"Immediate pre-pectoral implant-based breast reconstruction after J-pattern skin reducing mastectomy."

SUMMARY: Skin reducing-mastectomy, described several years ago, for single stage reconstruction is considered an oncologically safe procedure and is used in those woman with large and ptotic breasts. This study describes a new technique, the J-pattern skin-reducing breast reconstruction with prepectoral implant and acellular dermal matrix (Braxon fast), which is indicated to patients with large and ptotic breasts who would benefit from a breast reduction and need a mastectomy for curative or prophylactic purpose. We present our case series on 35 breasts in 19 women submitted to the above mentioned procedure from January 2021 to December 2022 at the Plastic and Reconstructive Surgery Department of the University Hospital Santa Maria della Misericordia of Udine, Italy, with a median follow up of 15 months. The advantages of the J scar and consist in a reduced risk of skin necrosis, a reduced bottoming out rate, a simplification of the surgical design and a lower impact of scars not involving the medial quadrants of the breast. Patients were administered the Breast Q 2.0 post-operative questionnaire at 3 months postoperatively, which showed a high average level of satisfaction with the reconstruction. We therefore believe that this surgical technique is a valid option in patients who have a voluminous breast and an adequate pinch test and wish to undergo a curative/prophylactic mastectomy with immediate heterologous reconstruction.

From Sub-Pectoral to Pre-Pectoral Implant Reconstruction: A Decisional Algorithm to Optimise Outcomes of Breast Replacement Surgery.

BACKGROUND: Innovations and advancements with implant-based breast reconstruction, such as the use of ADMs, fat grafting, NSMs, and better implants, have enabled surgeons to now place breast implants in the pre-pectoral space rather than under the pectoralis major muscle. Breast implant replacement surgery in post-mastectomy patients, with pocket conversion from retro-pectoral to pre-pectoral, is becoming increasingly common, in order to solve the drawbacks of retro-pectoral implant positioning (animation deformity, chronic pain, and poor implant positioning). MATERIALS AND METHODS: A multicentric retrospective study was conducted, considering all patients previously submitted to implant-based post-mastectomy breast reconstruction who underwent a breast implant replacement with pocket conversion procedure at the University Hospital of Udine-Plastic and Reconstructive Surgery Department-and "Centro di Riferimento Oncologico" (C.R.O.) of Aviano, from January 2020 to September 2021. Patients were candidates for a breast implant replacement with pocket conversion procedure if they met the following inclusion criteria: they underwent a previous implant-based post-mastectomy breast reconstruction and developed animation deformity, chronic pain, severe capsular contracture, or implant malposition. Patient data included age, body mass index (BMI), comorbidities, smoking status, pre- or post-mastectomy radiotherapy (RT), tumour classification, type of mastectomy, previous or ancillary procedures (lipofilling), type and volume of implant used, type of ADM, and post-operative complications (breast infection, implant exposure and malposition, haematoma, or seroma). RESULTS: A total of 31 breasts (30 patients) were included in this analysis. Just three months after surgery, we recorded 100% resolution of the problems for which pocket conversion was indicated, which was confirmed at 6, 9, and 12 months post-operative. We also developed an algorithm describing the correct steps for successful breast-implant pocket conversion. CONCLUSION: Our results, although only early experience, are very encouraging. We realized that, besides gentle surgical handling, one of the most important factors in proper pocket conversion selection is an accurate pre-operative and intra-operative clinical evaluation of the tissue thickness in all breast quadrants.

Patients' Question-Asking About Breast Implant-Associated Anaplastic Large Cell Lymphoma (BI-ALCL) and Breast Implant Illness (BII): Implementing Questions in BREAST-Q.

There has been recently heightened media-driven attention to BII and BI-ALCL. Nowadays the importance of receiving correct and complete evidence-based information about these diseases and the potential impact of these emerging issues on disposition to receive breast implants are not investigated on BREAST-Q. The BREAST-Q survey has the potential to create an evidence-based approach to aesthetic surgical practice. We suggest implementing the BREAST-Q subthemes domain in order to investigate the degree of satisfaction about the education received concerning BII and BI-ALCL and to investigate the possible change of patient perception towards breast implants. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Muscle-Sparing Skin-Reducing Breast Reconstruction with Pre-Pectoral Implants in Breast Cancer Patients: Long-Term Assessment of Patients' Satisfaction and Quality of Life.

