Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database.

INTRODUCTION: Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS: The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS: A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION: National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.

Gender-Affirming Surgeries: A National Surgical Quality Improvement Project Database Analyzing Demographics, Trends, and Outcomes.

BACKGROUND: Gender affirmation surgery is an exponentially growing field within plastic surgery. The aim of our study is to analyze demographics, procedure type, trends, and outcomes in the surgical management of gender identity disorder in the past few years. METHODS: The American College of Surgeons NSQIP database was queried for the years 2015 to 2019. International Classification of Diseases codes were used to identify all gender-affirming cases. Patients were categorized by procedure type using Current Procedural Terminology codes for feminizing/masculinizing top, bottom and head/neck procedures. Patient demographics, comorbidities, and postoperative complications were analyzed using SPSS statistics software. A comparative analysis was performed among the procedure type. RESULTS: From 2015 to 2019, 4114 patients underwent a gender-affirming surgery (GAS) increasing the number of surgeries by over 400%, according to the NSQIP database. Demographics include age (mean = 32 years), body mass index (mean = 28 kg/m2), race (60% White, 22% unknown, 13% African American, 4% Asian, 1% other). Female to male procedures represented the most commonly performed (n = 2647; 64%), followed by male to female (n = 1278; 31%) with head/neck procedures representing 5% (n = 189) of all procedures. Top surgeries were also the most common (n = 2347, 57%), followed by bottom surgeries (n = 1578, 38%). The overall complication rate was 6% (n = 247), 2.1% (n = 4) for head/neck procedures, 8% (n = 134) for bottom procedures, and 3.5% (n = 84) for top surgeries.A reoperation within 30 days and related to the initial GAS occurred for 52 patients. Postoperative complication rates were statistically different between bottom surgeries compared with the top and head/neck procedure groups (P < 0.001). Increasing age and body mass index showed a significantly higher odds of having a complication. CONCLUSIONS: Gender-affirming procedures have significantly increased over the past 5 years. Increased exposure through literature and research, as well as an improvement in social climates, including increasing insurance coverage have contributed to the expansion of these procedures. Low serious complication rates within 30 days prove GAS to be safe.

Impact of Radiation on Implant-Based Breast Reconstruction in Prepectoral Versus Submuscular Planes.

BACKGROUND: Postmastectomy implant-based breast reconstruction (IBR) in the setting of radiation (XRT) comes with a high risk of perioperative complications regardless of reconstruction method. The aim of study was to identify the effects of XRT on IBR using a prepectoral versus submuscular approach. METHODS: A retrospective chart review was performed after institutional review board approval was obtained. Patients at a single institution who had 2-stage IBR from June 2012 to August 2019 were included. Patients were separated into 4 groups: prepectoral with XRT (group 1), prepectoral without XRT (group 2), submuscular with XRT (group 3), and submuscular without XRT (group 4). Patient demographics, comorbidities, and postoperative complications were recorded and analyzed. RESULTS: Three hundred eighty-seven breasts among 213 patients underwent 2-stage IBR. The average age and body mass index were 50.10 years and 29.10 kg/m2, respectively. One hundred nine breasts underwent prepectoral reconstruction (44 in group 1, 65 in group 2), and 278 breasts underwent submuscular reconstruction (141 in group 3, 137 in group 4). Prepectoral tissue expander placement was associated with higher complication rates in the radiated group (38.6% compared with 34.0% submuscular) and lower complication rates in the nonradiated group (26.2% compared with 29.2% submuscular), although significantly less explants were performed in prepectoral group, regardless of XRT status. The 3 most common complications overall were contracture (15.1% radiated, 10.4% nonradiated), infection (18.4% radiated, 11.9% nonradiated), and seroma (15.7% radiated, 10.9% nonradiated). CONCLUSIONS: Two-stage, prepectoral tissue expander placement performs clinically better than submuscular in nonradiated patients compared with radiated patients; however, no statistical significance was identified. Prepectoral had a significantly less incidence of reconstructive failure than submuscular placement regardless of XRT status. Future larger-scale studies are needed to determine statistically significant difference in surgical approach.

The Biointegration of a Porcine Acellular Dermal Matrix in a Novel Radiated Breast Reconstruction Model.

