ASO Visual Abstract: One or Two Drains? A Propensity Score-Matched Analysis of Postoperative Complications After Tissue Expander Placement.

Postoperative drains help reduce seroma formation, which is associated with infection and delayed wound healing; however, multiple drains may increase patient discomfort and prolong hospital stays. The impact of drain quantity on complications after immediate breast reconstruction remains unclear. This study evaluated the association between number of drains used and postoperative complications after mastectomy and tissue expander (TE) placement. A single-institution, propensity score-matched analysis included patients who underwent a unilateral mastectomy and immediate TE placement from January 2017 to December 2023. Patients were grouped according to the use of one or two drains and matched on body mass index, implant plane placement, acellular dermal matrix use, sentinel lymph node biopsy, intraoperative TE fill volume, and mastectomy weight. Outcomes of interest were postoperative complications, including seroma, surgical site infection, and TE removal within 90 days. After matching, 984 patients (492 per group) were analyzed. No significant differences were observed in the rates of seroma (13% vs.10%, p=0.23), infection (12% vs. 12%, p=0.76), or TE removal (7.5% vs. 6.1%, p=0.46) between patients who had one drain as compared with those who had two drains. Overall 90-day complication rates were comparable (28% vs. 27%, p=0.66) between groups, and seroma management did not differ based on one versus two drains (p=0.89). Patients who receive one drain after TE placement do not have an increased risk of complications, including seroma formation, compared with those with two drains. Generally, reconstructive surgeons can safely opt for a single drain after TE placement.

Summary:In autologous breast reconstruction, skin envelope reconstruction is especially important given the flexibility of new breast parenchyma. Our experience suggests a better control of breast shape with subcutaneous tissue expander (TE) placement compared with submuscular TE placement. We speculate that capsule formation might be different in subcutaneous TE placement compared with submuscular TE placement. To elucidate this hypothesis, we collected capsules formed around the TE in two-stage breast reconstruction patients and evaluated differences in histology and capsule wall thickness between subcutaneous (n = 7) and submuscular (n = 8) TE placement. Our findings show that subcutaneous TE placement results in thinner capsule formation with low vascularity when compared with submuscular TE placement (354 ± 96 μm and 589 ± 92 μm, respectively; P < 0.001). Because thin connective tissue can reduce postoperative shrinkage of the skin envelope, it would be beneficial to predict and control the shape of reconstructed breast. Although further study is needed, differences in vascularity between subcutaneous tissue and muscle might affect the thickness of capsules.

Robot-assisted Placement of Pelvic Tissue Expander for Radiation After Prostatectomy and Cystectomy for Treatment of Prostate Cancer Biochemical Recurrence

Scalp tissue expansion is a reliable technique for reconstruction of scalp alopecia and other deformities. However, the conventional practice involves establishing temporary wound coverage before expander placement, expansion, and definitive reconstruction. We propose that immediate (at the time of injury and initial wound debridement, leaving an open wound during expansion) tissue expander placement may be a reasonable approach to the management of full-thickness scalp wounds not amenable to primary closure. We performed a retrospective chart review identifying all patients who underwent immediate placement of scalp tissue expanders at the Lviv Burn Center (Lviv Medical University Burn Center, Ukraine). A total of 15 patients were identified who received a total of 21 tissue expanders at the time of acute burn treatment. The indications included electrical burn (46.7%), trauma (20%), tumor resection (13.3%), flame burn (13.3%), and chemical burn (6.7%). Of the 21 expanders placed, 4 (19%) complications were reported. There was 1 (4.7%) implant exposure and 3 (14%) implant infections. All of the patients in this series had complete reconstructions after removal of their expanders because all complications occurred toward the end of expansion. Immediate placement of tissue expanders is a reasonable approach that greatly expedites scalp reconstruction. In this series, the complication rate was consistent with or slightly higher than published rates of complications in conventional techniques. Immediate expansion may be especially useful when other reconstructive options (such as free tissue transfer) are unavailable or not feasible.

