Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy.

INTRODUCTION: Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. METHODS: We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. RESULTS: One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. CONCLUSIONS: Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.

Use of a bovine pericardial patch angioplasty for completion of a complicated end to side anastomosis of a recipient vessel in the free flap reconstruction of a radiated wound: A case report.

Soft tissue sarcomas treated by extensive surgical resection and adjuvant radiation can lead to large tissue deficits that require free flap repair. Significant radiation can further compromise vessels necessitating novel therapeutic approaches. We describe an 82-year-old man who presented with a posterior thigh sarcoma and underwent wide local tumor resection and immediate reconstruction with a microvascular free flap. Due to radiated recipient vessels, this case required bovine patch angioplasty as a conduit for end to side anastomosis. Initial resection and pathology revealed a large myxofibrosarcoma. Wide local resection and radiotherapy resulted in a large irradiated soft tissue defect of 26 x 15 x 4 cm with exposed, radiation damaged neurovascular structures, and a lack of available regional flap options. The planned free flap, a 30 x 8 cm skin island from the left latissimus dorsi muscle with end-to-side anastomosis to the popliteal artery was complicated by friability of the vessel wall and insufficient perfusion. Given the extent of resection and radiation, there were no alternative recipient vessels present within the field. A bovine pericardial patch angioplasty of 2.5 cm in length was performed to the diseased popliteal vessel and an end to side anastomosis was successfully performed between the thoracodorsal artery and the patch. Improved reperfusion of the free flap was noted immediately following anastomosis indicating completion of the anastomosis of our complicated recipient vessel. During the uncomplicated postoperative course, the flap had good perfusion with Doppler signals present, and incision sites intact at discharge from acute hospitalization. Recurrent sarcomas that have undergone extensive resection and radiotherapy pose significant reconstructive challenges. For defects that require free tissue reconstruction when there are limited options for healthy, recipient vessels, bovine pericardial patch angioplasty may act as a robust conduit for diseased vessels.

Preventing Rectourethral Fistula Recurrence With Gracilis Flap.

BACKGROUND: Rectourethral fistula (RUF) is an uncommon serious condition with various etiologies including neoplasm, radiation therapy, and surgery. Treatment for RUF remains problematic with a high recurrence rate. Although studies have suggested the recurrence rate of RUF is lower after surgical repair using a gracilis flap, outcomes have varied and the studies were small and inadequately controlled. Here, we compare outcomes of RUF repair with and without gracilis flap to evaluate its efficacy in preventing fistula recurrence and identify risk factors for recurrence. METHODS: We retrospectively reviewed patients who had undergone surgical repair for RUF between 2007 and 2018 at our institution and had at least 30 days of follow-up. Patient demographics, comorbidities, and surgical outcomes were recorded and compared for patients who had gracilis flap repair and those who did not (controls). Single variable logistic regression analysis was used to identify risk factors for recurrence. RESULTS: The gracilis group (n = 24) and control group (n = 12) had similar demographics and comorbidities. Fistula recurrence was far less frequent in the gracilis group (8% vs 50%, P = 0.009). There were no significant differences in other outcomes including length of hospitalization and surgical complications. When recurrent RUF was treated with a muscle flap (gracilis or inferior gluteus), 83% of the group had no additional fistula recurrence. In the control group, history of radiation ( P = 0.04) and urinary incontinence ( P = 0.015) were associated with fistula recurrence. CONCLUSIONS: We recommend using a gracilis flap for RUF repair given its association with lower recurrence without increased surgical complications.

Utility of Postoperative Prophylactic Antibiotics in Prepectoral Breast Reconstruction: A Single-Surgeon Experience.

