Wise-Pattern Mastectomy with an Inferior Dermal Sling: A Viable Alternative to Elliptical Mastectomy in Prosthetic-Based Breast Reconstruction.

BACKGROUND: Prosthetic-based postmastectomy breast reconstruction in patients with large or pendulous breasts remains challenging because of inelastic and redundant skin, with various approaches to skin reduction at the time of mastectomy. This study describes the authors' experience with a Wise-pattern inferior dermal sling approach to skin-sparing mastectomy. METHODS: Retrospective chart review was performed on patients who underwent immediate prosthetic-based breast reconstruction after mastectomy from 2009 to 2021. A total of 240 patients who underwent Wise-pattern skin-sparing mastectomy (WSSM) were compared with a cohort of patients who had traditional elliptical skin-sparing mastectomy (ESSM), matched for mastectomy weight, prior radiation therapy, and smoking. Ninety-day postsurgical outcomes were examined. RESULTS: The WSSM cohort had a significantly higher body mass index (30.3 kg/m 2 versus 26.9 kg/m 2 ; P < 0.0001) and mastectomy weight (831 g versus 607 g; P < 0.0001). After propensity score matching, there was no significant difference in complication or treatment rates between WSSM and ESSM breasts except for mastectomy flap necrosis (11.6% versus 5.0%; P = 0.0082). WSSM patients who had mastectomy flap necrosis did not have significantly different treatment rates of admission, return to the operating room, or explantation compared with ESSM patients. CONCLUSIONS: In the largest reported series to date, WSSM was associated with a higher rate of mastectomy flap necrosis, but this did not translate into statistically significant differences in treatment. The inferior dermal flap likely acts as a protective layer of vascularized tissue, which appears to prevent evolution of mastectomy skin flap necrosis into more serious adverse outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Establishment and Feasibility of an Immediate Lymphatic Reconstruction Program in a Community Health System.

BACKGROUND: Breast cancer-related lymphedema (BCRL) remains a significant post-surgical complication of breast cancer treatment. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has shown promise in preventing BCRL. While the primary literature supporting ILR comes from academic institutions, the majority of breast cancer care in the USA occurs in the community setting. This study evaluated a preventative lymphedema program performing ILR at a community health system. PATIENTS AND METHODS: A prospective database including all patients who underwent ALND with concurrently attempted ILR from 2019 to 2021 was retrospectively reviewed. The historical benchmark lymphedema rate was calculated through retrospective review of electronic medical records for all patients who underwent ALND without ILR from 2011 to 2021. RESULTS: Ninety patients underwent ALND with ILR, of which ILR was successful in 69 (76.7%). ILR was more likely to be aborted in smokers (p < 0.05) and those with fewer lymphatic channels (p < 0.05) or a higher body mass index (BMI) (p = 0.08). Patients with successful versus aborted ILR had lower lymphedema rates (10.9% versus 66.7%, p < 0.01) and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (8.7 versus 19.8, p = 0.25), and lower lymphedema rates than the historical benchmark (10.9% versus 50.2%, p < 0.01). Among patients with successful ILR, older patients were more likely to develop lymphedema (p < 0.05). CONCLUSIONS: Successful ILR after ALND significantly reduced the lymphedema rate when compared with patients with aborted ILR and our institution's historical benchmark. Our experience supports the efficacy of ILR and highlights the feasibility of ILR within a community health system.

Oral Antibiotics Do Not Prevent Infection or Implant Loss after Immediate Prosthetic Breast Reconstruction.

BACKGROUND: Infectious complications following implant-based postmastectomy breast reconstruction (PMBR) are a significant cause of morbidity. Nationwide, antimicrobial stewardship efforts have sought to reduce the use of prophylactic antibiotics postoperatively. However, there are conflicting data regarding the utility of extended antibiotic prophylaxis (EAP) after PMBR, and many surgeons continue to prescribe them. METHODS: The authors conducted a retrospective study of 1077 women who underwent immediate prosthetic PMBR from January of 2008 to May of 2020. All patients received intravenous antibiotics preoperatively and up to 24 hours postoperatively. Before October of 2016, patients were also prescribed oral antibiotics until drain removal; thereafter, this practice was abandoned. Ninety-day outcomes were compared between EAP-positive and EAP-negative patients. Descriptive statistics and multivariable logistic regression analysis were used to assess the efficacy of EAP in preventing infection-related complications. RESULTS: There were 1004 breasts in the EAP-positive group and 683 in the EAP-negative group. Three hundred sixty-one reconstructions (21.4%) were prepectoral. Multivariable analysis demonstrated no difference in surgical-site infection (OR, 0.83; 95% CI, 0.56 to 1.25; P = 0.38), admission (OR, 0.78; 95% CI, 0.41 to 1.48; P = 0.44), reoperation (OR, 1.01; 95% CI, 0.68 to 1.48; P = 0.97), or explantation rates (OR, 1.06; 95% CI, 0.66 to 1.71; P = 0.81) between the EAP groups. The EAP-positive group was more likely to develop Gram-negative infections ( P < 0.001). Thirteen EAP-positive women (2.0%) developed allergic reactions, and four (0.6%) developed Clostridium difficile colitis attributable to the EAP. CONCLUSIONS: EAP after PMBR did not improve outcomes. Although use of EAP did not appear to worsen clinical outcomes, marked differences in the microbiology of associated infections may render them more difficult to treat. Moreover, a small but significant proportion of women experienced adverse reactions to the EAP. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Operation Change: A New Paradigm Addressing Behavior Change and Musculoskeletal Health Disparities.

BACKGROUND: In this study, we examined the implementation and efficacy of Operation Change, a community-based, culturally sensitive program to stimulate behavioral changes in activity level and improve musculoskeletal health in African-American (AA) and Hispanic/Latina (H/L) women with obesity and early-stage osteoarthritis. METHODS: Sixty-two women (32 AA and 30 H/L), 40-75 years old, with nontraumatic knee pain and body mass index values > 30, participated in a 12-week program of presentations, motivational interviewing, goal setting, and physical activities. Assessments (at 0, 6, and 12 weeks) included a demographic questionnaire, physical assessment, timed 50-ft walking test, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form-36 Health Survey (SF-36), 8-Item Physical Health Questionnaire (PHQ-8), and motivational interview assessment. RESULTS: Walking time improved significantly for H/L women (P < 0.0001) but not AA women (P = 0.0759). Both groups had significant mean weight loss (P < 0.05) with high variability among individuals. WOMAC scores for both groups indicated decreased pain (P < 0.0001) and stiffness (P < 0.0001) and improved physical functioning (P < 0.0001) by 12 weeks. SF-36 results were comparable to those of the WOMAC. PHQ-8 results improved significantly for H/L women (P < 0.0001) but not AA women (P = 0.077). Participants scored the motivational interviewing component of the program favorably. CONCLUSIONS: Participation in Operation Change increased physical activity, resulting in improvements in pain and function scores. This supports a new paradigm for behavioral modification that helps AA and H/L women take an active role in living with osteoarthritis.