Are Large Intraoperative Fill Volumes Associated With Increased Complications After Tissue Expander Placement?

Background: With the increased adoption of skin-sparing mastectomies, immediate 2-stage breast reconstruction is a common option for breast cancer patients. During the first stage of the procedure with tissue expander placement, higher intraoperative percent fill has been identified as a risk factor for complications. However, the postoperative outcomes of higher intraoperative fill volumes are not well established. The authors sought to evaluate if a higher initial intraoperative tissue expander fill volume is associated with higher complication rates in patients undergoing immediate breast reconstruction with tissue expander placement. Methods: A retrospective review of patients who underwent immediate breast reconstruction with a tissue expander placement from 2016 to 2018 was conducted. Patient demographics and perioperative data were recorded. Large intraoperative fill was defined as saline fill volume greater than 350 mL. The primary outcome evaluated was skin and nipple necrosis. Secondary outcomes were major infections, minor infections, seroma, and hematoma. Results: A total of 147 breasts in 86 patients were included. Mean intraoperative fill volume was 246.4 ± 106.6 mL. Thirty-five tissue expanders were filled with greater than 350 mL of saline intraoperatively. Patients with large intraoperative fill volume were older (mean age, 52.6 vs 47.9 years; P = .04), had a higher mean body mass index (BMI; 33.2 vs 25.9 kg/m2; P < .0001), and had larger preoperative breast anthropometrics (P < .0001). During a mean follow-up period of 20.1 months (range, 3-55 months), 9 breasts were noted to have skin/nipple necrosis. After multivariate analysis, large tissue expander fill volume was not a significant predictor of skin or nipple necrosis (P = .62). Hypertension and anticoagulant use were associated with increased skin and nipple necrosis (P = .04 and P = .03, respectively). Large fill volume was not associated with statistically significant increases in rates of other complications like major infections, minor infections, seroma, or hematoma. Conclusions: Larger fill volumes are often required and benefit patients with higher BMI or bra sizes. This also reduces the number of postoperative fills required. In this patient population, larger intraoperative tissue expander saline fill volume (greater than 350 mL) was not associated with increased postoperative complications. After careful patient selection and perfusion evaluation, larger fill volumes may be considered a safe option to improve the aesthetic outcomes in patients with high BMI.

The Batwing Mastopexy in Immediate Implant-Based Breast Reconstruction: An Aesthetic Enhancement for Patients with Cancer.

BACKGROUND: Historically, many patients with breast ptosis have been excluded from nipple-sparing mastectomies. By performing mastopexy at the time of immediate reconstruction, more patients with breast ptosis can be considered for nipple-sparing mastectomies. The authors review their experience of simultaneous batwing mastopexy performed at the time of immediate implant-based reconstruction. METHODS: Using retrospective chart review, the authors identified patients who underwent immediate implant-based breast reconstruction from 2015 through 2020 at a single institution. The patients were divided into two cohorts-batwing mastopexy and standard reconstruction (no mastopexy)-and compared. RESULTS: A total of 324 breast operations in 188 patients were included (80 concurrent batwing and 244 standard implant-based reconstructions). Patient characteristics were similar between the groups, except that patients in the batwing group had greater ptosis and more patients in the standard group underwent adjuvant chemotherapy. Mean follow-up was 15.9 months (range, 3.19 to 55.20 months). Complication rates were comparable in the batwing and standard groups, with no statistically significant differences in rates of hematoma (1.3 versus 3.3 percent; = 0.34), seroma (5.0 versus 8.2 percent; p = 0.34), major infection (8.8 versus 9.0 percent; p = 0.94), skin or nipple necrosis (6.3 versus 11.5 percent; p = 0.18), or explantation (11.3 versus 14.8 percent; p = 0.43). The rate of minor infections was higher in the group with concurrent batwing mastopexy (10.0 versus 3.7 percent; p = 0.03). CONCLUSIONS: The authors demonstrate that simultaneous batwing mastopexy can be performed safely at the time of immediate breast reconstruction. This technique provides comparable complication rates, improves aesthetic outcomes in patients with significant ptosis or macromastia, and allows nipple-sparing mastectomy to be an option for those who would otherwise be excluded. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Surgical Management of Gynecomastia: A Comprehensive Review of the Literature.

Gynecomastia is a graded condition characterized by enlargement of the male breast that affects a significant proportion of the male population. A plethora of varying surgical approaches currently exists in the literature; thus this comprehensive review sought to analyze surgical practice patterns and trends as they pertain to gynecomastia grade and severity. The current literature was queried utilizing the PubMed and MEDLINE databases-based on predefined parameters and individual review, 17 studies were ultimately included. Key data points included gynecomastia grade, surgical intervention, rate of complication, including hematoma, seroma, infection, and necrosis, and drain use. Two-sample t test was utilized for further analysis. A total of 1112 patients underwent surgical treatment for gynecomastia. Skin-sparing mastectomy with or without liposuction was the most frequently used procedure followed by mastectomy with skin reduction. Major complication rates ranged from 0% to 33%, with hematoma formation being most common (5.8%) followed seroma (2.4%). There was a higher rate of hematoma/seroma formation among authors who routinely utilized drain placement (9.78% versus 8.36%; P = 0.0051); however, this is likely attributable to the large discrepancy in percentage of grade III patients found in each group (50.23% versus 4.36%; P = 0.0000). As a wide variety of surgical techniques exist for the treatment of gynecomastia, an individualized approach based upon gynecomastia grade and patient preference may assist the surgeon in providing optimal outcomes. This senior author's preferred method for treatment of gynecomastia is illustrated in the included algorithm.

SPY Imaging Use in Postmastectomy Breast Reconstruction Patients: Preventative or Overly Conservative?

BACKGROUND: SPY Elite imaging uses an injectable fluorescing agent to intraoperatively assess the perfusion and viability of tissue, including skin flaps, during postmastectomy reconstruction for breast cancer patients. In this study, the authors sought to compare the surgeon's assessment of flap viability with that of SPY imaging perfusion, analyzing the clinical outcomes postoperatively. METHODS: In this study, the intraoperative difference between the plastic surgeon's assessment of skin viability and the SPY imaging assessment was analyzed by the skin flap area preserved in patients undergoing skin-sparing mastectomy. After the mastectomy, the operating surgeon marked the area of the skin flap to excise; then, the SPY imaging was performed and photographs and videos of the perfusion were collected. The skin flap was resected before implant or tissue expander placement according to the plastic surgeon's assessment. The patients were routinely followed up in the clinic postoperatively. RESULTS: A total of 55 breasts were analyzed. The surface area of diminished perfusion was significantly greater in the SPY imaging compared with the surgeon's assessment. CONCLUSIONS: In this study, intraoperative indocyanine green angiography was found to be conservative in its estimation of viability and, if followed, would result in a more aggressive resection than the area deemed viable by the operating surgeon. Based on the results, intraoperative indocyanine green angiography should be used in settings where perfusion is clinically assessed as marginal. It likely does not play a useful role in lower risk cases where the operating surgeon identifies no areas of concern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.