INTRODUCTION: Breast cancer is the most frequently diagnosed tumor in women; globally, it accounts 23% of all cancer deaths. Breast reconstruction after oncologic surgery has become crucial to enhance patients' quality of life and alleviate the psychological distress related to the disease. The aim of this study was to assess quality of life and esthetic satisfaction of breast cancer patients undergoing muscle-sparing skin-reducing breast reconstruction (MS-SR) with pre-pectoral implants. METHODS: Sixty-three patients who met definite oncological and reconstructive criteria were enrolled in the study. Specific questionnaires (EORTC QLQ-C30, QLQ-BR23) were administered preoperatively, 1, and 12 months after MS-SR breast reconstruction to evaluate patients' QoL. Satisfaction with procedure and related Quality of Life were assessed through BREAST-Q questionnaire preoperatively and 12 months after surgery. RESULTS: Sixty-three breast cancer patients underwent MS-SR. Seventy-eight procedures were carried out; in 15 patients a bilateral reconstruction was performed. One month after surgery, both EORTC QLQ-C30 and QLQ-BR23 average scores demonstrated a slight drop since preoperative values, but a significant improvement in QoL was documented 12 months after BR (p < 0.05). BREAST-Q test showed significant psychophysical and esthetic satisfaction 12 months postoperatively. CONCLUSIONS: Muscle-sparing skin-reducing breast reconstruction is an established and reliable technique. EORTC QLQ-C30, QLQ-BR23 and BREAST-Q scores showed an improvement of patients' QoL and esthetic satisfaction. Reduction of pain and other surgery-related symptoms are cornerstones of patient well-being. Both physicians and patients should build a thorough awareness of the silver lining of muscle-sparing skin-reducing breast reconstruction based on the high safety profile and highly satisfactory patient-reported results.

Comparative study of patient outcomes between direct to implant and two-stage implant-based breast reconstruction after mastectomy.

BACKGROUND: Breast reconstruction plays a central role in the outcome management of patients with breast cancer, particularly in terms of quality of life (QoL), which must be weighed carefully when considering the available surgical options. In the context of implant-based breast reconstruction, immediate replacement with prosthesis (direct-to-implant (DTI)) and acellular dermal matrix (ADM) is gaining popularity, at the expense of the traditional two-stage implant-based breast reconstruction with tissue expander (TE), and the literature suggests that patients tend to prefer interventions with "immediate" therapeutic efficacy and aesthetic satisfaction that obviate the need for further invasive surgery. We investigated this hypothesis by administering the BREAST-Q™ questionnaire to two groups of patients who had undergone the respective procedures. METHODS: We performed a cross-sectional observational study of 192 consecutive mastectomy patients who received implant-based reconstruction, comparing health-related quality of life (HR-QoL), patient-related outcomes (PROs) and satisfaction in patients who had undergone immediate dual plane DTI with ADM (96) versus the two-stage submuscular approach (96). We also counted the number of surgeries required in each group to achieve a definitive outcome. FINDINGS: Our study revealed no major differences in terms of QoL scores, with the two approaches being largely comparable. However, single-stage reconstruction seems to offer the additional advantages of better satisfaction with the care received, sparing the patient temporary body image dissatisfaction and reducing the number of surgeries required, thereby lessening the burden on the patient, the healthcare system and society as a whole.

Seroma Formation in Pre-pectoral Implant-Based ADM Assisted Breast Reconstruction: A Comprehensive Review of Current Literature.

In the field of implant-based breast reconstruction (IBBR), the most recent and successful progress has been the evolution of the prepectoral approach through the use of acellular dermal matrix (ADM). ADM-assisted breast reconstruction is now gaining a foothold as standard practice, but its advantages are often clouded due to discouraging studies reporting increased seroma formation. The origin of the serum accumulation still remains unclear, but it has always been the most frequent early complication in breast reconstruction, thus proving to be crucial to address since it can lead to further complications. Using a standardized approach to obtain high-quality scientific evidence, the aim of this review is therefore to investigate the occurrence of seroma in breast implant-based reconstructive surgery and its possible relation with matrices. We conducted the review investigating only pre-pectoral implant positioning and one specific ADM (BraxonÃÂî) which is the one who has the highest number of cases in literature. nterestingly, ADM does not appear to be causative of seroma formation, but a surgery-related origin is discussed. In this setting, a series of rigorous guidelines have therefore been identified and analyzed to allow not only the treatment, but also the prevention of seroma, thus leading to a reduction in the incidence of this frequent problem.

Quality of Life and Early Functional Evaluation in Direct-to-Implant Breast Reconstruction After Mastectomy: A Comparative Study Between Prepectoral Versus Dual-Plane Reconstruction.

