cancer who underwent mastectomy and subsequent BR within 1 year were included. Disability status (physical, intellectual, and/or sensory) documented before mastectomy defined the exposure; patients without documented disability served as comparators. Cancer diagnosis before mastectomy and BR on/after mastectomy date. The primary outcome was 90-day post-BR complications (infection, dehiscence, hematoma/seroma, bleeding, flap necrosis/failure, thromboembolism, ED visits, reoperation, inpatient admission, composite complication group), and one-year incident lymphedema post-mastectomy. Cohorts were propensity-score matched (PSM).

Results Among 33,529 eligible women with breast cancer who underwent mastectomy followed by BR, 1,396 patients with disabilities were identified and compared with 32,133 without disabilities. After 1:1 PSM, 1,396 patients remained in each cohort. In the PSM analysis, 90-day postoperative outcomes did not differ significantly between disability and non-disability cohorts, including infection (6.9% vs 7.0%), wound dehiscence (5.1% vs 5.1%), hematoma/seroma (29.7% vs 29.4%), flap failure (9.7% vs 9.7%), thromboembolism (1.4% vs 1.4%), ED visits (6.5% vs 6.6%), reoperation (17.4% vs 17.6%), composite complications (40.3% vs 40.7%), and inpatient admission (32.9% vs 33.5%). After mastectomy, lymphedema at 18 months occurred in 4.7% of patients vs 4.6%.

Conclusion This study found statistically insignificant complication rates for BR in patients with disabilities, challenging its high-risk perception. Therefore, surgical options should be offered equally to patients with and without disabilities.

References 1. Lippi L, Ferrillo M, Losco L, et al. Aesthetic Rehabilitation Medicine: Enhancing Wellbeing beyond Functional Recovery. Medicina. 2024;60(4):603. doi:10.3390/medicina60040603 2. Pačarić S, Orkić Ž, Babić M, et al. Impact of Immediate and Delayed Breast Reconstruction on Quality of Life of Breast Cancer Patients. IJERPH. 2022;19(14):8546. doi:10.3390/ijerph19148546 3. Stone EM, Bonsignore S, Crystal S, Samples H. Disabled patients' experiences of healthcare services in a nationally representative sample of U.S. adults. Health Services Research. 2025;60(4):e14598. 4. Courtney‑Long EA, Carroll DD, Zhang QC, et al. Prevalence of Cancer Screening Among Adults With Disabilities - United States, 2013. Preventing Chronic Disease. 2017;14:E28.

Introduction

Endocrine therapy (ET) is a cornerstone of treatment for hormone receptor-positive breast cancer, yet whether its systemic side effects, arthralgias, vasomotor symptoms, and fatigue, translate into impaired breast-specific quality of life following post-mastectomy breast reconstruction (PMBR) remains unknown. The BREAST-Q enables rigorous, domain-specific assessment of satisfaction with breasts, psychosocial well-being, physical well-being of the chest (PWBC), and sexual well-being (SXWB) following PMBR. Prior studies have examined the influence of reconstructive modality, timing, and radiation on these outcomes, but the specific contribution of ET to longitudinal BREAST-Q performance is underexplored. We aimed to assess the association between ET and postoperative quality of life following PMBR, controlling for comorbidities and adjuvant therapies.

Methods

We conducted a retrospective cohort study of premenopausal women (ages 18-51) who underwent PMBR at Mass General Brigham between January 2017 and February 2024. Patients were identified and screened using predefined inclusion/exclusion criteria. Of 431 patients screened, 224 met eligibility criteria: 71 in the control (no ET) group and 153 in the ET group. Autologous flap reconstruction was performed in 68 patients (18 control, 50 ET) and implant-based reconstruction in 156 patients (53 control, 103 ET). BREAST-Q domains (Satisfaction with Breasts [SWBR], PSYCH, PWBC, SXWB) were assessed at three postoperative intervals: 3 months, 6-12 months, and 2-3 years post-mastectomy. Between-group comparisons used Mann-Whitney U tests. Multivariable linear regression (MVR) models were constructed adjusting for age, BMI, race, smoking, adjuvant chemotherapy, postmastectomy radiation therapy (PMRT), reconstructive modality, reoperation status, and two separate comorbidity variables: (1) any comorbidity and (2) psychiatric comorbidity.