BACKGROUND: Immediate tissue expander placement remains a preferred method for breast reconstruction after mastectomy. The use of prophylactic postoperative antibiotic administration is thought to reduce rates of surgical site infection and reconstructive failure, but has not been studied in patients undergoing reconstruction in the prepectoral plane. METHODS: We retrospectively identified all patients undergoing immediate prepectoral tissue expander placement after mastectomy by a single plastic surgeon from 2015 to 2018. We identified 2 cohorts of patients: one group that received prophylactic antibiotics at the time of discharge and one group that did not. We collected treatment and outcomes data to compare rates of postoperative complications between cohorts. RESULTS: We identified 69 patients with 115 breasts who received discharge antibiotics and 63 patients with 106 breasts who did not. The antibiotic cohort had significantly lower rates of tissue expander loss (4.3% vs 17.0%, P = 0.003), unplanned operation (10.4% vs 24.5%, P = 0.007), and infection (7.0% vs 24.5, P < 0.001). CONCLUSIONS: The use of prophylactic postoperative antibiotics in prepectoral breast reconstruction is associated with significantly lower rates of postoperative complications. Further randomized controlled studies are warranted to explore the effect of antibiotic therapy on outcomes and to determine what the optimal duration of antibiotic therapy may be.

A Critical Analysis of Prosthetic Augmentation of Autologous Microvascular Breast Reconstruction.

INTRODUCTION: The combined approach using both an implant and autologous tissue for breast reconstruction has become more common over the last 10 years. We sought to provide a systematic review and outcomes analysis of this technique. METHODS: We searched PubMed and the Cochrane Library database to identify studies that described implant augmentation of autologous flaps for breast reconstruction. The references of selected articles were also reviewed to identify any additional pertinent articles. RESULTS: We identified 11 articles, which included 230 patients and 378 flaps. Implants used ranged in size from 90 to 510 cc, with an average size of 198 cc. Implants were more frequently placed at the time of autologous reconstruction and in the subpectoral plane. There were no total flap losses, and partial flap loss occurred in 3 patients (1%). There were no cases of venous or arterial thrombosis and no early return to the operating room for flap compromise. Eight implants (2%) were lost because of infection or extrusion, and capsular contracture occurred in 9 breasts (3%). When stratified by the timing of implant placement (immediate vs delayed), there were no significant differences in any postoperative outcomes except the immediate group had a higher infection rate. CONCLUSIONS: The criteria for women to be candidates for autologous tissue breast reconstruction can be expanded by adding an implant underneath the flap. We found the overall flap loss rate is comparable with standard autologous flap reconstruction, and the implant loss rate is lower than that in patients who undergo prosthetic reconstruction alone.

The "Dual-Plane" DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are routinely elevated on a single dominant perforator from the deep epigastric vascular system. However, the single perforator may not always perfuse an entire flap adequately, particularly suprascarpal tissue. We often perform "dual-plane" single perforator DIEP flaps by rerouting the superficial (SIEA/V) system directly into a branch of the deep (DIEA/V) vascular system pedicle, thus allowing both systems to contribute and enhance flap perfusion. METHODS: A prospectively collected database of patients undergoing microvascular breast reconstruction was reviewed for patients undergoing "dual-plane" DIEP flaps. These were matched to a similar cohort of patients undergoing "traditional" single perforator DIEP free flaps over the same time period. Treatment demographics and flap-specific morbidity outcomes were assessed, including performance in the setting of radiation. RESULTS: Over 2 years, 23 "dual-plane" DIEP flaps were performed (15 patients), compared with 35 single-perforator "traditional" DIEP flaps (23 patients). Rates of delayed healing were similar between both cohorts (2.9 vs. 4.3%, p = 0.28). Rates of palpable fat necrosis were significantly lower in "dual-plane" DIEP flaps compared with "traditional" flaps (0 vs. 14.3%, p = 0.03). Rates of clinically palpable fat necrosis following radiation were significantly lower in the "dual-plane" flaps (4.3 vs. 40%, p = 0.02). CONCLUSION: The "dual-plane" DIEP flap is one we routinely consider in our algorithm, as it allows for full preservation of functional abdominal musculature, and offers enhanced flap perfusion by incorporating both the deep and superficial (dominant) vascular systems. This results in lower fat necrosis rates, particularly in the setting of post-reconstruction radiation.

