Cases Of Immediate Breast Reconstruction Research Articles

Surgical complications after immediate implant-based breast reconstruction for breast cancer in women over 65 years.

While immediate breast reconstruction rates in breast cancer are increasing, they remain low in women over 65 years old. The aim was to investigate surgical outcomes in women older than 65 years receiving implant-based immediate breast reconstruction. The population-based Stockholm Breast Reconstruction Database includes all adult women with breast cancer receiving an implant-based immediate breast reconstruction in Stockholm, Sweden, 2005-2015. Primary outcomes within 30 days from immediate breast reconstruction were: infection requiring antibiotics and reoperation on. Implant removal was a secondary outcome. Women more than 65 years were compared with younger age groups. Chi-square tests and multivariable logistic regression were applied for the primary outcomes, and Kaplan-Meier analysis for the secondary outcome. Among 1749 cases of immediate breast reconstruction, 140 (8.0%) were in women more than 65 years. Median follow-up was 74 months (1-198). Postoperative infection was not more common in women older than 65 years old (22 of 140, 15.7%) than in women under 65 years old (303 of 1609, 18.8%; P = 0.221). Reoperation on was more frequent in women older than 65 years than in other age groups (more than 65: 8.6%; 50-64: 6.5%; 40-49: 3.5%; less than 40: 1.6%; P < 0.001), however, age older than 65 years was not an independent risk factor in the multivariable analysis (OR 1.00, 95% c.i. 0.44 to 2.28). Overall, 6-year probability of implant removal was 11.4%, (8.1% due to complications and 3.3% due to patient preference). There was no statistically significant difference between age groups for either reason (P = 0.085 and P = 0.794 respectively). Older age alone was not associated with worse surgical outcomes after implant-based immediate breast reconstruction in highly selected patients older than 65 years when compared with their younger counterparts.

Study on the Impact of Post-Mastectomy Radiotherapy on Immediate Breast Reconstruction and Complications: A Meta-Analysis

Background and objective: Immediate breast reconstruction not only reduces the number of surgeries for patients after mastectomy but also decreases psychological and physical trauma, making it increasingly popular. However, there is currently no consensus on the integration of post-mastectomy radiotherapy (PMRT) with reconstruction techniques. This review evaluates the impact of PMRT on complications following immediate breast reconstruction, providing guidance for clinical treatment decisions. Methods: PubMed, Web of Science, Embase, and other databases were searched for studies published in the past 15 years on outcomes of implant-based breast reconstruction in the context of radiotherapy to identify articles for analysis. RevMan 5.4 software was used to analyze the risks of seroma, infection, wound dehiscence, flap necrosis, implant exposure, capsule contracture, and reconstruction failure. Results: A total of 11 relevant studies were included, comprising 6323 cases of immediate breast reconstruction. It was found that breasts receiving postoperative irradiation had a significantly increased risk of complications, with statistically significant differences in seroma (P = 0.004), infection (P &lt; 0.00001), wound dehiscence (P = 0.04), implant exposure (P &lt; 0.00001), capsule contracture (P &lt; 0.00001), and reconstruction failure (P &lt; 0.00001). There was no statistically significant difference in flap necrosis (P = 0.88). Conclusion: The results indicate that postoperative radiotherapy significantly increases the risk of complications for patients undergoing immediate implant-based reconstruction. Preventive measures may be taken in advance with the assistance of healthcare providers if necessary.