Intraoperative fluorescence angiography (FA) has been described as a useful adjunct to physical examination in predicting mastectomy skin flap viability for immediate breast reconstruction. Its use has been described as a screening tool for mastectomy skin flap viability as well as a test used only for patients at high risk for mastectomy skin flap loss. We performed a national database review of implant-based breast reconstruction surgeries to determine the practice patterns of FA in this patient cohort and to determine if this technology impacted clinical outcomes. A national insurance claims database was reviewed to select patients having undergone direct-to-implant (DTI) and immediate tissue expander (TE) placement with and without intraoperative FA as well as patients who had FA at the time of mastectomy without reconstruction. Patient characteristics that prompted FA and postoperative outcomes with and without FA were evaluated to determine its clinical impact in the observed practice pattern. Of the 48,464 patients identified, 836 had FA. More than twice as many patients undergoing DTI had FA than patients undergoing immediate TE placement (10.4% vs 5%, P < 0.0001). Twelve percent of patients receiving FA at the time of mastectomy had reconstruction delayed. Fluorescence angiography was associated with a trend toward lower overall complication rates in DTI patients (8.0% vs 11.9% without FA) but a significantly higher overall complication rate with immediate TE placement (13.8% vs 10.5% without FA, P = 0.018) and was associated with higher reoperation (12.0% vs 8.3% without FA, P = 0.037) in the TE group. There was no difference in other individual complications, readmission, or explantation for either clinical group with and without FA. Regression analysis identified obesity (odds ratio, 1.32; P < 0.001) and younger age (odds ratio, 1.74; P < 0.001) to be associated with performing FA, whereas obesity, diabetes, and tobacco use were associated with higher complication rates. Younger and otherwise healthier obese patients were more likely to have FA. A greater proportion of DTI patients had FA than TE patients with improved outcomes in the former group and worse outcomes in the latter group. Obesity, tobacco use, and diabetes were associated with worse outcomes, whereas only obesity was associated with FA use.

1133 Background: Management of pregnancy-associated breast cancer (PABC) requires balancing benefits of therapy with potential risks to the developing fetus. Surgical management can be influenced by gestational age of fetus and tumor stage. Minimal data describe surgical and obstetrical outcomes after mastectomy with immediate breast reconstruction (IR) in a pregnant patient (pt). Methods: Pts who underwent IR after mastectomy were identified within a multi-institutional PABC cohort. Retrospective chart review was performed for outcomes including adverse intraoperative events, immediate postoperative complications, gestational age at delivery and fetal weight. Other parameters evaluated included stage at presentation, duration of surgery, and use of delayed reconstruction in pts who did not receive IR. Results: Within a cohort of 79 PABC pts, 25 (32%) had mastectomy while pregnant, 8 (32%) of whom had IC; 17 (68%) did not undergo IR. Mean gestational age at time of IR was 16.6 weeks (range 10-30) and all IR utilized tissue expander (TE) placement followed by permanent implant placement in 7 pts. In the IR cohort, 1 (12.5%) pt was stage 0, 3 (37.5%) stage I and 4 (50%) stage IIB. There were no intraoperative or immediate postoperative surgical complications. The mean duration of surgery was 198 min with IR (7 pts) vs. 157 min without IR (available for 12 pts). All women who underwent IR delivered at, or close to, term infants of normal birthweight. One pt had pre-term labor after surgery at 29 weeks which resolved with tocolysis. Mean gestational age at delivery was 37.3 weeks in the IR cohort vs. 36.3 weeks in the non-IR cohort. No fetal abnormalities or major obstetrical complications were seen after IR. Post-mastectomy radiation (PMRT) was provided after pregnancy in 2 pts (25%) in the IR cohort and cosmetic outcome was not adversely affected. Conclusions: This report represents one of the largest series describing IR after mastectomy in PABC. Results suggest immediate tissue expander placement after mastectomy may increase duration of surgery but does not lead to adverse obstetrical or fetal outcomes. IR with tissue expanders may preserve reconstructive options when PMRT is indicated.