Three-dimensional Analysis of How Radiation Affects Deep Inferior Epigastric Perforator (DIEP) Flap Volume, Projection, and Position in Breast Cancer Reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap has gained popularity for autologous free flap breast reconstruction. Historically, patients receiving post mastectomy radiation therapy (PMRT) were not candidates for immediate autologous reconstruction due to concerns for flap volume depletion, fat necrosis, and flap failure. However, this literature is anecdotal and lacks case controls. We objectively analyzed the effects radiation imparts on immediate DIEP flap reconstruction using 3-dimensional software and inherent controls. METHODS: We performed a cohort study on breast cancer patients who underwent immediate bilateral DIEP flap reconstructions followed by PMRT between 2005 and 2014. Exclusion criteria included patients less than 6 months from PMRT completion and bilateral PMRT. Three-dimensional photographs were analyzed using Geomagic (Rock Hill, SC) software to compare flap position, projection, and volume between the irradiated and nonirradiated reconstructed breasts. Breast Q survey evaluated patients' satisfaction. RESULTS: Eleven patients met inclusion criteria. Average time from PMRT completion to photo acquisition was 1.93 years. There was no statistical difference in average volume or projection in the irradiated versus nonirradiated side (P = 0.087 and P = 0.176, respectively). However, position of the irradiated flaps was significantly higher on the chest wall compared to controls (mean difference, 1.325 cm; P < 0.004). CONCLUSIONS: Three-dimensional analysis exhibited no statistical differences in projection or volume between irradiated DIEP flaps and nonirradiated controls. However, irradiated DIEP flaps were positioned higher on the chest wall, similar to observations in irradiated tissue expanders/implants. Patients were satisfied as measured by Breast Q. Immediate bilateral DIEP flap reconstructions can safely be performed with PMRT with satisfactory results.

In Vivo Changes of Breast Perfusion After Augmentation.

BACKGROUND: Revision surgeries after breast augmentation are associated with an increased risk of complications (eg, nipple areolar complex [NAC]) necrosis. Consequently, maintaining perfusion to the NAC is a critical aspect of secondary breast surgery. OBJECTIVES: The purpose of this study was to examine in vivo changes in perfusion to the NAC after implant breast augmentation using magnetic resonance imaging (MRI) technology. METHODS: High-resolution 3 Tesla MRI images of 10 women (20 breasts) with previous breast augmentation were compared to a control population of 15 women (30 breasts). Perforators from the internal mammary artery and lateral thoracic artery were examined for the diameter of the originating perforator, distance between the nipple and most distally visualized point of the medial and lateral perforator, and dominance pattern between the medial vs lateral perforators. RESULTS: No difference was found in the caliber of the medial vessels in the implant group compared to the control group. In contrast, the caliber of the lateral blood vessels trended towards being 20% larger in diameter in the augmented breasts. The distances between the nipple and the medial and lateral vessels increased. The frequencies in the distribution of dominance were not significantly different between the implant group and the control group. CONCLUSIONS: Overall, medial and lateral blood supply to the NAC are preserved in the augmented patient. Our results suggest a slight delay effect that seems to increase the caliber of the lateral perforators. In addition, the tissue expansion provided by the implants effectively increases the length of both perforators. LEVEL OF EVIDENCE: 3 Therapeutic.

Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction.

BACKGROUND: Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase. METHODS: The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point. RESULTS: A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively. CONCLUSIONS: Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Radiation therapy and expander-implant breast reconstruction: an analysis of timing and comparison of complications.

