Scientific Abstract Presentations: Breast Session 11 Sunday, October 18 Sun, Oct 18 8:00-9:30 a.m. CDT

PURPOSE: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed for type 2 diabetes mellitus and obesity management, with well-established cardiometabolic benefits. However, their effects on surgical wound healing remain underreported. This study investigates the association between perioperative GLP-1 RA use and short- and long-term postoperative outcomes following autologous breast reconstruction surgery.

METHODS: A retrospective cohort study was conducted using a large multicenter US database. Patients who underwent autologous breast reconstruction surgery and were long-term users of GLP-1 RAs perioperatively (GLP1+) were compared with matched controls who did not receive GLP-1 RAs (GLP1-). Propensity score matching (1:1) was performed based on age, race, tobacco use, diabetes mellitus, body mass index, chronic kidney disease, chronic corticosteroid use, and peripheral arterial disease, resulting in 708 patients per group. Outcomes were identified using ICD-10 and CPT codes, including surgical site infection, wound dehiscence, return to the operating room for flap necrosis, and hospital readmission, and were assessed at 30 days and 1 year post-surgery.

RESULTS: Demographic characteristics were well-balanced between the cohorts after matching. At 30 days post-surgery, the GLP1+ group demonstrated significantly lower rates of surgical site infection compared to the GLP1- group (1.6% vs 3.5%, RR 0.44, p=0.022). No significant differences were observed in rates of wound dehiscence (3.0% vs 2.4%, p=0.512), return to operating room for flap necrosis (12.3% vs 13.6%, p=0.476), or hospital readmission (5.6% vs 5.9%, p=0.820). At one-year follow-up, the GLP1+ group continued to show significantly lower surgical site infection rates (4.1% vs 7.6%, RR 0.54, p=0.007) and a reduced rate of return to the operating room for flap necrosis (31.0% vs 37.9%, RR 0.82, p=0.008). Wound dehiscence (5.2% vs 5.8%, p=0.637) and hospital readmission (11.7% vs 14.4%, p=0.129) rates remained comparable between groups.

CONCLUSIONS: Perioperative GLP-1 RA use was associated with significantly reduced surgical site infections at both 30 days and one year following autologous breast reconstruction surgery. Additionally, GLP1+ patients experienced lower rates of return to the operating room for flap necrosis at one year. These findings suggest that GLP-1 RAs may not adversely affect wound-healing outcomes and may confer protective benefits in these patients. The results support continued perioperative use of GLP-1 RAs in appropriate surgical candidates, balancing the well-established systemic cardiometabolic benefits with favorable wound-related outcomes. Further prospective studies are warranted to elucidate the mechanisms underlying these protective effects and to establish evidence-based perioperative management protocols for patients receiving GLP-1 RA therapy and undergoing autologous breast reconstruction.

Background Infection is a common and impactful complication following tissue expander (TE)-based breast reconstruction. Seroma has been shown to be a significant risk factor for infection. Dual-port TE devices allow for seroma aspiration and quantification postoperatively. We hypothesized that aspiration volume could serve as a predictor of TE infection after drain removal. Methods A retrospective review of 180 breasts in 118 patients who underwent immediate prepectoral dual-port TE-based reconstruction was conducted. Timing of infections was delineated based on drain removal. Logistic regression was used to identify infection predictors. Receiver-operating-characteristic (ROC) analysis evaluated aspiration volume's ability to predict post drain removal infections. Paired tests compared aspiration volumes between bilateral breasts within infected and non-infected patients. Results Infection occurred in 35 breasts (19.4%): 16 pre drain removal and 19 post drain removal. Infections before drain removal were significantly associated with extended drain duration (OR 1.14, p = 0.024). Post drain removal infections were significantly associated with higher median aspiration volumes (40.0 mL vs. 3.0 mL, p < 0.001). ROC analysis yielded an AUC of 0.77, with a predictive volume threshold of 18.04 mL. Bilateral comparison confirmed higher aspiration volumes in infected breasts (mean difference 23.59 mL, p = 0.01). Conclusion TE infections follow a bimodal distribution. Infections occurring prior to drain removal correlate with duration of drain use, while infections post drain removal correlate with increased postoperative seroma volume. Increased aspiration volumes signal impending infection and may benefit from intervention to prevent florid infection and potential implant loss.