The objectives of this study were to evaluate 1) the rate of immediate breast reconstruction; 2) the frequency of immediate tissue expander placement; and 3) to compare perioperative outcomes in patients who underwent breast reconstruction after mastectomy for breast cancer with immediate tissue expander placement (TE) with those with no reconstruction (NR). Using the Nationwide Inpatient Sample database, we examined the clinical data of patients with breast cancer who underwent mastectomy with or without immediate TE from 2006 to 2010 in the United States. A total of 344,253 patients with breast cancer underwent mastectomy in this period in the United States. Of these patients, 31 per cent had immediate breast reconstruction. We only included patients with mastectomy and no reconstruction (NR: 237,825 patients) and patients who underwent only TE placement with no other reconstruction combination (TE: 61,178 patients) to this study. Patients in the TE group had a lower overall postoperative complication rate (2.6 vs 5.5%; P < 0.01) and lower in-hospital mortality rate (0.01 vs 0.09%; P < 0.01) compared with the NR group. Fifty-three per cent of patients in the NR group were discharged the day of surgery compared with 36 per cent of patients in the TE group. Using multivariate regression analyses and adjusting patient characteristics and comorbidities, patients in the TE group had a significantly lower overall complication rate (adjusted odds ratio [AOR], 0.6) and lower in-hospital mortality (AOR, 0.2) compared with the NR group. The rate of immediate reconstruction is 31 per cent. TE alone is the most common type of immediate reconstruction (57%). There is a lower complication rate for the patients who underwent immediate TE versus the no-reconstruction cohort.

Tissue expanders in breast reconstruction are traditionally placed retropectoral. Increasingly, patients are undergoing prepectoral placement. The impact of this placement on the initiation of adjuvant treatment is unknown. A retrospective review was conducted to identify women diagnosed with breast cancer who underwent mastectomy followed by radiation and/or chemotherapy. Women were divided into 3 groups: prepectoral tissue expander placement, retropectoral tissue expander placement, and no immediate reconstruction. A treatment delay was defined as greater than 8 weeks between tissue expander placement and adjuvant therapy. Of 634 women, 205 (32%) underwent tissue expander placement, and 429 (68%) did not have immediate reconstruction. Of those with tissue expanders placed, 84 (41%) had prepectoral placement, and 121 (59%) had retropectoral placement. The median time to adjuvant therapy was 49 days for the entire cohort: no reconstruction, 47 days; prepectoral, 57 days; and retropectoral, 55 days. Treatment delays were observed in 34% of women: no reconstruction, 28%; prepectoral, 51%; and retropectoral, 46% ( P < 0.001). Tissue expander placement was associated with a delay to adjuvant therapy when compared with no reconstruction ( P < 0.001). The location of the tissue expander did not impact the odds of having a delay. On multivariable analysis, having reconstruction, having postoperative infection, not undergoing chemotherapy treatment, and being a current smoker were associated with a delay to adjuvant therapy. A delay to treatment was not associated with worse survival. Placement of a tissue expander delayed adjuvant therapy. The location of tissue expander placement, retropectoral versus prepectoral, did not impact the time to adjuvant treatment.

Association Between Radiographic Mastectomy Flap Thickness and Risk of Post-Radiation Therapy Breast Reconstruction Complication

Prepectoral tissue expander (TE) placement is an increasingly used breast reconstruction technique but may have a higher risk for mastectomy skin flap ischemia compared to subpectoral TE placement. Hyperbaric oxygen therapy (HBOT) has been shown to salvage compromised mastectomy skin flaps, but there is limited evidence on which patients require HBOT and benefit most from this treatment. We retrospectively reviewed patients undergoing immediate TE breast reconstruction over a 6-year period. Patient demographics, intraoperative data, HBOT treatment, complications, and final breast reconstruction type were collected. Analyses were performed by patient and by breast. Among 348 patients (552 breasts), 299 (86%) patients (477 breasts) had prepectoral and 49 (14%) patients (75 breasts) had subpectoral TE placement. Only prepectoral patients received HBOT (19 patients/33 breasts vs 0 patients/breasts, P = 0.037). Breasts receiving HBOT had higher rates of mastectomy skin necrosis (30-day: 73% vs 5.6%, P < 0.001; 90-day: 76% vs 6.5%, P < 0.001), returns to the OR for necrosis excision (30-day: 18% vs 3.2%, P = 0.001; 90-day: 21% vs 5.4%, P = 0.003), and TE explantation (30-day: 21% vs 1.8%, P < 0.001; 90-day: 24% vs 3.8%, P < 0.00001) at the 30- and 90-day postoperative periods. However, these rates did not significantly increase from 30 to 90 days. For those with mastectomy skin necrosis, HBOT salvaged significantly more mastectomy pockets (76% vs 41%, P < 0.0001). Patients with prepectoral TE placement were significantly more likely to receive HBOT. Compared to no treatment, HBOT was able to salvage almost twice as many mastectomy pockets, providing valuable information for mastectomy skin flap ischemia treatment options.