BACKGROUND: Ideal acellular dermal matrices (ADM) for breast reconstruction exhibit native extracellular matrix (ECM) structure to allow rapid biointegration and appropriate mechanical properties for desired clinical outcomes. In a novel in vivo model of irradiated breast reconstruction, we describe the cellular and vascular ingrowth of Artia, a porcine product chemically prepared to mimic the biomechanics of human ADM, with retained natural ECM structure to encourage cellular ingrowth. METHODS: Utilizing the murine dorsal skinfold model, Artia was implanted into 16 C57bl/6 mice. Eight of the mice received a single dose 35 Gy radiation to the skin, followed by 12 weeks to produce radiation fibrosis and 8 mice served as nonradiated controls. Real-time photoacoustic microscopy of vascular integration and oxygen saturation within the ADM were made over 14 days. At 21 days, vascular ingrowth (CD31), fibroblast scar tissue formation (alpha smooth-muscle actin α-SMA, vimentin), and macrophage function (M2/M1 ratio) were evaluated. Scanning electron microscopy images of Artia were produced to help interpret the potential orientation of cellular and vascular ingrowth. RESULTS: Repeated photoacoustic microscopy imaging demonstrated vascular ingrowth increasing over 14 days, with a commensurate increase in oxygen saturation within both radiated and nonradiated ADM-albeit at an insignificantly lower rate in the radiated group. By day 21, robust CD31 staining was seen that was insignificantly greater in the nonradiated group. Of the fibroblast markers, vimentin expression was significantly greater in the radiated group (P < 0.05). Macrophage lineage phenotype was consistent with remodeling physiology in both radiated and nonradiated groups. Scanning electron microscopy demonstrated transversely organized collagen fibrils with natural porous ECM structure to allow cellular ingrowth. CONCLUSIONS: Artia demonstrates appropriate biointegration, with increased oxygen saturation by 14 days, consistent with the performance of other collagen substrates in this model. Radiation fibrosis resulted in higher vimentin expression yet did not impact macrophage phenotype while only modestly decreasing Artia biointegration suggesting that ADM may have a role in reconstructive efforts in a radiated setting. Taken together with its enhanced biomechanics, this porcine ADM product is well poised to be clinically applicable to breast reconstruction.

Prepectoral Wise-Pattern Staged Implant-Based Breast Reconstruction for Obese or Ptotic Patients.

INTRODUCTION: The obese or ptotic breast demonstrates significant difficulty in breast reconstruction after mastectomy with increased rates of perioperative complications compared with the general population, regardless of reconstruction type. Implant-based reconstruction in this patient population with the traditional horizontal elliptical skin-sparing mastectomy tends to have aesthetically displeasing qualities secondary to skin flap redundancy and blunting of the breast contour. Wise-pattern closures have been described with submuscular direct-to-implant and 2-stage reconstructions, with more favorable complication profile when staged. Our study aims to report outcomes and safety of a prepectoral 2-stage wise-pattern closure technique in the obese and/or ptotic population. METHODS: A retrospective chart review was performed to identify all overweight, obese, and/or grade III ptotic patients who have undergone a 2-stage, wise-pattern skin closure with prepectoral placement of tissue expander by a single surgeon. Patient demographics, comorbidities, and perioperative descriptors were reported. Delayed wound healing, infection, seroma formation, and explantation or reoperation were recorded for each patient involved in the study. RESULTS: Thirty-seven obese and/or ptotic breasts among 21 patients underwent immediate prepectoral tissue expander placement with wise-pattern skin reduction closure with mean body mass index of 35.3 kg/m, and 25% of patients were diabetic The most common complication rates by breast were seroma formation (50%) and wound/dehiscence at T-point (28.6%), which all ultimately healed with intervention as described. One major (2.7%) and 1 minor (2.7%) infection were successfully treated with antibiotics. There were no cases of implant exposure. Two operative complex repairs and 1 elective explantation were performed. Diabetes and increasing body mass index were statistically associated with an increased overall perioperative complication rate. CONCLUSIONS: Prepectoral, 2-stage breast reconstruction with wise-pattern skin reduction performs well in obese and/or ptotic patients with favorable rates of perioperative complications. Wound dehiscence was prevalent but managed with wound care when complex repair was not required to expedite adjuvant chemotherapy. Infection rates and reoperation rates were low, and all patients reported positive aesthetic results at the completion of reconstruction.

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.

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.

Incorporation of fluorophore-cholesterol conjugates into liposomal and mycobacterial membranes.