February 2026 Purpose The histologic response of the periprosthetic capsule plays a critical role in implant-related complications. Antibiotic-impregnated beads are increasingly used in infected tissue expander (TE) reconstruction; however, their impact on capsule morphology remains unclear. This study evaluates whether the use of antibiotic beads is associated with differences in capsule thickness, calcification, collagen fiber organization, and lymphocytic infiltration. Methods A retrospective histologic analysis was performed on capsule specimens from infected drainless TE patients with and without antibiotic bead placement. Sections were stained with hematoxylin and eosin and analyzed using the validated semiquantitative histological assessment tool described by Larsen et al. Capsule thickness (µm) was measured excluding synovial-like metaplasia and stromal layers per standardized protocol. Fiber organization (1–3 scale; 1 being highly disorganized), lymphocytic infiltration (1–3 scale; 1 having few single lymphocyte aggregates), and calcification (present/absent) were graded according to validated criteria. The assessor was blinded to antibiotic bead status. Statistical analysis included Wilcoxon rank-sum testing for continuous and ordinal variables and Fisher's exact testing for categorical variables. Results Capsule thickness was significantly lower in the antibiotic bead group (n=25, mean 0.312 mm, median 0.2 mm, range 0.1–1.1) compared with the no-bead group (n=13, mean 1.008 mm, median 0.6 mm, range 0.2–2.8; p=0.0023). Calcification was present in 58.3% (14/24) of bead specimens and absent in all non-bead specimens (0/13; p=0.00035). No significant differences were observed in collagen fiber organization (p=0.787) or lymphocytic infiltration (p=0.686). Conclusion For patients who develop tissue expander infections, antibiotic beads appear to be a safe adjunct. Their use was not associated with heightened inflammation or disorganized fibrosis and was linked to thinner capsule formation. While calcification was more common, it did not reflect increased inflammatory burden. These findings support the continued use of antibiotic beads in expander salvage, as they do not appear to worsen capsule pathology and may favorably influence fibrotic remodeling.

Background: Reduction mammaplasty continues to grow in popularity as more patients seek symptomatic relief and aesthetic alterations to the chest wall. Previous research has noted no significant difference in outcomes related to mass of breast tissue resected, but patient counts and demographic diversity were limited. Our study seeks to evaluate the relationship between mass of breast tissue resected and surgical outcomes in a larger, more diverse cohort.

Methods: A retrospective review was conducted at a single tertiary hospital in Philadelphia from 2017 to 2024 of patients who had undergone reduction mammaplasty. Patients with a follow up time of less than 30 days were excluded from analysis. Demographic information, perioperative data, and postoperative complications were collected of the included cohort. Total volume of resected breast tissue was collected from pathology notes. Statistical analysis was conducted using a multivariable logistic regression with adjustments for age, sex, BMI, duration of surgery, and other covariates. A Receiver Operator Curve (ROC) analysis was conducted to determine thresholds above which the risk of complications increase significantly.

Results: A final count of 515 patients were included in the analysis, with a mean total breast tissue resection volume of 1408.5 ± 745.7g [135-4801g]. A majority of patients identified as African American (n=314, 67%) and had a Grade 3 ptosis prior to surgery (n=337, 65.4%). In multivariable logistic regression, increasing resection volume (per 50 g) was significantly associated with higher odds of fat necrosis (OR 1.05, 95% CI 1.02–1.07, p = 0.0009), excessive postoperative pain (self-reported) (OR 1.05, 95% CI 1.01–1.08, p = 0.0072), and seroma formation (OR 1.03, 95% CI 1.01–1.06, p = 0.0214). Conversely, larger resection volume was associated with a lower odds of developing excessively wide scars (OR 0.94, 95% CI 0.90–0.98, p = 0.0047) as noted by providers in post-operative visit notes. Associations between resection volume and other complications (NAC necrosis, wound dehiscence, cellulitis, surgical-site infection, hematoma, delayed healing, T-point breakdown, keloid formation) were not statistically significant after adjustment (p > 0.05). Additionally, there was no significant difference in readmission, reoperation, or ED visit rates based on volume resected. The ROC analysis determined an optimal threshold of 1987g, above which the risk of seroma increases significantly (15.5% vs 2.6%, p<0.001). A similar threshold was seen for excessive postoperative pain at 1823g (5.4% vs 1.4%, p=0.018). For fat necrosis, this threshold decreased to 1153g (8/2% vs 2.0%, p=0.0041).

Conclusion: In larger cohorts, mass of breast tissue resected had a significant association with certain postoperative complications, namely fat necrosis, seroma formation, and excessive postoperative pain. Our team noted a thresholds ranging from 1100 to 2000g removed from both breasts, above which the rates of these complications increased significantly. These results can inform surgeons during preoperative planning and inform discussions with patients.