Anatomical types and anastomosis methods of concomitant veins of deep inferior epigastric artery

To summarize the anatomical types of the concomitant veins of deep inferior epigastric artery and the corresponding choice of anastomosis methods, and to evaluate the indications and safety of various methods. Between October 2015 and June 2021, 296 female patients received breast reconstruction with autologous free lower abdominal flap, including 154 cases of immediate breast reconstruction and 142 cases of delayed breast reconstruction. The average age of the patients was 36.5 years, ranged from 26 to 62 years. Unilateral free deep inferior epigastric artery perforator flap transplantation was performed in 172 cases, and unilateral free muscle-sparing rectus abdominis myocutaneous flap transplantation was performed in 124 cases. The internal thoracic vessels were selected as the recipient vessels in all cases. The length of vascular pedicle ranged from 9.5 to 13.0 cm, with an average of 11.2 cm. The concomitant veins of deep inferior epigastric artery included three anatomical types: one-branch type in 26 cases (8.8%), two-branch type in 180 cases (60.8%), and Y-shaped structure in 90 cases (30.4%). Anastomosis of inferior epigastric artery was performed with the proximal end of internal thoracic artery, while that of vein should be adjusted according to the diameter, length, wall thickness, and branches of the vein. The specific classification of venous anastomosis included: ① The sole concomitant vein of deep inferior epigastric artery was anastomosed with the internal mammary vein (26 cases); ② The two concomitant veins of deep inferior epigastric artery were anastomosed with the internal mammary vein respectively (151 cases); ③ The larger one of two concomitant veins of deep inferior epigastric artery was anastomosed with the internal mammary vein, and the other one was ligated and discarded (29 cases); ④ The two concomitant veins of deep inferior epigastric artery were Y-shaped, and the common trunk segment was directly anastomosed with the internal mammary vein (31 cases); ⑤ The smaller branch of the concomitant veins of Y-shaped structure was ligated, and the thicker branch was anastomosed with the internal mammary vein (17 cases); ⑥ The concomitant veins of Y-shaped structure were anastomosed with the internal mammary veins respectively (42 cases). Among the patients who underwent venous anastomosis according to scheme ④, 3 cases had venous crisis of flap after operation, of which 1 case was successfully rescued by emergency exploration; the other 2 cases had flap necrosis, of which 1 case survived after being repaired by pedicled latissimus dorsi flap, and 1 case closed the wound directly. Flaps with other venous anastomosis protocols survived completely. All 296 patients were followed up 12-70 months, with an average of 37.5 months. The reconstructed breast has good shape, good elasticity, and no skin flap contracture. The donor site of the flap only left linear scar, and the abdominal wall function was not affected. The method of direct anastomosis of concomitant veins of deep inferior epigastric artery with Y-shaped structure is relatively risky, and the vessels are prone to be twisted and compressed, leading to the occurrence of venous crisis. It can improve the safety of surgery if only one large vein is anastomosed or two veins are separated to anastomose respectively.

Preoperative Radiotherapy Trials to Facilitate Immediate Breast Reconstruction after Mastectomy

Postmastectomy radiotherapy (PMRT) is often a component of treatment algorithms for locally advanced or node-positive breast cancer. Breast reconstruction may be delayed or not performed due to negative effects of PMRT on the reconstruction. Administering radiotherapy in the preoperative setting allows for immediate breast reconstruction (IBR) to be performed in patients who have indications for PMRT and desire IBR. This review summarizes the current literature on this new concept. Most prospective treatment protocols included neoadjuvant systemic therapy followed by radiotherapy (RT) dose of 50–50.4 Gy conventionally fractionated and mastectomy with immediate autologous reconstruction after 6–8 weeks. There were no cases of IBR being aborted due to technical complications and overall postoperative complications ranged from 3 to 36%. These were typically non-operatively managed, and cosmetic results when evaluated were favorable. Initial oncologic outcomes indicate low locoregional recurrence rates (≤ 10%) and high 5-year overall survival rates of 87–98%. Although published studies are heterogeneous in nature, they suggest that preoperative RT followed by mastectomy with IBR is technically feasible and safe. Larger prospective studies with longer follow-up times may establish this as a new standard in the multidisciplinary treatment of high-risk breast cancer.

Characteristics of adhesion areas between the tissue expander and capsule in implant-based breast reconstruction.

