Early Functional Outcomes After Prepectoral Breast Reconstruction: A Case-Matched Cohort Study.

INTRODUCTION: Staged, tissue expander-based implant reconstruction continues to be the most common mode of breast reconstruction after mastectomy and has evolved significantly for the past 60 years. Prepectoral acellular dermal matrix (ADM)-assisted breast reconstruction is gaining popularity with complication rates similar to total submuscular and ADM-assisted partially submuscular reconstruction. Ours is among the first reports comparing postoperative pain and early functional outcomes between 2-stage ADM-assisted prepectoral and partial submuscular breast reconstruction. METHODS: Patients reconstructed with a 2-stage, ADM-assisted prepectoral approach were case matched with patients who had undergone ADM-assisted, partial submuscular reconstruction. Demographics and complication rates were compared. Primary outcomes included postoperative pain, number of days until full active shoulder range of motion was achieved, and postoperative days until drain removal. RESULTS: Forty-five breasts among 24 patients were reconstructed with ADM-assisted prepectoral tissue expanders after mastectomy and 90 breasts among 48 patients were reconstructed with ADM-assisted partial submuscular placement. There was a similarly acceptable complication profile between the 2 groups. The prepectoral group had significantly lower inpatient pain scores, required significantly less intravenous opioids and less oral opioids as outpatients. The prepectoral group saw a return to full active range of shoulder motion in half the number days of the partial submuscular group. Drain duration was similar between groups. CONCLUSIONS: Prepectoral ADM-assisted breast reconstruction can be performed safely and with significantly less pain and earlier return to function than partial submuscular expander placement. Expander placement exclusively in the prepectoral pocket did not result in increased drain duration while affording patients the benefits of avoiding surgical elevation of the pectoralis muscle.

Treatment With Topical Deferoxamine Improves Cutaneous Vascularity and Tissue Pliability in an Irradiated Animal Model of Tissue Expander-Based Breast Reconstruction.

PURPOSE: Postmastectomy radiation therapy is an important component of the multimodality approach to later-stage breast cancers. Unfortunately, despite its proven survival benefits, postmastectomy radiation therapy is deleterious to the skin and soft tissue, causing increased complications and worse aesthetic outcomes after breast reconstruction.There is currently no effective pharmaceutical agent to mitigate the soft tissue fibrosis and hypovascularity associated with soft tissue radiation. We hypothesized that a novel topical formulation of deferoxamine (DFX) will result in improved cutaneous vascularity and soft tissue pliability in an animal model of irradiated tissue expander-based breast reconstruction. METHODS: This study consisted of 16 hairless rats divided into 4 equal groups: a control group (expander only), a tissue expanded and irradiated group, a tissue expanded + DFX group, and a tissue expanded/irradiated/DFX group. A novel topical formulation of DFX consisted of reconstituted drug dissolved in agents designed to enhance dermal penetrance. Vessels per high-power field (vHPF) were quantified histologically; micro-computed tomography angiography was used to assess vessel volume fraction (VVF) and vessel length density. RESULTS: Irradiated skin had less vascularity compared with control (3.81 vHPF vs 8.25 vHPF, P = 0.03; 0.79% VVF vs 1.53% VVF, P = 0.06). Treatment of irradiated skin with topical DFX reversed these effects, resulting in vascular findings similar to the control group histologically (7.94 vHPF vs 8.25 HPF, P = 0.985) and via micro-computed tomography angiography (1.05% VVF vs 1.53% VVF, P = 0.272). Similarly, radiation resulted in less volume expansion compared with controls (0.72 vs 0.8 mL, P = 0.04), whereas treatment with topical DFX reversed this effect, allowing for an expansion volume similar to the control group (0.81 vs 0.80 mL, P = 0.999). CONCLUSIONS: In an animal model of irradiated tissue expander-based breast reconstruction, treatment with topical DFX improved the cutaneous vascularity and tissue pliability, resulting in vascular density and final tissue expansion volumes similar to those found in the nonirradiated control group. Topical DFX may be an effective agent for the treatment of soft tissue radiation injury; future studies are indicated to further characterize this novel drug formulation.

Reducing Infection Rates in Implant-Based Breast Reconstruction: Impact of an Evidence-based Protocol.

BACKGROUND: Infection is the most significant complication in implant-based breast reconstruction, potentially leading to reconstructive failure. We hypothesized that implementation of an evidence-based protocol marked by preoperative decolonization and sterility optimization would result in a decline in postoperative infection rates. METHODS: Informed by a literature review, we developed an evidence-based, perioperative infection prevention protocol implemented in 2015. Surgical outcomes were compared between patients who had undergone implant-based breast reconstruction before and after protocol implementation. A Fisher exact test was used to compare infection rates before and after protocol implementation. A logistic regression analysis was modeled to evaluate the impact of the protocol on infection rate while controlling for nonmodifiable risk factors. RESULTS: Three hundred fifty-eight breasts underwent reconstruction before protocol implementation and 135 afterward. Patients were similar in terms of demographics and surgical characteristics. There was a significantly reduced incidence of clinically relevant infection after protocol implementation (9.5%-2.9%, P = 0.013). Logistic regression analysis confirmed that the protocol was independently associated with a decrease in infection risk (odds ratio, 0.244; P = 0.021). After protocol implementation, no gram-positive bacteria were isolated among cultures obtained from infected periprosthetic fluid. Radiation and drain duration greater than 21 days were independently associated with greater risk for infection. CONCLUSIONS: Our evidence-based protocol was associated with a significant decline in infection rates among implant-based breast reconstruction patients and was particularly effective for gram-positive infections. We will continue to use this protocol in our practice and will consider future directions for addressing gram-negative infections as well.