BACKGROUND Implant-based reconstruction remains the most common approach to post-mastectomy breast reconstruction. Advances in surgical technique have shifted reconstructive practice from the submuscular to the prepectoral plane; however, limited data exist regarding how implant characteristics have evolved during this transition. The purpose of this study was to assess temporal trends in implant volume and projection in the context of this paradigm shift. We hypothesized that the transition from submuscular to prepectoral implant placement would be associated with the use of smaller-volume, less-projected implants, based on the premise that the pectoralis muscle may partially obscure full device projection. METHODS A single institution retrospective review was performed of patients who underwent unilateral immediate two-stage implant-based reconstruction from January 2012 to December 2024. Trends in implant volume and projection, body mass index (BMI), as well as plane of implant placement, were analyzed across the study period. Multivariable analysis was used to assess the association of patient demographic, oncologic, and surgical characteristics, including plane of implant placement, on implant volume and projection over time. RESULTS Overall, 2,032 patients were included; 403 underwent prepectoral reconstruction, and 1,629 underwent submuscular reconstruction. The median age was 52 years, 44% of patients underwent neoadjuvant chemotherapy, and 24% underwent postoperative radiation. Between 2012 and 2018, submuscular implant placement was the predominant technique at the study institution. Prepectoral implant placement gained traction in 2018, and the number of cases with this technique continued to increase as the number of submuscular cases decreased. In mid to late 2021, prepectoral plane placement became the predominant technique. The average implant volume and projection were highest in 2016 (515 cc and 5.23 cm, respectively) and lowest in 2024 (424 cc and 4.74 cm, respectively). There was no concurrent trend in BMI observed during these years. Prepectoral implant placement was associated with smaller implant volume (Beta= -20, 95% CI: -38 to -3.1, p=0.021) and lower projection (Beta= -0.17, 95% CI: -.30 to -0.05, p=0.005) compared with submuscular placement. CONCLUSION Over a 12-year period, implant selection in breast reconstruction has trended toward smaller volumes and lower projections. Although these changes may reflect evolving aesthetic preferences, our analysis suggests that the plane of implant placement may also be an important explanatory factor. This study offers contemporary insight into reconstructive practice patterns and helps inform modern implant selection strategies.

Purpose: Irrigation practices during implant-based breast reconstruction vary widely, with ongoing debate regarding the relative efficacy of antibiotic-based versus chlorhexidine-based solutions in preventing surgical site infections (SSI). During implant or tissue expander placement, the breast pocket is routinely irrigated to reduce bacterial contamination and biofilm formation prior to prosthesis insertion; there is no clear consensus regarding the optimal irrigation solution. This study aims to compare SSI rates associated with antibiotic-based vs. chlorhexidine-based irrigation solutions. Methods: A retrospective review was conducted of implant-based breast reconstruction operations performed between 2017 and 2025 at a single academic institution. Patient demographics, comorbidities, operative characteristics, surgeon volume, irrigation type, and postoperative outcomes were collected. Irrigation solutions were categorized as antibiotic-based, chlorhexidine-based, saline-based, or mixed. SSIs were identified using ICD diagnostic codes and confirmed by chart review. Infection rates were calculated on a per-breast basis. Comparative analyses were performed between irrigation groups, with secondary analyses stratified by surgeon, procedure type, laterality, and comorbidity burden. Results: A total of 1,061 operations involving 1,761 reconstructed breasts were included, performed by 16 surgeons, with the three highest-volume surgeons performing 389, 141, and 92 procedures, respectively. Irrigation distribution included 813 breasts receiving antibiotic-based irrigation, 759 receiving chlorhexidine-based irrigation, 64 receiving saline irrigation, and 113 receiving mixed irrigation. Overall SSI rates were comparable between the two primary groups, occurring in 2.6% of breasts receiving antibiotic-based irrigation and 2.2% of breasts receiving chlorhexidine-based irrigation, with no statistically significant difference detected. SSI rates were 3.1% in the saline irrigation group and 1.77% in the mixed irrigation group. Conclusion: Antibiotic-based and chlorhexidine-based irrigation demonstrate comparable SSI rates in implant-based breast reconstruction across a high-volume, multi-surgeon practice, suggesting practical equivalence in routine clinical use. Thus, irrigation choice may be influenced by surgeon preference, institutional protocols, patient-specific considerations, and cost, rather than differences in infection outcomes alone. Observed variability by surgeon and irrigation subtype underscores the importance of standardized protocols, consistent documentation, and appropriate adjustment for case mix in future comparative studies.

Introduction

Tranexamic acid (TXA) is increasingly utilized in breast surgery due to its antifibrinolytic properties and demonstrated reduction in postoperative bleeding and hematoma formation in breast reductions and augmentations. However, limited literature evaluates the impact of TXA in immediate pre-pectoral direct-to-implant (DTI) breast reconstruction, particularly with respect to route of administration. This study compares postoperative outcomes among patients receiving no TXA, topical TXA, or intravenous TXA intraoperatively in immediate pre-pectoral DTI reconstruction.

Methods

A retrospective cohort study was performed of patients undergoing immediate pre-pectoral DTI reconstruction from January 2023 to December 2025. Patients were stratified by no TXA, topical TXA, or intravenous TXA. Univariate and multivariate logistic regression analyses were conducted to assess associations between TXA route and postoperative complications while controlling confounders (p  0.05). Propensity score matched analysis was completed using 1:1 nearest neighbor matching with a caliper of 0.2, adjusting for BMI, neoadjuvant radiation, and adjuvant radiation.