BACKGROUND: In conservative mastectomies, in which the native skin envelope is preserved, positioning an implant in the submuscular plane commonly leads to functional consequences like upper limb movement impairment and animation phenomena. In recent years, however, a new conservative prepectoral breast reconstruction technique has been proposed, with demonstrated surgical safety and aesthetic effectiveness. The aim of our study was to explore and compare the functional and aesthetic outcomes of the prepectoral/acellular dermal matrix (ADM)-wrapped implant procedure versus subpectoral/ADM-assisted reconstruction. PATIENTS AND METHODS: A retrospective nonrandomized comparative study of 94 patients (121 breasts) undergoing direct-to-implant breast reconstruction after skin-/nipple-sparing and skin reduction was conducted from February 2013 to October 2017. Fifty-five patients (group A) received subpectoral ADM-assisted reconstruction with dual-plane implant positioning, and 39 patients (group B) received prepectoral partially or totally ADM-wrapped implant reconstruction. Patients were allocated to either group A or B depending on the mastectomy flap thickness and vitality, as assessed clinically during the operation. Details of rehabilitation program, postoperative pain at 72 hours, postoperative analgesic therapies, demographic data, and complications were recorded. Upper limb function was assessed before and 1 month after surgery by a physiatrist according to a precise protocol. Patients were asked to fill in the BREAST-Q reconstruction questionnaire after surgery to evaluate outcomes. RESULTS: Differences in upper limb function between groups, namely flexion (P = .03), abduction (P = .003), internal rotation (P = .02), and external rotation (P = .05), were statistically significant. Although most patients required postoperative rehabilitation, the individual rehabilitation intervention frequency was greater in the subpectoral group (91% in group A vs 74% in group B). There was also a significant difference in postoperative pain (within 72 hours), with less pain perceived in the prepectoral group (P = .01). Furthermore, prepectoral patients reported slightly better postoperative quality of life than subpectoral patients, particularly in the domains of sexual well-being (P = .005) and satisfaction with breast (P = .002). CONCLUSION: In our case series, prepectoral implant positioning with partial or total ADM coverage led to less impairment of upper limb function in terms of flexion, abduction, and internal and external rotation, and also reduce the need for rehabilitation. Furthermore, as a result of the less invasive procedure, prepectoral patients had less immediate postoperative pain and were more satisfied with breast appearance.

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study.

Background and objectives: The metabolic response after exercise causes a significant increase in the muscle blood flow. While these effects are demonstrated for intra-muscular vessels, there is no evidence about the inter-muscular vessels, such as the septocutaneous perforators supplying the skin after they branch out from the deep source artery. The aim of our prospective study was to quantify the changes in the anterior tibial artery perforators arterial blood flow after mild isotonic exercise in a young and healthy population. Material and Methods: We performed a prospective analysis of 34 patients who were admitted to the Plastic Surgery Department from December 2019 to April 2020. Flow velocities of two previously identified anterior tibial artery perforators were recorded both before and after 10 complete flexion-extensions of the foot. The time to revert to basal flow was measured. We further classified the overmentioned patients based on their level of physical activity. Results: We registered a significant increase in systolic, diastolic and mean blood flow velocities both in proximal and distal anterior tibial artery perforators after exercise. Fitter patients exhibited a higher increase in proximal leg perforators than those who did less than three aerobic workouts a week. The time to return to basal flow ranged from 60 to 90 s. Conclusions: This was the first study to describe the effect of muscular activity on perforators blood flow. Even mild exercise significantly increases the perforator flow. Waiting at least two minutes at rest before performing the Doppler study, thus avoiding involved muscle activation, can notably improve the reliability of the pre-operative planning.

Skin-Reduction Breast Reconstructions with Prepectoral Implant.

UNLABELLED: Skin-reduction mastectomy with prepectoral implant reconstruction is a novel technique for immediate breast reconstruction, with subcutaneous implant placement in patients eligible for skin-reducing mastectomy. Implants were placed above the pectoralis muscles in a compound pocket made by a dermal flap and acellular dermal matrix. The procedure was performed on 33 breasts in 27 selected patients. In three cases, there was skin ischemia; in one case, it healed spontaneously; and in two patients, a surgical necrosectomy and primary closure were needed. No implant loss occurred. This new technique proved to be a useful alternative, with good cosmetic results, in selected patients requiring mastectomy. These preliminary results need to be confirmed by long-term and comparative studies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Daily serum collection after acellular dermal matrix-assisted breast reconstruction.

BACKGROUND: The acellular dermal matrix (ADM)-assisted breast reconstruction technique is widely known, but discouraging results due to early postoperative complications have been reported. As the literature identifies seroma as the most common issue after breast surgery without identifying its pathogenesis, we aimed to report the trend of postoperative daily serum collection after ADM-assisted breast reconstruction and compare it with data in the literature in order to discover more about this little-known topic. METHODS: A retrospective study on 28 consecutive patients who received ADM-assisted breast reconstruction between February 2013 and February 2014 was performed. In order to reduce the number of variables that could affect serum production, only one brand of ADM was used and all tissues were handled gently and precisely. The daily drainage volume was recorded per patient during the first four days of hospitalization. Likewise, postoperative complications were noted during routine follow-up. RESULTS: In total, five (17.9%) bilateral and 23 (82.1%) unilateral ADM-assisted breast reconstructions (33 implants) were performed. The mean age, body mass index, and length of hospital stay were 53.6 years, 21.3 kg/m(2), and 4.5 days, respectively. One major complication led to implant loss (3.0%), and nine minor complications were successfully treated with ambulatory surgery (27.3%). Serum collection linearly decreased after 24 hours postoperatively. CONCLUSIONS: Daily drainage decreased following the theoretical decline of acute inflammation. In concordance with the literature, daily serum production may not be related to the use of ADM.