Fluorescently-labeled steroids that emit intense blue light in nonpolar solvent (λem (CH2Cl2)≈440nm, ΦF=0.70) were prepared by treating cholesteryl chloroformate with 4-amino-1,8-naphthalimides. The lipid portion of the conjugates embeds into liposomal membrane bilayers in minutes, leaving the fluorophore exposed to the external aqueous environment. This causes a 40-nm red-shift in λem and significant quenching. DFT optimizations predict the conjugates to be about 30Å long when fully extended, but rotation about the linker group can bring the compounds into an 'L'-shape. Such a conformation would allow the cholesteryl anchor to remain parallel to the acyl chains of a membrane while the fluorescent group resides in the interfacial region, instead of extending beyond it. When incubated with Mycobacterium smegmatis mc2 155, a bacterial species known to use natural cholesterol, the labeled steroids support growth and can be found localized in the membrane fraction of the cells using HPLC. These findings demonstrate stable integration of fluorescent cholesterols into bacterial membranes in vivo, indicating that these compounds may be useful for evaluating cholesterol uptake in prokaryotic organisms.

The Performance of Patient-Worn Actigraphy Devices to Measure Recovery after Breast Reconstruction.

INTRODUCTION: Annually, over 250,000 women are diagnosed with breast cancer with over one-third undergoing mastectomy and contemplating reconstruction. Surgical breast reconstructive options vary in post-operative recovery, yet with a paucity of objective data to inform women of their expected recovery after flap or implant-based reconstruction. As a result, patient decision-making is based primarily on surgeon preference and subjective data regarding perceived invasiveness of surgical options. This study aims to identify recovery outcomes of interest to breast cancer patients and to determine the feasibility of objectively measuring patient recovery after mastectomy and reconstruction using patient-worn actigraphy devices. METHODS: Three survivorship focus groups for patients after mastectomy with and without reconstruction were used to identify recovery outcomes they considered relevant. Cloud storage systems and actigraphy devices were piloted to determine performance. Actigraphy devices were worn by patients peri-operatively to measure post-operative sleep quality and steps taken, normalized to individual patient pre-operative control data. RESULTS: Focus groups identified sleep quality, return to activity (measurable with actigraphy), and driving as variables impacting surgical decision-making. We prospectively measured outcomes for four women undergoing immediate pre-pectoral tissue expander placement and four women undergoing immediate free flap reconstruction. Actigraphy data demonstrated an initial decrease in activity, increase in sleep variability and increased heart rate that approached the patients' pre-operative normalized data as they recovered over time. CONCLUSIONS: These data demonstrate that actigraphy data would be of interest to patients making breast reconstruction decisions and that the data can be successfully collected to inform decision-making.

Fenestration Improves Acellular Dermal Matrix Biointegration: An Investigation of Revascularization with Photoacoustic Microscopy.

BACKGROUND: Acellular dermal matrices have revolutionized alloplastic breast reconstruction. Furthering our knowledge of their biointegration will allow for improved design of these biomaterials. The ideal acellular dermal matrix for breast reconstruction would provide durable soft-tissue augmentation while undergoing rapid biointegration to promote physiologic elasticity and reduced infectious complications. The inclusion of fenestrations in their design is thought to promote the process of biointegration; however, the mechanisms underlying this theory have not been evaluated. METHODS: Biointegration of standard and fenestrated acellular dermal matrices was assessed with serial photoacoustic microscopic imaging, in a murine dorsal skinfold window chamber model specifically designed to recapitulate the microenvironment of acellular dermal matrix-assisted alloplastic breast reconstruction. Photoacoustic microscopy allows for a serial, real-time, noninvasive assessment of hemoglobin content and oxygen saturation in living tissues, generating high-resolution, three-dimensional maps of the nascent microvasculature within acellular dermal matrices. Confirmatory histologic and immunohistochemical assessments were performed at the terminal time point. RESULTS: Fenestrated acellular dermal matrices demonstrated increased fibroblast and macrophage lineage host cell infiltration, greater mean percentage surface area vascular penetration (21 percent versus 11 percent; p = 0.08), and greater mean oxygen saturation (13.5 percent versus 6.9 percent; p < 0.05) than nonfenestrated matrices by 2 weeks after implantation. By 21 days, host cells had progressed nearly 1 mm within the acellular dermal matrix fenestrations, resulting in significantly more vascularity across the top of the fenestrated matrix (3.8 vessels per high-power field versus 0.07 vessels per high-power field; p < 0.05). CONCLUSIONS: Inclusion of fenestrations in acellular dermal matrices improves the recellularization and revascularization that are crucial to biointegration of these materials. Future studies will investigate the optimal distance between fenestrations.

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.