This study compared complication rates and outcomes between patients who underwent premastectomy radiation therapy (Pre-MRT) followed by mastectomy with microsurgical immediate breast reconstruction (IMBR) and patients who underwent mastectomy followed by postmastectomy RT (PMRT) then microsurgical delayed breast reconstruction (DBR). This is a secondary analysis of a randomized clinical trial (NCT02912312) that randomized patients with breast cancer to receive hypofractionated (40.05 Gy in 15 fractions) or conventionally fractionated (50 Gy in 25 fractions) regional nodal irradiation between August 2018 and August 2022. Demographic, treatment, and outcomes data were collected. The primary outcome was the rate of autologous flap loss. Secondary outcomes included rates of other recipient-site complications. A total of 144 patients were included: 41 underwent Pre-MRT with IMBR and 103 underwent PMRT with DBR, including 66 patients who had tissue expander (TE) placement at the time of mastectomy and 37 who underwent total mastectomy. The median time from mastectomy to DBR was 12.8 months (interquartile range 9.7 to 16.3 months). There were no complete autologous flap losses in either group, and rates of other recipient-site complications were similar between the groups. Infection at the recipient site occurred in 20% (13 of 66) of patients in the PMRT group who underwent TE placement, and 9 (14%) required TE explantation because of complications. Pre-MRT with microvascular IMBR is associated with a similar complication rate to PMRT with microvascular DBR while avoiding complications relating to TE placement and a reduced time to achieve definitive breast reconstruction. A larger randomized clinical trial of Pre-MRT followed by mastectomy and IMBR is currently underway (NCT05774678).

Plastic surgeons are frequently faced with difficult and challenging soft tissue defects in all areas of the body. To reconstruct these defects, there are many operative approaches available to the reconstructive surgeon including skin grafts, local flaps, regional flaps, and free-tissue transfer. Despite these many options, occasionally the best alternative for reconstruction of a wound is tissue expansion, where skin of similar quality, texture, and color can be used to close a soft tissue defect. Unfortunately, there are significant problems related to tissue expander reconstruction including a complication rate as high as 50%. As a result, tissue expander reconstruction has not achieved the widespread popularity commensurate with its potential clinical utility. To reduce the complication rate related to open tissue expander placement, and consequently to improve its clinical utility, we have employed endoscopic techniques for the placement of tissue expanders. Endoscopic approaches are currently being used in many areas of surgery and have resulted in substantial benefits. Endoscopic placement of tissue expanders has the benefit of reducing operative time, major complication rate, time to full expansion, and length of hospital stay. The purpose of this article is to critically examine the current open technique for tissue expander placement and to compare this technique with minimally invasive endoscopic tissue expander placement. We will discuss in detail the current problems associated with open tissue expander placement, the benefits of endoscopic tissue expansion, the technique of endoscopic tissue expander placement, and the outcomes for these techniques.

