Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

Multivariate Analysis of Risk Factors for Complications in Pediatric Tissue Expansion.

BACKGROUND: Tissue expanders represent one of the main surgical options for skin reconstruction in cases of tumors, traumalike burn injury, scar contracture, and alopecia. However, the tissue expander device is also associated with complications such as infection and extrusion. The aim of this study was to analyze risk factors for major complications of use of tissue expanders in pediatric patients using multivariate analysis. METHODS: A retrospective, single-center observational study was performed over 10 years in pediatric patients who were treated with tissue expanders for tumors, nevus, scars, burn reconstruction, and alopecia from April 2012 to March 2022. The primary outcome was overall complications per operation and expander, including infection and extrusion. Ten predictor variables were included as risk factors based on previous studies and as new factors considered important from clinical experience. Univariate and multivariate logistic regression analyses were performed to identify risk factors for major complications such as expander infection or extrusion. RESULTS: The study included 44 patients who underwent 92 operations using 238 tissue expanders. The overall complication rate per expander was 14.3%. Univariate logistic regression analysis identified associations of younger age, number of expanders used per operation, history of infection, and tissue expander locations with a higher complication rate. In multivariate logistic regression analysis, younger age (odds ratio, 1.14; P = 0.043) was associated with a high likelihood of expander complications. CONCLUSIONS: Younger age is an independent risk factor for tissue expander complications in pediatric patients. This factor should be considered in preoperative planning and discussions with the patient's family.

Prediction model for haematoma after tissue expander placement: A retrospective cohort study of 7080 cases over 20 years.

Haematoma is an early complication of tissue expander placement and can lead to infection, capsule contracture and various complications, hindering successful reconstruction. However, no scientific models can accurately predict the risk of haematoma following tissue expansion. Therefore, this study aimed to develop and validate a prediction model for haematoma following tissue expander placement. The medical records of patients who underwent expander placement between 2001 and 2021 were obtained from the clinical database of the Department of Plastic Surgery at the Xijing Hospital. A total of 4579 consecutive patients with 7080 expanders and 179 expanded pocket haematomas were analysed. Multivariate logistic regression analysis identified adult age (P = 0.006), male sex (P < 0.001), scar reconstruction (P = 0.019), perioperative hypertension (P < 0.001), face and neck location (P = 0.002) and activated partial thromboplastin time above the normal range (P < 0.001) as risk factors for haematoma. Therefore, these were included in the prediction model, and a nomogram was constructed. The discrimination of the nomogram was robust (area under the curve: 0.78; 95% confidence interval: 0.72-0.83). Further, the prediction model had a strong fit (Hosmer-Lemeshow test, P = 0.066) and maintained similar discrimination after considering performance optimism (bootstrapped area under the curve: 0.79; 95% confidence interval: 0.73-0.84). This clinical prediction model was created using a generalisable dataset and can be utilised to obtain valid haematoma predictions after expander placement, assisting surgeons in implementing preventive measures or interventions to reduce the occurrence of haematoma.

Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter?

The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement.

Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction.

BACKGROUND: Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss. METHODS: A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss. RESULTS: The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016). CONCLUSION: Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.

Textured versus Smooth Tissue Expanders: A Comparison of Complications in 3526 Breast Reconstructions.

BACKGROUND: Increased understanding of breast implant-associated anaplastic large-cell lymphoma has led to a shift away from textured breast devices. A few small studies have compared the complication rates of textured and smooth tissue expanders (TEs). The aim of this study was to compare complication profiles in patients undergoing two-stage postmastectomy breast reconstruction with either textured or smooth TEs. METHODS: The authors performed a retrospective review of female patients who underwent immediate breast reconstruction with textured or smooth TEs from 2018 to 2020 at their institution. Rates of seroma, infection/cellulitis, malposition/rotation, exposure, and TE loss were analyzed in the overall cohort and subgroups undergoing prepectoral and subpectoral TE placement. A propensity score-matched analysis was used to decrease the effects of confounders comparing textured and smooth TEs. RESULTS: The authors analyzed 3526 TEs (1456 textured and 2070 smooth). More frequent use of acellular dermal matrix, SPY angiography, and prepectoral TE placement was noted in the smooth TE cohort ( P < 0.001). Univariate analysis suggested higher rates of infection/cellulitis, malposition/rotation, and exposure in smooth TEs (all P < 0.01). Rates of TE loss did not differ. After propensity matching, no differences were noted in infection or TE loss. Prepectoral smooth expanders had increased rates of malposition/rotation. CONCLUSIONS: TE surface type did not affect rates of TE loss, although increased rates of expander malposition were noted in the smooth prepectoral cohort. Further research is needed to examine breast implant-associated anaplastic large-cell lymphoma risk with temporary textured TE exposure to improve decision-making. CLINICAL QUESTION/LEVEL OF EVIDENCW: Therapeutic, III.