Results

A total of 72 patients (134 breasts) were included, with 67 breasts in the non-TXA control group and 67 breasts in the TXA group. 24 breasts received intraoperative topical TXA while 43 breasts received intravenous TXA. Average age (47 vs. 49 years) and BMI (27.4 vs. 26.4 kg/m²) were similar between the TXA and non-TXA groups. When comparing TXA to no TXA in general, there were no significant differences in overall complications (22.4% vs. 14.9%; p=0.375). Within the TXA cohort, analysis demonstrated significantly higher complication rates with topical TXA compared to IV TXA. Overall complications were more frequent in the topical group (41.7% vs. 11.6%; p=0.012), as were major complications (25.0% vs. 4.7%; p=0.021).

Discussion

In immediate pre-pectoral DTI reconstruction, topical TXA use was associated with significantly higher rates of overall and major postoperative complications on propensity-matched analysis. These findings suggest that topical TXA administration intraoperatively may be associated with increased postoperative risk in this population and warrant further investigation before routine use is considered.

Background: Cannabis use has increased dramatically in the US, and is now more prevalent than cigarette smoking. Cannabinoids can increase microvascular vasoconstriction and are associated with increased risk of peripheral arterial disease (1), but the clinical implications of these findings on wound healing in surgery remain unclear. The risk of wound healing complications after elective breast surgery is higher in nicotine users (2,3), but it is unclear whether cannabis has a similar effect. This study examines whether preoperative cannabis use independently increased the risk of wound complications and emergency department (ED) visits following mastopexy and breast reduction. Methods: We utilized a federated research network encompassing 44 healthcare organizations (TriNetX) to identify patients undergoing mastopexy or breast reduction surgery. The experimental cohort consisted of patients with a documented preoperative cannabis use diagnosis, while the control cohort included patients without a cannabis-related diagnosis. Patients with concurrent substance abuse diagnoses (cocaine, methamphetamines) were excluded from both cohorts to isolate the effect of cannabis. Propensity score matching (1:1) was performed to balance age, sex, race/ethnicity, nicotine use, type 2 diabetes, alcohol-related disorders, obesity, anxiety disorders, depressive episodes, and procedure type. Outcomes were assessed within a 90-day postoperative window, and included wound dehiscence, seroma/hematoma, surgical site infection (SSI), and ED visits. ED visits were also evaluated at a 30-day window. Results: Following propensity score matching, 2,448 patients were included in the final analysis (n=1,224 per cohort). Cannabis use was associated with a higher rate of wound dehiscence (5.6% vs 3.8%; RR 1.5, 95% CI 1.04–2.16; p=0.028) and seroma/hematoma formation (3.6% vs 2.1%; RR 1.7, 95% CI 1.05–2.73; p=0.029). SSI rates did not differ between cohorts (3.7% vs 3.0%; RR 1.2, 95% CI 0.79–1.87; p=0.369). The strongest effect was observed for ED utilization: cannabis users had higher 30-day ED visit rates (14.2% vs 11.1%; RR 1.28, 95% CI 1.04–1.58; p=0.021), an association that strengthened at 90 days (25.1% vs 18.1%; RR 1.38, 95% CI 1.19–1.61; p<0.001). Conclusion: Preoperative cannabis use is independently associated with increased rates of wound dehiscence, seroma/hematoma, and emergency department utilization following breast reduction and mastopexy. However, risk of surgical site infection is not increased. Surgeons are well aware of the increased risk of postoperative complications caused by nicotine use, but given the rising prevalence of cannabis use in the population, plastic surgeons should incorporate preoperative screening and appropriate counseling regarding cannabis use before breast surgery.

1. Agrawal SP et al. Marijuana and Peripheral Vascular Disease: Pathophysiology, Clinical Evidence, and Cardiovascular Implications. Cardiol Rev. 2025 Sep 19.
2. Hillam JS et al. Smoking as a risk factor for breast reduction: An analysis of 13,503 cases. J Plast Reconstr Aesthet Surg. 2017 Jun;70(6):734-740
3. Posso AN et al. Impact of non-tobacco nicotine use on postoperative complications in breast reduction: A propensity score-matched analysis. J Plast Reconstr Aesthet Surg. 2025 Nov:110:80-88

Introduction: Glucagon-like peptide-1 (GLP-1) receptor agonists have demonstrated efficacy in the management of obesity and diabetes, but their effects on postoperative outcomes have not yet been clearly established (1-4). Furthermore, studies evaluating perioperative GLP-1 receptor agonist use in prosthetic breast reconstruction remain limited.