In Vivo Dose Measurements in the Postmastectomy Irradiation of a Patient With a Gas-Based Tissue Expander

BACKGROUND: Postmastectomy radiation therapy has well-defined ill effects on the character of the skin envelope of the breast, most directly causing contraction and elevation of the breast, especially at the inframammary fold (IMF). These effects negatively impact breast symmetry, overall aesthetic outcomes, and patient satisfaction. Though radiation-induced skin changes have been qualitatively described, quantitative changes to the position of the IMF due to radiation have not yet been described. Despite maneuvers to lower the fold when postmastectomy radiation therapy is expected, the reoperation rates have been reported as high as 28%. Delineating numerical values may allow more specific intraoperative adjustments to better approximate the IMF to the pretreatment level. Herein we discuss our analysis of the effect of radiation on IMF position in patients who underwent expander placement and subsequent radiation. METHODS: Patients who underwent breast reconstruction with tissue expanders from January 2015 to October 2019 at UCLA by four attending surgeons were reviewed. Operative reports were reviewed and indicated disruption of the IMF in all patients during mastectomies, requiring resetting of the IMF with suture. Patient inclusion criteria required that patients have corresponding sets of pictures at three timepoints: (1) preoperative (before mastectomy), (2) postoperative (after tissue expander placement and before radiation), and (3) postradiation (before exchange to permanent implant). Photographs were retrospectively analyzed by a single surgeon. In the lateral view, the distance from the acromion to IMF was measured, compared with acromion to elbow, and recorded as a ratio to allow for variation of photographic focal length differences. Changes in IMF from pre- to postradiation were measured as a percentage change. RESULTS: Fifteen patients with appropriate photos over the past year were analyzed of which 10 had pictures at all three timepoints, and 5 had only the last 2 timepoints and were excluded. All operative reports were reviewed verifying that the IMF was disrupted after mastectomy in all group. Fourteen had unilateral radiation and 1 had bilateral radiation, thus 16 breasts were reviewed separately. For the 10 patients with preoperative photos, the IMF ratio from timepoints 1–3 (preoperative to postradiation) was −12.5% + 5.2%, indicating a significant elevation of the IMF following radiation. CONCLUSIONS: Inframammary position after tissue expander placement and radiation reliably elevates approximately 12% above the position of the preoperative fold. This study is the first of its kind to quantitatively measure radiation change elevation on the IMF in tissue expander reconstructions. This finding may be a useful guide for setting the IMF at the time of tissue expander placement and avoid need for the second stage fold lowering at the time of implant exchange.

Preoperative risk assessment is essential in determining which surgical candidates will have the most to gain from an operation. The 5-item modified frailty index (mFI-5) has been validated as an effective way to determine this risk. This study sought to evaluate the performance of the mFI-5 as a predictor of postoperative complications after tissue expander placement. Patients who underwent placement of a tissue expander were identified using the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project database. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status, diabetes, chronic obstructive pulmonary disease, chronic heart failure, and hypertension), and other factors commonly used to risk stratify (age, body mass index [BMI], American Society of Anesthesiologists (ASA) classification, and history of smoking) were associated with complications. In 44,728 tissue expander placement cases, the overall complication rate was 10.5% (n = 4674). The mFI-5 score was significantly higher in the group that experienced complications (0.08 vs 0.06, P < 0.001). Compared with the mFI-5 individual components and other common variables used preoperatively to risk stratify patients, univariate analysis demonstrated that mFI-5 had the largest effect size (odds ratio [OR], 5.46; confidence interval [CI], 4.29-6.94; P < 0.001). After controlling for age, BMI, ASA classification, and history of smoking, the mFI-5 still remained the predictor of complications with the largest effect size (OR, 2.25; CI, 1.70-2.97; P < 0.001). In assessing specific complications, the mFI-5 is the independent predictor with the largest significant effect size for surgical dehiscence (OR, 12.76; CI, 5.58-28.18; P < 0.001), surgical site infection (OR, 6.68; CI, 4.53-9.78; P < 0.001), reoperation (OR, 5.23; CI, 3.90-6.99; P < 0.001), and readmission (OR, 4.59; CI, 3.25-6.45; P < 0.001) when compared with age, BMI, ASA class, and/or history of smoking alone. The mFI-5 can be used as an effective preoperative predictor of postoperative complications in patients undergoing tissue expander placement. Not only does it have the largest effect size compared with other historical perioperative risk factors, it is more predictive than each of its individual components.