Surgical and Patient-Reported Outcomes After Mastectomy and Implant-Based Prepectoral Reconstruction Using TIGR® Synthetic Mesh.

Background Single-stage direct-to-implant (DTI) breast reconstruction after mastectomy has gained popularity over the last decade, thanks to the wide use of biological matrices and synthetic meshes. Despite their high cost, there is no evidence of superior outcome from the biological matrices compared to the synthetic meshes. In this study, we aimed to evaluate our experience with TIGR, a synthetic, long-term absorbable mesh, in mastectomy and immediate breast reconstruction (MIBR) with a focus on patient-reported outcomes (PROMs). Methods This was a single-trust prospective quality improvement study conducted between 2017 and 2019. The main objectives were complication rates including infection, implant loss, and other surgical complications in patients undergoing TIGR mesh-assisted MIBR in the prepectoral plane for either cancer or risk reduction. PROMs were measured using the validated European Organisation for Research and Treatment of Cancer (EORTC) breast questionnaire module. Clinical evaluations were conducted at one week, three weeks, and 12 months postoperatively. All patients provided written consent, and the audit was registered with the Quality Improvement Department of the organization. Results One hundred and twelve meshes were used in 93 patients with a mean age of 49 (24-75) years and a body mass index (BMI) of 23.4 (19.1-29.6). During the follow-up period, complications occurred in 26 patients (28%), including infection in four (4.3%), complete skin flap necrosis in one (1%), partial flap necrosis in three (3.2%), and implant loss in four (4.3%) patients. PROM data from 41 individuals indicated a moderate overall quality of life (82.7%), with high functional domain scores with relatively lower emotional functioning scores. Symptom domains generally scored poorly except for body image and sexual functioning. Conclusion Mastectomy and immediate prepectoral breast reconstruction using TIGR mesh is safe with low major complication rates. It is associated with high functional and quality of life scores but low scores in symptom domains which could be multifactorial. However, limitations due to study type and follow-up duration suggest caution in generalizing findings.

The Results of Surveillance Imaging After Breast Conservation Surgery and Partial Breast Reconstruction With Chest Wall Perforator Flaps; A Qualitative Analysis Compared With Standard Breast-Conserving Surgery for Breast Cancer.

INTRODUCTION: Partial breast reconstruction (PBR) using chest wall perforator flaps (CWPF) allows for excision of tumors in the outer quadrant of the breast in women with small to moderate non-ptotic breasts resulting in a good aesthetic outcome. There are limited data available in the literature regarding long-term follow-up and the effect of CWPF on subsequent surveillance mammographic interpretation and recall rates. A retrospective audit with qualitative analysis of initial mammograms was performed to assess this. PATIENTS AND METHODS: This retrospective analysis of a prospectively maintained database included all consecutive patients who underwent either PBR with CWPF or wide local excision (WLE) between January 2013 and December 2014 by a single surgeon in a tertiary referral center. Qualitative analysis of the postoperative mammograms was performed after review by 2 blinded radiologists. RESULTS: Thirty-six patients were included in the study, 18 in each arm. The CWPF group was younger and had larger tumor size anticipated on preoperative imaging, which correlated with larger specimens excised. Both groups were comparable with respect to tumor pathological characteristics. Comparing the first postoperative mammograms, both groups were similar in features reported such as calcifications, fat necrosis, volume loss, and radiotherapy changes. During the follow-up period (median 4 years), 138 surveillance mammograms were performed. One patient was recalled for further imaging in the CWPF group. There was no significant difference in the need for diagnostic imaging and biopsy between the groups. CONCLUSION: Patients who underwent PBR using CWPF had similar features on postoperative surveillance mammograms compared with that post WLE.

TIGR matrix for implant-based breast reconstruction - a long-term resorbable mesh.

The use of biological and synthetic meshes to aid implant coverage in implant-based breast reconstruction is well established. This technique allows single stage implant-based reconstruction compared to the traditional technique which required tissue expansion before permanent implant placement and therefore involved two operations for the patient. They can further be used for pre-pectoral implant reconstructions in a similar direct-to-implant strategy. This retrospective observational study by Pompei et al has evaluated the use of TIGR Matrix, a long-term resorbable mesh, in 49 patients with 60 operated breasts for both reconstructive and aesthetic cases. They have reported their operative method and followed up their cases for a mean of 12 months. They have reported a cumulative mesh complication rate of 5.4% and one implant was explanted due to infection. They identified a significant correlation between obesity and mesh-related complications. This study is significant as there remains little data regarding the long term outcomes of resorbable synthetic mesh for breast reconstruction. Their reported complication rates are consistent with those in other studies for synthetic meshes. As synthetic meshes can be significantly cheaper than their biological counterparts, this work could promote more widespread use.

Staged approach to partial breast reconstruction to avoid mastectomy in women with breast cancer.

BACKGROUND: The lateral chest wall perforator flaps (CWPF) offer an excellent option for partial breast reconstruction (PBR) in women undergoing breast conservation surgery (BCS) for laterally placed tumours in small to moderate non-ptotic breasts. METHODS: A total of 20 patients underwent PBR with lateral CWPF over the last 4 years, as two-stage approach. This approach was undertaken for patients with high tumour to breast ratio (>30% predicted resection) in an attempt to avoid mastectomy. The reconstruction was carried out 2-4 weeks after wide local excision in order to ensure clear margins prior to undertaking PBR. RESULTS: Twenty-three women were selected for attempt at BCS with 2-stage approach. Three patients had extensive disease so they were then counseled for mastectomy after the first surgery and 20 patients had successful BCS. Out of 20 patients, 13 were symptomatic and 7 were screen-detected with mean age of 49 years. The median tumour size on pre-op imaging was 43 mm (23-75 mm). A percentage of 50% women with unifocal cancers undergoing primary surgery had disease overestimated on pre-op imaging. The complication rate was low. Good to excellent aesthetic outcomes were reported in 90% cases. Patients reported high satisfaction scores. CONCLUSIONS: We recommend considering two-stage approach in selected women with high tumour-breast ratio to ensure successful BCS prior to PBR. This approach facilitates BCS and avoids mastectomy in borderline cases, particularly lobular cancers, DCIS, bifocal cancers and post neoadjuvant chemotherapy where pre-operative disease estimation could be challenging. Our small series has shown that this approach results in safe oncological surgery with good aesthetic outcomes in the selected group of women.

Proteus Mediastinitis Causing Fatal Pseudoaneurysm following Aortic Valve Replacement.

We report an unusual case of Gram-negative mediastinitis following aortic valve replacement via median sternotomy. The patient presented two months after surgery following a urinary tract infection in septic shock with a discharging sternal wound and blood cultures positive for Proteus mirabilis. Imaging revealed a large anterior mediastinal abscess and aortic pseudoaneurysm which subsequently ruptured resulting in fatality. Gram-negative mediastinitis is a rare complication of cardiac surgery that can present late following initial clinical improvement and should be considered when "remote site" infections are present. Computerised Tomography scanning has a role to play in the identification of this.