Impact of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction.

BACKGROUND: This study aimed to compare the impact of postmastectomy radiation therapy (PMRT) on outcomes after prepectoral versus subpectoral implant-based breast reconstruction with local deepithelialized dermal flap and acellular dermal matrix (ADM). METHODS: From 2010 to 2017, 274 patients (426 breasts) underwent prepectoral reconstruction. In this group, 241 patients (370 breasts) were not exposed to PMRT, whereas 45 patients (56 breasts) were exposed to PMRT. Of 100 patients (163 breasts) who underwent partial subpectoral reconstruction, 87 (140 breasts) were not exposed to PMRT, whereas 21 patients (23 breasts) were exposed. The outcomes were assessed by comparing complication rates between the pre- and subpectoral groups. RESULTS: A higher rate of capsular contracture was found for the prepectoral patients with PMRT than for those without PMRT (16.1 vs 3.5%; p = 0.0008) and for the subpectoral patients with PMRT than for those without PMRT (52.2 vs 2.9%; p = 0.0001). The contracture rate was three times higher for the subpectoral patients with PMRT than for the prepectoral patients with PMRT (52.2 vs 16.1%; p = 0.0018). In addition, 10 (83.3%) of 12 cases with capsular contracture in the subpectoral cohort that received PMRT were Baker grades 3 or 4 compared with only 2 (22.2%) of 9 cases of the prepectoral group with PMRT (p = 0.0092). CONCLUSIONS: The patients undergoing subpectoral breast reconstruction who received PMRT had a capsular contracture rate three times greater with more severe contractures (Baker grade 3 or 4) than the patients receiving PMRT who underwent prepectoral breast reconstruction.

Thoracic Intercostal Nerve Blocks Reduce Opioid Consumption and Length of Stay in Patients Undergoing Implant-Based Breast Reconstruction.

BACKGROUND: Traditionally, narcotics have been used for analgesia after breast surgery. However, these agents have unpleasant side effects. Intercostal nerve blockade is an alternative technique to improve postoperative pain. In this study, the authors investigate outcomes in patients who receive thoracic intercostal nerve blocks for implant-based breast reconstruction. METHODS: A retrospective chart review was performed. The operative technique for breast reconstruction and administration of nerve blocks is detailed. Demographic factors, length of stay, and complications were recorded. The consumption of morphine, Valium, Zofran, and oxycodone was recorded. Data sets for patients receiving thoracic intercostal nerve blocks were compared against those that did not. RESULTS: One hundred thirty-two patients were included. For patients undergoing bilateral reconstruction with nerve blocks, there was a significant reduction in length of stay (1.87 days versus 2.32 days; p = 0.001), consumption of intravenous morphine (5.15 mg versus 12.68 mg; p = 0.041) and Valium (22.24 mg versus 31.13 mg; p = 0.026). For patients undergoing unilateral reconstruction with nerve blocks, there was a significant reduction in consumption of intravenous morphine (2.80 mg versus 8.17 mg; p = 0.007). For bilateral reconstruction with intercostal nerve block, cost savings equaled $2873.14 per patient. For unilateral reconstruction with intercostal nerve block, cost savings equaled $1532.34 per patient. CONCLUSION: The authors' data demonstrate a reduction in the consumption of pain medication, in the hospital length of stay, and in hospital costs for patients receiving intercostal nerve blocks at the time of pectoralis elevation for implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.