BACKGROUND: The optimal timing of expander-implant exchange in the setting of postmastectomy radiation therapy (PMRT) remains unclear with prior reports yielding inconsistent and variable results. The purpose of this study was to characterize complications associated with the sequencing of expander-implant breast reconstruction before or after PMRT and to compare the outcomes between early (<4 months) and late (>4 months) expander-implant exchange in the subset of patients who received PMRT before exchange. MATERIALS AND METHODS: The medical records of all patients PMRT in the setting of tissue expander-implant breast reconstruction between June 2004 and June 2011 at our institution were reviewed retrospectively. Patients were first classified as having undergone expander-implant exchange before the initiation of PMRT or after the completion of PMRT. Patients who underwent expander-implant exchange after PMRT were then classified as having undergone exchange early (<4 months after PMRT) or late (>4 months after PMRT). All complications requiring additional surgery or hospitalization were recorded. RESULTS: Fifty-five eligible patients were identified as having undergone 56 two-stage tissue expander-implant breast reconstructions. Twenty-two reconstructions underwent exchange before PMRT and 34 reconstructions underwent exchange after PMRT. There was no significant difference in overall complication rate (54.55% vs 47.06%, P = 0.785) or reconstruction failure rate (13.64% vs 20.59%, P = 0.724) between the 2 cohorts. Twenty reconstructions underwent exchange less than 4 months after PMRT and 14 underwent exchange more than 4 months after PMRT. There was no significant difference in overall complication rate (40% vs 57.14%, P = 0.487) or failure rate (25% vs 14.29%, P = 0.672) between the 2 groups. Trends suggest a higher rate of infection in patients who underwent exchange earlier (30% vs 14.29%, P = 0.422) and a higher rate of capsular contracture in patients who underwent exchange later (5% vs 21.43%, P = 0.283); however, statistical significance was not reached. CONCLUSIONS: Our findings suggest that neither the sequencing nor timing of expander-implant exchange in the setting of PMRT affects overall complication or reconstruction failure rate. However, the timing of exchange may impact the type of complication encountered. Further investigation is necessary to determine an optimal time for expander-implant exchange.

A Pilot Randomized Clinical Trial of Early Ambulation after Groin Reconstruction with Sartorius Muscle Flaps.

The use of muscle flaps, such as the sartorius muscle, for groin coverage in high-risk vascular patients has been shown to reduce complication rates. However, it remains unknown whether earlier postoperative ambulation is associated with improved postoperative outcomes for groin muscle flaps following infrainguinal vascular surgery. Methods: We performed a pilot randomized trial to analyze the effect of early ambulation on postoperative outcomes in patients who had groin reconstruction with sartorius muscle flaps following infrainguinal vascular surgery at our academic institution. Results: Fourteen patients were randomized to standard ambulation (on postoperative day 6), and 14 patients were randomized to early ambulation (on postoperative day 2). The treatment arms were similar with respect to age, body mass index, risk category, smoking status, and comorbidities. Median length of stay was 6 days in the early group versus 7 days in the standard group. Immediate and long-term physical function and general health were better in the early group There were slightly more wound complications in the standard (57.1%) versus the early group (42.9%), and the early group had more lymphatic complications (35.7% versus 14.3%). Conclusions: The decision to ambulate a patient after this surgery continues to be a decision between the vascular and plastic surgeons. However, this pilot trial has shown the safety profile of early ambulation and that it should be considered for specific patients. Additionally, this trial has provided valuable information for performing a larger scale randomized controlled trial to determine the optimal postoperative protocol for patients with these reconstructions.

From Bench to Bedside: The Role of a Multidisciplinary Approach to Treating Patients with Lymphedema.

Background: Lymphedema is a condition characterized by dysfunction of the lymphatic system resulting in chronic, progressive soft tissue edema that can negatively impact individuals' function, self-image, and quality of life. Understanding of the disease process has evolved significantly in the past two decades with advances in diagnostic modalities and surgical techniques revolutionizing prior treatment algorithms. Methods and Results: We reviewed our current approach at the University of Southern California to improving outcomes in lymphedema treatment. Given the complexity of this medical condition, patients are best served by a multidisciplinary approach. At our institution, this involves a collaborative effort between bench researchers, lymphatic therapists, medical physicians, and lymphedema surgeons. Basic science and translational research provide further understanding into the underlying mechanisms of lymphangiogenesis and the possibility for potential therapeutic interventions. Our surgical algorithms require patients to undergo a thorough diagnostic evaluation and consultation with certified lymphatic therapists prior to undergoing either physiologic or debulking operations. Patients are followed clinically following any interventions. Further community outreach and education is carried out in order to improve upon early diagnosis and symptom recognition. Conclusions: Optimizing lymphedema care requires a collaborative interplay between researchers, physicians, and therapists. Additionally, patient and provider education on early disease recognition and treatment options is an equally critical aspect of improving patient outcomes.

Quantifying the Psychosocial Benefits of Masculinizing Mastectomy in Trans Male Patients with Patient-Reported Outcomes: The University of California, San Francisco, Gender Quality of Life Survey.