Purpose: The aim of this study was to evaluate the outcomes of individual breasts on GLP-1 receptor agonists undergoing expander- and implant-based breast reconstruction.

Methods: A retrospective review of patients undergoing prosthetic-based breast reconstruction between November 2022 and October 2025 at a single institution was conducted. Patients were stratified based on perioperative GLP-1 agonist use.

Results: A total of 883 individual breasts were included in this analysis. The mean age of individual breasts on GLP-1 agonists (n=84) was 51 years old (SD 7.82) with an average BMI of 29.4kg/m2 (SD 4.68). Compared to the control group, perioperative GLP-1 agonist use was not significantly associated with unplanned prosthetic removal (18.2% vs. 19.0%, p=0.965) or development of infection within 90 days of operation (11.0% vs. 16.9%, p=0.159), despite a 1.64 times higher odds for infection in the GLP-1 group (OR 1.64; 95% CI: 0.32 – 1.23). The GLP-1 group showed no significant association with prosthetic removal due to seroma (0.5% vs 1.2%, p=0.395), hematoma (1.5% vs 0%, p=0.618), wound dehiscence (3.5% vs 1.2%, p=0.331), or abandoning reconstruction (2.4% vs 0%, p=0.244).

Conclusions: Perioperative use of GLP-1 agonists before prosthetic-based breast reconstruction showed a marginally increased risk of developing postoperative infection, though non-significant. These findings may reflect limited statistical power due to the relatively small sample size of the GLP-1 cohort. Given this data, further investigation is needed to evaluate and standardize the optimal duration of GLP-1 receptor agonist discontinuation prior to breast reconstruction to improve patient outcomes.

References: 1. Wang JY, Wang QW, Yang XY, et al. GLP-1 receptor agonists for the treatment of obesity: Role as a promising approach. Front Endocrinol (Lausanne). 2023;14:1085799. doi:10.3389/fendo.2023.1085799 2. Salingaros S, Zhang A, Rohde CH, Spector JA. Active GLP-1 RA Use Is Associated With Lower Rates of Surgical Complications Across Diabetic BMI Cohorts: A Retrospective Analysis of 72,578 Surgical Encounters. Ann Plast Surg. Feb 13 2026;doi:10.1097/sap.0000000000004657 3. Aschen SZ, Zhang A, O'Connell GM, et al. Association of Perioperative Glucagon-like Peptide-1 Receptor Agonist Use and Postoperative Outcomes. Ann Surg. Apr 1 2025;281(4):600-607. doi:10.1097/sla.0000000000006614 4. Friedman O, Tal D. Breast implant explantation with mastopexy in patients using GLP-1 receptor agonizts: A retrospective comparative analysis. J Plast Reconstr Aesthet Surg. Dec 2025;111:76-85. doi:10.1016/j.bjps.2025.09.028

Purpose Multifocal and multicentric breast cancers are defined by two or more invasive or in situ carcinomas in the same or different quadrants of the breast, respectively. These multiple ipsilateral breast cancers (MIBCs) have traditionally been managed with mastectomy. However, recent prospective data demonstrated low (3.1%) recurrence rates in patients with MIBCs following breast-conserving surgery (BCS) (1). Oncoplastic reduction mammoplasty (ORM) has an established oncologic safety profile in unifocal breast cancer, but remains limited in MIBC despite its potential to expand breast-conserving options (2). This study aims to assess oncologic outcomes of ORM for MIBC compared with unifocal BCS and to test the hypothesis that ORM is a viable and safe option for MIBC patients seeking BCS over mastectomy.

Methods Patients with MIBC who underwent bilateral ORM for unilateral breast cancer at a high-volume, single academic institution from January 2019 to December 2025 were identified in electronic medical records using procedure codes for reduction mammaplasty and partial mastectomy. Demographics, tumor characteristics, and postoperative outcomes were collected. Univariate analyses compared surgical and oncologic outcomes with established outcomes following ORM for unifocal disease.

Results A total of 71 patients were included. Median age at ORM was 53 years (IQR: 45-61 years) and median follow-up was 17.6 months. Partial mastectomy and ORM were performed concurrently in 68 (95.8%) patients. Median tumor size by largest dimension was 22mm (IQR: 16-35mm). Positive margin and re-excision rates were 9.9% and 6.5%, respectively. Two patients with ductal carcinoma in situ and positive margins did not undergo re-excision as resection includded dissection down to the pectoral fascia. One (1.4%) local recurrence and one (1.4%) distant metastatic event occurred during follow-up. The most common postoperative complications were dehiscence (25.3%), infection (25.3%), and seroma (15.5%). Nipple or nipple-areolar complex necrosis occurred in 2 (2.8%) cases and no patients required conversion to mastectomy. The median time from ORM to adjuvant therapy was 66 days (IQR: 54-78 days) and the majority (84.5%) of patients began adjuvant therapy within 10 weeks of ORM. Revision surgery was completed by 6 (8.5%) of patients.