Lower Extremity Pediatric Tissue Expansion: A Single Surgeon's 16-Year Experience.

BACKGROUND: Tissue expansion is a well-established approach to soft tissue reconstruction in the pediatric population for lower extremity pathologies. Unfortunately, complication rates range from 19% to 40% in literature, including infection and implant extrusion, leading to delays in reconstruction. These challenges have prompted investigation toward categorizing risk factors for lower extremity tissue expander placement. METHODS: A retrospective study of pediatric patients who underwent lower extremity tissue expander placement by the senior author (R.J.R.) was performed over a 16-year period. Patient charts were reviewed to categorize baseline and operative characteristics. Primary outcome variables were surgical-site infection, expander extrusion, and expander deflation. Univariate and multivariate logistic regressions were performed ( α < 0.05). RESULTS: There were 59 tissue expanders in our cohort. The overall complication rate was 27.1% with a 77.2% successful reconstruction rate. Greater number of expanders placed during 1 operation is associated with 2.5 increased odds of having any complication and is associated with 0.4 decreased odds of having a successful reconstruction. Incisions made in scar tissue for expander placement appear to be associated with a greater than 7 times increased odds of readmission. CONCLUSIONS: Reconstruction of soft tissue pathologies using lower extremity tissue expanders in the pediatric population is an effective yet challenging technique. This study identified that the number of expanders inserted during 1 operation, incisions made over scar tissue, and expanders placed in the anterior thigh were correlated with having a negative impact on reconstructive outcomes. Extra care should be taken with patients who require multiple expanders during 1 operation and with choosing the location and incision of expander placement.

Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Conflicting evidence exists regarding the utility of prophylactic postoperative antibiotics in tissue expander (TE)-based breast reconstruction. This study evaluated the risk of surgical-site infection between patients receiving 24 hours of perioperative antibiotics alone versus prolonged postoperative antibiotics within a propensity score-matched cohort. METHODS: Patients undergoing TE-based breast reconstruction receiving 24 hours of perioperative antibiotics alone were propensity score-matched 1:3 to patients receiving postoperative antibiotics based on demographics, comorbidities, and treatment factors. Incidence of surgical-site infection was compared based on duration of antibiotic prophylaxis. RESULTS: Of a total of 431 patients undergoing TE-based breast reconstruction, postoperative antibiotics were prescribed in 77.2%. Within this cohort, 348 were included for propensity matching (no antibiotics, 87 patients; antibiotics, 261 patients). After propensity score matching, there was no significant difference in incidence of infection requiring intravenous (no antibiotics, 6.9%; antibiotics, 4.6%; P = 0.35) or oral antibiotics (no antibiotics, 11.5%; antibiotics, 16.1%; P = 0.16). In addition, rates of unplanned reoperation ( P = 0.88) and 30-day readmission ( P = 0.19) were similar. After multivariate adjustment, prescription of postoperative antibiotics was not associated with a reduction in surgical-site infection (OR, 0.5; 95% CI, -0.3 to 1.3; P = 0.23). CONCLUSIONS: Within a propensity score-matched cohort accounting for patient comorbidities and receipt of adjuvant therapies, prescription of postoperative antibiotics after TE-based breast reconstruction conferred no improvement in rates of TE infection, reoperation, or unplanned health care use. These data underscore the need for multicenter randomized trials on the utility of antibiotic prophylaxis in TE-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Impact of Initial Filling Medium on Outcomes of Subpectoral, Two-Stage, Implant-Based Breast Reconstruction: Air versus Saline.