BACKGROUND: Gender-affirming surgery is a medically necessary treatment to alleviate gender dysphoria for transgender patients. Although previous studies suggest improved psychosocial outcomes after gender-affirming surgery, there are no transgender-specific instruments available to assess its effects on patient quality of life. METHODS: Using qualitative methods, the authors developed the first quality-of-life survey, the University of California, San Francisco, Gender Quality of Life (UCSF Gender QoL) survey, for trans male patients undergoing gender-affirming mastectomy. The UCSF Gender QoL survey was then administered prospectively to 51 trans male patients undergoing inframammary mastectomy with free nipple grafting at the University of California, San Francisco. The brief version of the World Health Organization Quality of Life survey was also given as a measure of external validity. The Cronbach alpha was value calculated to measure internal validity. RESULTS: Thirty-six patients completed surveys 6 weeks after surgery, and 22 patients completed surveys 1 year after surgery, for response rates of 71 percent and 43 percent, respectively. The UCSF Gender QoL survey detected a significant improvement in quality of life 6 weeks and 1 year after chest surgery. The effect sizes were large, and the Cronbach alpha exhibited excellent internal validity. CONCLUSIONS: This study establishes the UCSF Gender QoL survey as one of the first patient-reported outcomes tools for evaluating quality of life in trans male patients after gender-affirming chest reconstruction. Although the study is limited by a small cohort at a single center, establishing the validity of the UCSF Gender QoL survey provides an invaluable tool for future research into various aspects of gender-affirming chest surgery.

Surgical Correction of Breast Animation Deformity with Implant Pocket Conversion to a Prepectoral Plane.

BACKGROUND: Animation deformity is an undesirable outcome of subpectoral breast reconstruction that results in abnormal breast contraction with activity, breast pain, and increased implant visibility. Surgical correction requires implant removal and conversion of the reconstruction to a prepectoral plane. The authors present their institutional experience with their preferred surgical technique to treat this challenging problem and outline solutions for increased success in these patients. METHODS: A retrospective review was performed of all patients undergoing conversion of their subpectoral breast reconstruction to a prepectoral plane at the authors' institution. Patient demographics and surgical details were analyzed, and postoperative outcomes and morbidity were assessed. The effects of changing operative strategies on enhanced success are also reported. RESULTS: A total of 80 breast conversions were performed over a 2.5-year period. All patients demonstrated resolution of animation deformity at a mean follow-up of 15.2 months. Two reconstructions (2.5 percent) required an unplanned return to the operating room, and 11 reconstructions (13.8 percent) were treated for infection. Preconversion fat grafting and the use of acellular dermal matrix were both associated with a reduced incidence of postoperative asymmetry and capsular contracture (p < 0.05). There were no reconstructive failures associated with conversion to a prepectoral pocket. CONCLUSIONS: Treatment of animation deformity in the reconstructed patient can be safely performed by surgical conversion to a prepectoral plane. The use of acellular dermal matrix, and preconversion fat grafting, in appropriate patients can improve results. The authors promote this operative algorithm for all reconstructive patients experiencing symptomatic animation deformity with subpectoral breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Correction of animation deformity with subpectoral to prepectoral implant exchange.

BACKGROUND: Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. METHODS: We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. RESULTS: Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). CONCLUSIONS: Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits.