Conclusion These findings demonstrate that concurrent ORM and partial mastectomy for MIBCs can be performed with low local recurrence and acceptable oncologic outcomes when compared to established benchmark rates of 6% (95% CI: 3-12%) for re-excision and 10% (95% CI: 6-17%) for positive margins in unifocal disease (2). Postoperative complications occurred; however, delays to adjuvant therapy were limited to a minority of patients. Importantly, no patients required conversion to mastectomy, which supports that ORM is a safe and feasible option for patients with MIBC who are seeking breast-conserving surgical options over mastectomy.

References 1. Boughey JC, Rosenkranz KM, Ballman KV, et al. Local Recurrence After Breast-Conserving Therapy in Patients With Multiple Ipsilateral Breast Cancer: Results From ACOSOG Z11102 (Alliance). J Clin Oncol. 2023;41(17):3184-3193. doi:10.1200/JCO.22.02553. 2. Tekdogan B, Martineau J, Scampa M, Kalbermatten DF, Oranges CM. Oncoplastic reduction mammoplasty: Systematic review and proportional meta-analysis of surgical outcomes. J Plast Reconstr Aesthet Surg. 2024;89:86-96. doi:10.1016/j.bjps.2023.11.052.

Purpose: Breast augmentation and implant-based breast reconstruction remain among the most commonly performed procedures in plastic surgery, with ongoing debate on optimal implant pocket plane selection (1). Subpectoral placement provides reliable soft tissue coverage but is associated with animation deformity, leading to increased prepectoral implant placement and secondary pocket conversion to the prepectoral plane (2,3). Capsular contracture remains a significant complication of implant-based surgery, with higher rates estimated in prepectoral versus subpectoral implant placement (4). However, its incidence following pocket conversion remains incompletely defined, particularly in aesthetic breast augmentation. The purpose of this study was to evaluate capsular contracture following subpectoral to prepectoral pocket conversion and to compare outcomes between reconstructive and aesthetic cohorts.

Methods: A retrospective chart review was performed of all adult patients undergoing implant pocket conversion from the subpectoral to the prepectoral plane at a single-surgeon practice from August 2003 to January 2026. Charts were reviewed for demographics, operative management, and postoperative complications. The primary outcome was capsular contracture, considered positive at a Baker grade III or greater. Outcomes were compared between reconstructive and aesthetic cohorts using a Chi-squared analysis. A p-value <0.05 was considered statistically significant.

Results: A total of 102 women (194 breasts) underwent pocket change from subpectoral to prepectoral plane and were included in our analysis. The cohort was subdivided in 52 reconstructive patients (96 breasts) and 50 aesthetic patients (98 breasts). Mean age at operation was 50 years old overall (51 y.o. reconstructive, 49 y.o. aesthetic). At mean follow-up of 26.9 months (0.3-281.3 months), capsular contracture was present in 39 breasts (20.1%) overall, including 19 breasts (19.8%) of the reconstructive cohort and 20 breasts (20.4%) of the aesthetic cohort (p= 0.915).

Conclusions: Subpectoral to prepectoral pocket conversion leads to similar capsular contracture incidence across reconstructive and aesthetic breast implant placement. These findings are consistent with previously found rates of capsular contracture following pocket change in implant-based breast reconstruction (1.6% -21.1%), but higher than rates of capsular contracture following initial implant placement for both aesthetic or reconstructive settings (3,5). This study provides additional insight regarding outcomes following pocket conversion and may assist surgeons in counseling patients undergoing revision implant surgery.

References: 1) American Society of Plastic Surgeons. 2024 Complete Plastic Surgery Statistics Report. Accessed November 20, 2025. 2) Hidalgo DA. Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg. 2000 May;105(6):2202-16. 3) Hammond DC, Schmitt WP, O'Connor EA. Treatment of breast animation deformity in implant-based reconstruction with pocket change to the subcutaneous position. Plast Reconstr Surg. 2015;135(6):1540-1544. 4) Li S, Mu D, Liu C, et al. Complications Following Subpectoral Versus Prepectoral Breast Augmentation: A Meta-analysis. Aesthetic Plast Surg. 2019;43(4):890-898. 5) Cerceo JR, Cai L, Yesantharao P, Thornton B, Nazerali R. Risk stratification in subpectoral to prepectoral pocket conversion to reduce post-reconstruction animation deformity. J Plast Reconstr Aesthet Surg. 2023;77:253-261.