Results

No statistically significant differences in BREAST-Q scores were observed between ET and control groups in unadjusted analyses across any domain or timepoint (all p>0.05). However, unadjusted differences met or exceeded the minimal clinically important difference (MCID) of 3-4 points at early timepoints: at 3 months, SWBR (3 points), PWBC (4 points), and PSYCH (5 points); at 6-12 months, SWBR (11 points). In MVR models adjusting for any comorbidity, PMRT was significantly associated with lower PWBC at 3 months (β=-14.6, p=0.03), and any comorbidity was associated with higher PSYCH scores at 3 months (β=14.72, p=0.038). In models adjusting for psychiatric comorbidity, PMRT predicted lower PWBC at 3 months (β=-14.9, p=0.024), and psychiatric comorbidity demonstrated a borderline association with lower SXWB at 6-12 months (β=-9.03, p=0.05). ET was not independently associated with any BREAST-Q domain in either adjusted model (Table 1).

Conclusions

ET did not independently impair breast-specific quality of life across any BREAST-Q domain or follow-up interval after controlling for comorbidities and adjuvant therapies.. Patients receiving ET can be reassured that reconstruction-specific quality of life is preserved in the setting of ET. PMRT and psychiatric comorbidities emerged as the primary drivers of early postoperative PRO variability, with PMRT predicting lower physical well-being at 3 months and psychiatric comorbidity associated with reduced sexual well-being at 6-12 months. Clinicians should direct targeted perioperative support toward patients with psychiatric diagnoses or planned radiation to optimize recovery outcomes.

Background: Mastectomy skin flap necrosis (MSFN) remains a frequent complication following immediate breast reconstruction, delaying adjuvant therapy and increasing healthcare burdens. Although indocyanine green (ICG) angiography enables real-time intraoperative perfusion assessment, lack of standardized grading systems limits reproducibility and broader adoption. This study evaluates the predictive value of a standardized five-point grading system ("perfusion grade") combined with quadrant-level perfusion (QP) mapping to establish a reproducible intraoperative framework for MSFN risk stratification.

Methods: A cohort study was performed in patients undergoing skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction between May 2024 and January 2026. After mastectomy and prior to reconstruction, a single intravenous ICG bolus was administered. SPY Elite angiography was used to assign each breast a standardized five-point grade, a qualitative perfusion scale ranging from Grade 1 (diffuse, profound hypoperfusion with no capillary refill) to Grade 5 (uniform, rapid fluorescence with robust capillary refill). Grades 2–4 represent progressively improving global perfusion patterns based on fluorescence intensity and distribution. Beginning February 2025, quantitative QP values were recorded for each breast quadrant and nipple–areolar complex (when present). MSFN within 30 days was classified using the validated SKIN score. Receiver operating characteristic (ROC) curves were used to evaluate predictive performance.

Results: The cohort included 177 breasts from 100 patients. MSFN occurred in 26% (n=45) of breasts, with median onset at 9 (IQR 8–11) days. MSFN was more frequent in NSM versus SSM (39.3% vs 18.6%, p=0.005) and in patients with lower BMI (25.8±3.9 vs 27.6±5.8 kg/m², p=0.023). Breasts with MSFN had higher rates of wound complications (60% vs 12%, p<0.001).

MSFN incidence decreased stepwise with improving perfusion grade (p<0.001), occurring in 100% of Grade 1, 66.7% of Grade 2, 56% of Grade 3, 15.3% of Grade 4, and 8.3% of Grade 5 flaps. Full-thickness necrosis (SKIN D) likewise decreased with improving grade (100%, 33.3%, 8%, 4%, and 0%, respectively).

Quantitative analysis showed progressively lower QP values with worsening SKIN grade (p<0.001), most prominently in the lower outer quadrant. Average QP demonstrated the greatest discrimination for MSFN (AUC 0.785), followed by minimum QP (AUC 0.779) and qualitative grade (AUC 0.751). An average QP threshold <58.6 achieved highest sensitivity (82.4%), while qualitative grade <3.5 provided the highest specificity (82.9%).

Conclusions: A standardized five-point ICG grading system combined with quantitative perfusion mapping reliably predicts MSFN after immediate breast reconstruction. These complementary metrics support a tiered intraoperative decision-making algorithm: average QP for risk screening, minimum QP for focal ischemia identification, and qualitative grading for confirmation of flap viability prior to closure. Integration of a standardized qualitative perfusion grade with QP mapping provides complementary predictive value and offers a reproducible intraoperative framework to guide flap management and reduce postoperative necrosis.