BACKGROUND: Prepectoral breast reconstruction following mastectomy has become a more widely performed technique in recent years because of its numerous benefits for women. These include full pectoralis muscle preservation, reduced loss of strength, reduced pain, and elimination of animation deformity. As with any breast reconstruction technique, widespread adoption is dependent on a low morbidity profile in the setting of postmastectomy radiation therapy, as this adjuvant therapy is routine in breast cancer treatment. The authors assess the clinical outcomes of patients undergoing postmastectomy radiation therapy following prepectoral breast reconstruction, and compare these to outcomes of patients undergoing postmastectomy radiation therapy with submuscular reconstruction. METHODS: A single surgeon's experience with immediate prepectoral breast reconstruction, followed by postmastectomy radiation therapy, from 2015 to 2017 was reviewed. Patient demographics and incidence of complications during the tissue expander stage were assessed. In addition, the morbidity profile of these patients was compared to that of patients undergoing submuscular/dual-plane reconstruction and postmastectomy radiation therapy over the same period. RESULTS: Over 3 years, 175 breasts underwent immediate prepectoral reconstruction, and 236 breasts underwent immediate submuscular/dual-plane reconstruction. Overall rates of adjuvant radiation therapy (postmastectomy radiation therapy) were similar between prepectoral [26 breasts (14.9 percent)] and submuscular [31 breasts (13.1 percent)] (p = 0.6180) reconstruction. There were no significant differences in complication rates between the two reconstructive cohorts, in the setting of postmastectomy radiation therapy, including rates of explantation (15.4 percent versus 19.3 percent; p = 0.695). CONCLUSIONS: Prepectoral breast reconstruction is a safe and effective option in the setting of postmastectomy radiation therapy. The morbidity profile is similar to that encountered with submuscular reconstruction in this setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy with immediate prosthetic reconstruction is routinely performed because of excellent aesthetic results and safe oncologic outcomes. Typically, subpectoral expanders are placed, but in select patients, this can lead to significant postoperative pain and animation deformity, caused by pectoralis major muscle disinsertion and stretch. Prepectoral reconstruction is a technique that eliminates dissection of the pectoralis major by placing the prosthesis completely above the muscle with complete acellular dermal matrix coverage. METHODS: A single surgeon's experience with immediate prosthetic reconstruction following nipple-sparing mastectomy from 2012 to 2016 was reviewed. Patient demographics, adjuvant treatment, length and characteristics of the expansion, and incidence of complications during the tissue expander stage were compared between the partial submuscular/partial acellular dermal matrix (dual-plane) cohort and the prepectoral cohort. RESULTS: Fifty-one patients (84 breasts) underwent immediate prepectoral tissue expander placement, compared with 115 patients (186 breasts) undergoing immediate partial submuscular expander placement. The groups had similar comorbidities and postoperative radiation exposure. There was no significant difference in overall complication rate between the two groups (17.9 percent versus 18.8 percent; p = 0.49). CONCLUSIONS: Prepectoral breast reconstruction provides a safe and effective alternative to partial submuscular reconstruction, that yields comparable aesthetic results with less operative morbidity. In the authors' experience, the incidence of acute and chronic postoperative pain and animation deformity is significantly lower following prepectoral breast reconstruction. This technique is now considered for all patients who are safe oncologic candidates and are undergoing nipple-sparing mastectomy and prosthetic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes.

BACKGROUND: Radiation therapy is increasingly used in breast cancer therapy. With total skin-sparing mastectomy and nipple/areola complex preservation, defining the risks of various treatment regimens for morbidity is important, in the setting of immediate prosthetic reconstruction. The authors assessed the effects of premastectomy and postmastectomy radiation therapy on outcomes in total skin-sparing mastectomy and immediate prosthetic reconstruction. METHODS: All patients undergoing total skin-sparing mastectomy and immediate prosthetic reconstruction at the authors' institution between 2006 and 2012 were identified. Cohort 1 included patients undergoing total skin-sparing mastectomy and reconstruction with no radiation. Cohort 2 included patients with a prior history of radiation before total skin-sparing mastectomy and reconstruction. Cohort 3 included patients undergoing radiation after total skin-sparing mastectomy and reconstruction. RESULTS: A total of 580 patients underwent 903 breast reconstructions following total skin-sparing mastectomy. Cohort 1 included 727 breasts, cohort 2 included 63 breasts, and cohort 3 included 113 breasts. Any radiation delivery caused an increased rate of infection requiring antibiotics (21.6 percent, p = 0.00) and an increased risk of expander/implant loss (18.75 percent, p = 0.00). Cohort 2 had a higher risk of wound breakdown (p = 0.012). All cohorts showed similar low rates of nipple/areola necrosis. CONCLUSIONS: Both preoperative and postoperative radiation following total skin-sparing mastectomy and immediate prosthetic reconstruction result in higher, but acceptable, complication risks. Complications related to nipple/areola preservation are similar to those in nonradiated patients and in those undergoing skin-sparing mastectomy. Thus, nipple/areola complex preservation is safe in women undergoing radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.