Prepectoral Breast Reconstruction Prompts Revisiting the Anatomic Boundaries of the Breast: A Radiographic and Cadaveric study.

BACKGROUND: This study aimed to determine the location of superficial fascial system (SFS) condensations in relation to classic anatomic breast boundaries. Cadaveric studies have provided some understanding, but knowledge about the precise location of these condensations remains limited. METHODS: Preoperative breast MRI was conducted to assess the fascial condensations defining the breast footprint relative to landmarks like the latissimus, clavicle, sternal border, and inframammary fold (IMF). Concurrently, cadaveric mastectomies were performed to measure the breast borders in relation to these landmarks for comparison. RESULTS: 290 breasts underwent preoperative MRI. Eight cadaveric breast dissections were completed. Radiographically, the lateral breast fascial condensation was 3.9 cm medial to the latissimus dorsi, while cadaveric measurements were 4.5 cm. The medial condensation was 2.1 cm lateral to the sternal border radiographically and 4.8 cm to midline in cadavers. The superior fascial condensation was 2.3 cm inferior to the clavicle radiographically and 5.5 cm by dissection. The inferior condensation was above the IMF in 82.7% of breasts by MRI and 100% of cadaveric breasts. MRI and cadaveric investigation showed similar patterns of breast tissue fascial condensations relative to standard breast boundaries. Breast skin flap thickness was greater peripherally (MRI: 11.5 mm, cadaver: 11.1 mm) than centrally (MRI: 6.6 mm, cadaver: 5.5 mm). CONCLUSIONS: MRI and cadaveric analysis demonstrated a close correlation between SFS and standard breast boundaries, although variations existed among subjects. Collaborating with breast oncologists and utilizing preoperative imaging to identify individual fascial condensations may enhance the camouflage of prepectoral implants after mastectomy.

A Novel Small-Animal Model of Irradiated, Implant-Based Breast Reconstruction.

BACKGROUND: There is currently a need for a clinically relevant small-animal model for irradiated, implant-based breast reconstruction. Present models are inadequate in terms of suboptimal location of expander placement and mode of radiation delivery, correlating poorly with the human clinical scenario. The authors hypothesized that by delivering fractionated radiation and placing an expander under the scalp of the animal, they would achieve soft-tissue changes histologically analogous to those seen in human irradiated, implant-based breast reconstruction. METHODS: This study consisted of 11 immunocompetent, hairless rats divided into three groups as follows: untreated control (n = 3), tissue-expanded scalps (n = 4), and fractionated irradiation plus tissue expansion of the scalp (n = 4). At the completion of the experiment for each group, skin tissue samples were analyzed histologically for vascularity, epidermal and dermal thickness, and collagen fiber alignment or scar formation. RESULTS: Expanded rat epidermis was significantly thicker and dermis was more vascular than nonexpanded skin. The authors observed a greater degree of collagen fiber alignment in the expanded group compared with nonexpanded skin. The combination of irradiation and expansion resulted in significant dermal thinning, vascular depletion, and increased scar formation compared with expanded skin alone. CONCLUSIONS: The authors describe a novel small-animal model for irradiated, implant-based breast reconstruction where histologic analysis shows structural changes in the skin consistent with known effects of radiation therapy and expansion in human skin. This model represents a significant improvement from previous ones and, as such, holds the potential to be used to test new therapeutic agents to improve clinical outcomes.

Combined Gluteus and Pudendal Thigh Flap Reconstruction of Vaginal Defects following Robotic Abdominoperineal Resection.

Low-lying rectal cancers are being treated more frequently with robotic-assisted abdominoperineal resection, obviating the need for laparotomy and the ability to raise vertical rectus abdominis musculocutaneous flaps. For female patients, posterior vaginectomy often accompanies the resection. Combined pudendal thigh flaps as an extension of bilateral gluteus advancement flaps allow for posterior vaginal resurfacing with thin pliable fasciocutaneous flaps, which rest on the gluteal flap soft-tissue bulk that obliterates the pelvic dead space. For patients with advanced cancers who have had neoadjuvant chemoradiation, the pudendal skin paddle can be planned more laterally to bring in healthier medial thigh skin. The donor incisions lie within the gluteal cleft and crease and groin creases recapitulating normal perineal anatomy and aesthetics.