BACKGROUND: In two-stage expander-based breast reconstruction, the use of air as the initial filling medium has been suggested to confer clinical advantages over conventional saline, but this has not been demonstrated in a large series. This study aimed to evaluate the association between material type (air versus saline) for initial expander filling and postoperative outcomes. METHODS: This retrospective study included patients who underwent immediate, subpectoral, tissue expander-based breast reconstruction between January of 2018 and March of 2021. The participants were categorized into two groups according to the material used for initial filling: saline-inflated expanders, which were used during the first 22 months consecutively, and air-inflated expanders, which were used during the latter 17 months consecutively. Complications including mastectomy flap necrosis and postoperative expansion profiles were compared. Multivariable analyses were performed to identify independent predictors of postoperative complications. RESULTS: A total of 443 breasts (400 patients), including 161 air-filled and 282 saline-filled breasts, were analyzed. The two groups had similar baseline characteristics. The air-filled group showed a significantly lower rate of mastectomy flap necrosis; this difference remained significant after adjustment for other variables in the multivariable analysis. The rates of other complications did not differ between the two groups. The air-filled group had fewer office visits and a shorter period to complete expansion. CONCLUSIONS: The use of air for initial expander filling could provide safe and reliable outcomes with reduced patient discomfort during postoperative expansion; thus, air-filled expanders might be an effective alternative to saline-filled expanders. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Complication Profiles of Smooth vs Textured Tissue Expanders in Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders. OBJECTIVES: We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs). METHODS: A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis. RESULTS: A total of 5 articles met inclusion criteria, representing 1709 patients in the STE cohort and 1716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days.Our meta-analysis found no differences in all surgical outcomes except for explantation risk. STE use was associated with increased odds of explantation by over 50% compared to TTE use (odds ratio = 1.53; 95% CI = 1.15 to 2.02; P = .003). CONCLUSIONS: Overall, STEs and TTEs had similar complication profiles. However, STEs had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single case of BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL.

Smooth vs Textured Expanders: Patient Factors and Anatomic Plane Are Greater Factors in Determining First-Stage Breast Reconstruction Outcomes.

BACKGROUND: Textured implants and expanders are associated with an increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). As a result, plastic surgeons are utilizing smooth expanders, but many perceive these produce undesirable outcomes including infection, seroma, and lateral displacement. OBJECTIVES: The aim of this study was to compare clinical outcomes of smooth and textured expanders. METHODS: Breast reconstruction patients from January 2018 to May 2021 were retrospectively reviewed. Included patients underwent placement of tissue expanders at the time of mastectomy. Primary outcomes included postoperative seroma, infection, malposition, days to final reconstruction, explantation, and the need for capsulorrhaphy. RESULTS: In total, 233 patients were reviewed, of whom 167 met both inclusion and exclusion criteria. There was no statistically significant difference in poor outcomes comparing smooth and textured expanders. Days to final reconstruction was lower with smooth expanders per breast (P = .0424). The subpectoral group was associated with an increased likelihood of undergoing capsulorrhaphy (P = .004). Prepectoral placement was associated with more seromas (P = .0176) and infections (P = .0245). Demographic factors included older age as a protective factor for undergoing capsulorrhaphy (odds ratio [OR] = 0.962, P = .038), obesity increased the risk of infection (OR = 5.683, P = .0279) and malposition (OR = 6.208, P = .0222), and radiation was associated with malposition (OR = 3.408, P = .0246). CONCLUSIONS: There was no significant difference in poor outcomes between smooth and textured expanders. Patient demographics and anatomical plane placement had greater effects on infection, seroma, and the need for capsulorrhaphy compared with tissue expander texturing.

A Simple Technique Using Peri-Prosthetic Irrigation Improves Implant Salvage Rates in Immediate Implant-Based Breast Reconstruction.

Background and objectives: Implant-related complications leading to implant loss contribute to major morbidity in immediate breast reconstruction (IBR). Various techniques have been advocated to improve rates of reconstruction salvage. The objective of our study was to assess if a peri-prosthetic irrigation system was an effective adjunct to the conventional wash-out technique in improving reconstruction salvage rates. Methods: The study included patients who had immediate implant-based breast reconstruction from January 2015 to November 2020. The conventional technique of reconstruction salvage, using debridement, wash-out, and implant/expander exchange with systemic use of antibiotics, was performed for patients undergoing exploration for infection until May 2019. A simple technique using a continuous peri-prosthetic irrigation system with vancomycin (1 g/L normal saline over 24 h) for 2 days was added as an adjunct to the conventional technique. Treatment details and clinical outcomes were compared between the groups. The study was approved by the Clinical Governance department. Results: During the study period, 335 patients underwent IBR. A total of 65 patients (19.4%) returned to the theatre due to post-operative complications, of which 45 (13.4%) were due to infection. A conventional technique was used in 38 (84.4%) patients, and peri-prosthetic irrigation was used as an adjunct in 7 patients (15.6%). A total of 16 (42.1%) in the conventional group and all 7 (100%) in the irrigation group had successful reconstruction salvage. No patients had complications due to antibiotic irrigation. Conclusions: The peri-prosthetic irrigation system is a simple, safe, and effective adjunct to conventional techniques in improving reconstruction salvage in IBR.