Purpose:

Public concern regarding the safety of breast implants has risen over the past decade, with social media accelerating the spread of patient experiences and apprehensions. Prior analyses found that negative online sentiment about breast implant illness (BII) was associated with increasing explantation rates.1 However, these relationships were significantly confounded by heightened fear of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), which peaked in 2019 following the FDA recall of textured implants, and independently drove explantation trends.1 The purpose of this study is to evaluate the relationship between social media sentiment specific to systemic symptoms associated with breast implants (SSBI) - formerly known as BII - and verifiable FDA reports of these symptoms, rather than explantation rates alone. This approach minimizes confounding from concurrent BIA-ALCL–related anxiety or explanation due to other indications or societal trends to determine whether online sentiment correlates more directly with documented SSBI reports.

Methods:

The FDA Manufacturer and User Facility Device Experience (MAUDE) database was queried from 2015–2023 containing the terms "breast implant illness", "BII", or "systemic symptoms" for reports related to SSBI. Posts from the social media platform X (formerly Twitter) mentioning "breast implant illness" were collected from 2015–2023. All posts and reports were verified for inclusion by multiple reviewers for relevance, and duplicate entries were removed prior to analysis. X posts were then analyzed using two transformer-based natural language processing (NLP) models that classified each post by sentiment (positive or negative) and emotion (fear, sadness, anger, disgust, neutral, surprise, and joy). Temporal correlation analyses were performed between annual counts of specific sentiments and emotions with SSBI MAUDE reports via the Pearson correlation coefficient. P-values were calculated with statistical significance set at p < 0.05.

Results:

Between 2015 and 2023, there were 3,667 MAUDE reports of SSBI and 6,095 posts on X related to BII. Both X posts (1,509) and SSBI MAUDE reports (1,015) peaked in 2019. FDA report volume most strongly correlated with posts expressing fear (r = 0.910, p = 0.0007) and negative sentiment (r = 0.936, p = 0.0002). These correlations are substantially stronger than those previously reported associations between negative social media sentiment and explantation rates (r = 0.728).1

Conclusion:

Fear-driven and negative social media discourse show a strong correlation with FDA SSBI reports underscoring the influence of online sentiment on patient perception, behavior, and symptom attribution. The stronger correlations observed in this study compared to prior explanation-based analyses indicate that isolating SSBI reports minimizes the confounding effects of BIA-ALCL–related concern or other external influences that may inform patients' decision to undergo breast implant explanation, and more accurately captures patient attitudes. Healthcare providers should recognize that fluctuations in online sentiment can precede changes in patient behavior, emphasizing the importance of proactive communication and education in aesthetic and reconstructive breast surgery.

Citations:

1. Fijany AJ, Holan CA, Bishay AE, et al. Beyond the Posts: Analyzing Breast Implant Illness Discourse With Natural Language Processing and Deep Learning. Aesthet Surg J. Jun 16 2025;45(7):745-752. doi:10.1093/asj/sjaf047

Introduction: Autologous breast reconstruction offers sustained patient satisfaction and quality of life, though access is shaped by complex reimbursement structures. Procedures like DIEP flaps are reimbursed using S-codes, which better reflect the time and expertise required (1).

In 2021, the CPT Editorial Panel revised CPT 19364 to include DIEP flap and autologous free flap reconstructions (2). Several commercial insurers subsequently discontinued S-code reimbursement in favor of CPT 19364 (3). In 2022, CMS announced S-codes would be discontinued effective December 31, 2024 (4). Although they reversed this decision in 2023, many payers had already transitioned, creating uncertainty regarding access and financial sustainability (4). Given estimates suggesting substantial reductions in surgeon reimbursement under exclusive CPT-based payment, this study evaluates the impact of these S-code changes on autologous free flap breast reconstruction utilization in a large claims database (1).

Methods: We conducted a retrospective cohort study using the Merative MarketScan databases (January 2007–December 2023). All free flaps were identified using CPT 19364 or S-codes S2066–S2068, regardless of reconstruction timing. For utilization analyses, quarterly rates per 100 mastectomies were calculated, and interrupted time series (ITS) analyses with segmented regression assessed immediate changes and post-intervention trends following the 2021 CPT clarification. Analyses were stratified by coding type and patient Metropolitan Statistical Area (urban versus rural).

Reimbursement analyses used a separate cohort of delayed flaps to isolate reconstruction-specific costs. Reimbursement values per claim were adjusted to 2023 U.S. dollars, and temporal changes were analyzed with gamma regression.

Results: A total of 19,505 autologous free flap breast reconstruction procedures were identified for utilization analyses, 51.6% billed using CPT 19364 and 48.4% billed using S-codes. Prior to 2021, reconstruction rates increased significantly among both urban and rural groups. ITS analyses demonstrated a significant immediate decline in S-code use after 2021. CPT-coded procedures showed no immediate change overall; however, utilization increased significantly over time among urban patients. Total flap rates declined immediately in rural patients, yet continued to increase overall across cohorts at pre-2021 rates.

Median reimbursement among 2,597 delayed flaps was higher for S-coded than CPT-coded procedures ($11,451 vs $6,331; p<0.001), with gamma regression confirming lower payments post-2021 (p<0.001).

Conclusions: The 2021 CPT clarification was associated with immediate S-code declines, transient reductions in rural reconstruction, and a gradual rise in CPT-coded procedures among urban patients, while overall reconstruction rates maintained their pre-2021 growth trajectory. These findings suggest that reimbursement changes may be associated with geographic shifts in access to autologous breast reconstruction, particularly among rural populations.

References: 1. Rochlin D, Matros E, Lee C, Sheckter C. The Financial Impact of S Code Termination for Autologous Breast Reconstruction: Considerations for Patient Access. Plast Reconstr Surg. 2024;153(3):658e. doi:10.1097/PRS.0000000000010983 2. Kozlow J, Adler E, French C. A look at new changes coming to E&M and breast coding in 2021. Plast Surg News. December 2020. https://www.plasticsurgery.org/documents/medical-professionals/health-policy/psn-cpt-cornerdec-20.pdf 3. Free Flap Breast Reconstruction - Horizon Blue Cross Blue Shield of New Jersey. Accessed April 13, 2025. https://www.horizonblue.com/providers/policies-procedures/policies/reimbursement-policies-guidelines/free-flap-breast-reconstruction 4. Greco G. Reconsideration of S codes Associated with Breast Reconstruction Procedures. June 1, 2023. https://www.plasticsurgery.org/documents/advocacy/ASPS-CommentsBreast-Reconstruction-CMS-HCPCS_06-01-2023.pdf

The lumbar artery perforator (LAP) flap is a technically demanding option for autologous breast reconstruction in patients who lack sufficient tissue for profunda artery perforator or abdominally based flaps. Because of its technical difficulty, the LAP flap is still an evolving option in the field of breast reconstruction. As a result, published experience remains limited, and factors modulating operative efficiency and clinical outcomes are not well defined. This study evaluates patient and technical predictors of microsurgical efficiency and outcomes in the largest reported consecutive series of LAP flaps. A retrospective review of LAP flaps performed at a single institution by two surgeons from December 2018 to December 2025 was conducted. To quantify practice patterns, cases were stratified into three chronological eras (Eras 1-3, n=115 each). Multivariate regression was used to identify independent predictors of operative duration, flap ischemia time, microsurgical outcomes, length of hospital admission, and postoperative complications, with microsurgical and donor-site outcomes stratified by flap and flank.
Most reconstructions were bilateral (87.5%) and performed in a delayed fashion following mastectomy. Multi-flap (stacked) reconstruction was performed in 52.1% of cases. Median patient BMI was 25.1 (IQR 4.5). Median hospital length of stay differed across eras (Era 1: 3 [1] days; Era 2: 4 [3] days; Era 3: 5 [2] days; p<0.001). Mean operative duration was 547.2 ± 126.2 minutes and differed significantly across eras (p=0.007), wherein practice patterns evolved from a 100% co-surgeon model in Era 1 to a 100% single-surgeon model in Era 3 (p<0.001), accompanied by transition from a double position-change approach (supine-prone-supine) to a single position change (prone-supine). Operative time among co-surgeon cases decreased slightly from Era 1 to Era 2 (505.3 vs. 498.9 minutes). The transition to single-surgeon cases in Era 2 was associated with an increase in operative duration (612.6 minutes), followed by improved efficiency in Era 3 when procedures were performed exclusively by a single surgeon (559.4 minutes). Median flap ischemia time increased significantly across eras (106.0 vs. 173.0 vs. 228.0 minutes; p<0.001). Donor site complication rates were similar across eras (30%, p=0.566) as were rates of flap failure (4.9%, p=0.742), microsurgical complications (15.7% p=0.631), postoperative flap complications (17.7%, p=0.87), and takeback (8.7%, p=0.72).
On multivariate analysis, longer operative duration was independently associated with bilateral reconstruction (p<0.001), multi-flap reconstruction (p=0.002), higher BMI (p<0.001), two position changes (p<0.001), and a single-surgeon approach (p<0.001). Longer flap ischemia time was independently associated with multi-flap design (p=0.002), while a single position change was associated with shorter ischemia time (p=0.014). BMI independently predicted flap loss (p=0.015), and multi-flap reconstruction predicted postoperative flap complications (p=0.001). Surgeon model (co- vs. single surgeon) was not associated with flap failure or microsurgical complications. Longer hospital stay was independently associated with multi-flap reconstruction (p<0.001) and higher BMI (p<0.001) In this large consecutive series of 345 LAP flaps, assessment of practice patterns and independent predictors demonstrates that this complex reconstruction can be performed with consistent outcomes despite evolution in operative approach to meet an evolving patient population and institutional demands. These data add to the limited literature supporting the LAP flap as a reliable option despite technical complexity.