Benefits of Using Magnetic Resonance Imaging During Breast Tissue Expansion: Literature Review and Case Series.

Breast cancer results in up to 1.6 million new candidates for yearly breast reconstruction (BR) surgery. Two-stage breast reconstruction surgery with the use of a tissue expander (TE) is a common approach to reconstructing the breast after mastectomy. However, a common disadvantage encountered with the traditional breast TE is the magnetic injection port, which has been reported to cause injuries in patients undergoing magnetic resonance (MR) imaging. Therefore this type of breast TE is labeled "MR unsafe." Recent technological advances have incorporated radio-frequency identification (RFID) technology in the TE to allow for the location of the injection port without magnetic components, resulting in an MR-conditional TE. This paper aims to review the information regarding the safety profile of TEs with magnetic ports and to gather distinct clinical scenarios in which an MR-conditional TE benefits the patient during the BR process. A literature review ranging from 2018 to 2022 was performed with the search terms: "tissue expander" OR "breast tissue expander" AND "magnetic resonance imaging" OR "MRI." Additionally, a case series was collected from each of the authors' practices. The literature search yielded 13 recent peer-reviewed papers, and 6 distinct clinical scenarios were compiled and discussed. Most clinicians find MRI examinations to be the state-of-art diagnostic imaging modality. However, due to the preexisting risks associated with TEs with magnetic ports, the MRI labeling classification should be considered when deciding which TE is the most appropriate for the patient requiring MRI examinations.

ADM-Assisted Direct-to-Implant Prepectoral Breast Reconstruction in Postmastectomy Radiation Therapy Setting: Long-Term Results.

BACKGROUND: Postmastectomy radiotherapy (PMRT) on immediate breast reconstruction historically involved a marked increase in complication rate (up to 50%). Prepectoral breast reconstruction (PPBR) has shown promising early postoperative results. This study aims to evaluate PPBR long-term results in PMRT setting. MATERIALS AND METHODS: This is a retrospective monocentric analysis of 485 PPBR (439 patients) undergoing Acellular-Dermal-Matrix assisted direct-to-implant reconstruction (46 bilateral procedures) between January 2015 and December 2020 (mean FU:35.6 months). Group 1 comprised 401 PPBR not submitted to PMRT, and 84 reconstructions receiving PMRT in Group 2. Patients' characteristics, postoperative complication and revisional surgery rate were examined. PMRT characteristics and subcutaneous tissue thickness, measured in Group 2 by CT scan, were also evaluated. RESULTS: Long-term complication rate was 11.2% in Group 1 vs. 21.4% in Group 2 (P-value = .019). Capsular contracture represented the only complication associated to a statistically significant difference between the 2 groups (P-value < .001). In Group 2, only 4.8% implant loss and 8.3% severe capsular contracture rate was found. In patients who underwent PMRT, 38.9% of complications settled with no consequences, and only 4.8% of patients needed revisional surgery in the long-term FU. According to multivariate analysis, drug intake and PMRT were significantly associated with postoperative complications. In Group 2, a thinner subcutaneous tissue was linked to a higher complication risk. CONCLUSION: In our series, patients treated with PPBR who underwent PMRT, presented a low complication rate and minimal need for revisional surgery in the long-term follow-up, suggesting that this technique is feasible and safe also in PMRT context.

Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

BACKGROUND: Tissue expander fill medium and volume have implications for the pressure exerted on mastectomy skin flaps. This study evaluated the influence of initial fill medium (air vs. saline) on complications in immediate breast reconstruction within a propensity score-matched cohort. PATIENTS AND METHODS: Patients undergoing immediate tissue expander-based breast reconstruction with initial intraoperative fill with air were propensity score matched 1:2 to those with saline initial fill based on patient and tissue expander characteristics. Incidence of overall and ischemic complications were compared by fill medium (air vs. saline). RESULTS: A total of 584 patients were included, including 130 (22.2%) with initial fill with air, 377 (64.6%) with initial fill with saline, and 77 (13.2%) with 0 cc of initial fill. After multivariate adjustment, higher intraoperative fill volume was associated with increased risk of mastectomy skin flap necrosis [regression coefficient (RC) 15.7; p = 0.049]. Propensity score matching was then conducted among 360 patients (Air: 120 patients vs. Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p > 0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p = 0.003), seroma (p = 0.004), and nipple necrosis (p = 0.03). CONCLUSIONS: Within a propensity score-matched cohort, initial fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. Initial fill with air and lower fill volumes may be strategies to reducing risk of ischemic complications among high-risk patients.

Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management.

BACKGROUND: Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation. PATIENTS AND METHODS: An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded. RESULTS: Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005). CONCLUSION: We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

A Propensity Score-Matched Comparison of Perioperative Outcomes in Prepectoral Smooth Versus Textured Tissue Expander Breast Reconstruction.

INTRODUCTION: Textured tissue expanders (TEs) had previously gained popularity due to minimizing expander migration, rotation, and capsule migration. Recent studies, though, have revealed increased risk of anaplastic large-cell lymphoma associated with certain macrotextured implants, prompting surgeons at our institution to switch to smooth TEs; evaluation is thus required for specific viability and similarity of outcomes of smooth TEs. Our study aims to evaluate perioperative complications in prepectoral placement of smooth versus textured TEs. METHODS: Our retrospective study evaluated perioperative outcomes of patients who underwent bilateral prepectoral TE placement, with either smooth or textured TE, at an academic institution between 2017 and 2021 performed by 2 reconstructive surgeons. The perioperative period was defined as the interval between expander placement until conversion to flap/implant or removal of TE due to complications. Our primary outcomes included hematoma, seroma, wounds, infection, unspecified redness, total number of complications, and returns to operating room secondary to complications. Secondary outcomes included time to drain removal, total number of expansions, hospital length of stay, length of time until the next breast reconstruction procedure, next breast reconstruction procedure, and number of expansions. RESULTS: Two hundred twenty-two patients were evaluated in our study (141 textured, 81 smooth). After propensity matching (71 textured, 71 smooth), our univariate logistic regression showed no significant difference in perioperative complications between smooth and textured expanders (17.1% vs 21.1%; P = 0.396) or complications that required a return to the operating room (10.0% vs 9.2%; P = 0.809). No significant differences were noted for hematoma, seroma, infections, unspecified redness, or wounds between both groups. A significant difference was noted in days to drain out (18.57 ± 8.17 vs 20.13 ± 0.07, P = 0.001) and type of the next breast reconstruction procedure (P < 0.001). Our multivariate regression showed that breast surgeon, hypertension, smoking status, and mastectomy weight were significant for increased risk for complications. CONCLUSION: Our study demonstrates similar rates and effectiveness of smooth versus textured TE when used for prepectoral placement, making smooth TEs a safe and valuable alternative for breast reconstruction because of their decreased risk of anaplastic large-cell lymphoma compared with textured TEs.

Wise Pattern versus Transverse Pattern Mastectomy in Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: The Wise pattern adapted to mastectomy incisions has become a valuable asset for breast reconstruction in patients with large and ptotic breasts. The authors compared the time for exchange, time to initiate postmastectomy radiotherapy, and complication rates between Wise pattern and transverse incision pattern reconstructions. METHODS: Records of patients who underwent immediate, two-stage, implant-based breast reconstruction (IBBR) between January of 2011 and December of 2020 were retrospectively reviewed. Two cohorts were compared according to the incision pattern: Wise pattern versus transverse incision pattern. Complications were compared after propensity score matching. RESULTS: The authors initially analyzed 393 two-stage immediate IBBRs in 239 patients [91 IBBRs (23.2%) in the Wise pattern group and 302 (76.8%) in the transverse pattern group]. Expansion time (53 days versus 50 days, P = 0.9), time for tissue expander-to-implant exchange (154 versus 175 days, P = 0.547), and time to initiate postmastectomy radiotherapy (144 days versus 126 days, P = 0.616) were not different between groups. Before propensity score matching, the 30-day rate of wound-related complications (32% versus 10%, P < 0.001) and the 30-day rate of wound complications requiring excision/débridement and closure procedures (20% versus 7%, P < 0.001) were significantly higher in the Wise pattern group. After propensity score matching, the 30-day rate of wound complications was persistently higher (25% versus 10%, P = 0.03) in the Wise pattern group. CONCLUSIONS: The Wise pattern mastectomy independently increases the incidence of wound-related complications versus only transverse patterns during two-stage IBBR, even after propensity score matching. Delayed tissue expander placement may improve the safety profile of this procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.