BackgroundThe use of anatomic implants has improved the aesthetic results of breast surgery; however, implant malrotation is an uncommon, but serious complication of these procedures. Nevertheless, little research has explored implant adhesion. In this study, we investigated adhesion between the expander and the capsule.MethodsSeventy-nine cases of immediate breast reconstruction via two-stage implantbased reconstruction performed between September 2016 and November 2017 were evaluated. Mentor CPX4 expanders were used in 14 breasts, and Natrelle expanders in 65. We analyzed areas of adhesion on the surfaces of the tissue expanders when they were exchanged with permanent implants. We investigated whether adhesions occurred on the cephalic, caudal, anterior, and/or posterior surfaces of the expanders.ResultsTotal adhesion occurred in 18 cases, non-adhesion in 15 cases, and partial adhesion in 46 cases. Of the non-adhesion cases, 80% (n=12) were with Mentor CPX4 expanders, while 94.4% (n=17) of the total adhesion cases were with Natrelle expanders. Of the partial adhesion cases, 90.7% involved the anterior-cephalic surface. The type of tissue expander showed a statistically significant relationship with the number of attachments in both univariate and multivariate logistic regression analyses (P<0.001) and with total drainage only in the univariate analysis (P=0.015).ConclusionsWe sought to identify the location(s) of adhesion after tissue expander insertion. The texture of the implant was a significant predictor of the success of adhesion, and partial adhesion was common. The anterior-cephalic surface showed the highest adhesion rate. Nevertheless, partial adhesion suffices to prevent unwanted rotation of the expander.

Does acellular dermal matrix expand in response to tissue expander inflation?

BackgroundAcellular dermal matrices (ADMs) have recently become widely used in breast reconstruction, but the correlation between the final expander volume and the surface area of the ADM is not well understood. In this study, the expansion of the surface area of ADM and the expander volume was studied retrospectively in cases of acellular dermis–assisted tissue expander breast reconstruction.MethodsTwenty cases of immediate breast reconstruction using an ADM–assisted tissue expander from January 2015 to December 2015 were evaluated. In all 20 cases, CGCryoDerm was used as the matrix, with a thickness of 1–3 mm. No slit incisions were made. Finally, the proportional increase in the area of the fully expanded ADM was compared to that of the tissue expander volume.ResultsThe proportional increase in the ADM surface area was calculated to be from 1.1 to 2.46, with a mean value of 1.7. Additionally, under the assumption that the expander had a spherical shape, the increase in its radius (the cube root of its volume) was assessed. The range of the proportional increase in the expander radius was 1.1 to 2.24, with a mean value of 1.66. The proportional increase in the radius of the expanded ADM surface area ranged from 1.04 to 1.34, with a mean ratio of 1.28.ConclusionsThe results of this study confirmed that the ADM expanded when the tissue expander was inflated. However, the ADM expanded to a lesser extent than the tissue expander, indicating that the muscle and other tissues expanded more than the ADM when the tissue expander was inflated.

Natural History of Seroma Following the Immediate Latissimus Dorsi Flap Method of Breast Reconstruction.

Background:The latissimus dorsi (LD) flap procedure remains a popular and useful breast reconstruction tool in China and Western countries, and donor site seroma formation is the main complication. This study was conducted in Chinese patients to determine whether stable cases of seromas would resolve without treatment.Methods:A retrospective review of 45 consecutive cases of immediate breast reconstruction with LD flap from April 2012 to February 2017 was conducted. The scope of the seroma was demarcated with a marker pen, and cases that remained stable over time (i.e. the size of the seroma did not increase) were observed without treatment. The measured outcomes included the incidence of seromas, the volume and duration of postoperative wound drainage, and other demographic characteristics.Results:Twenty-four patients (53.3%) developed a seroma at the donor site. Of these, 21 patients (87.5%) did not require treatment, and the seroma resolved over time. The mean duration of a sustained seroma was 6.8 ± 1.4 weeks (range: 4–9 weeks).Conclusions:This study observed the scope and progression of the seromas and found that seromas at the LD donor sites resolved over time without treatment.

Does neoadjuvant chemotherapy for breast cancer increase complications during immediate breast reconstruction?

Neoadjuvant chemotherapy (NAC) has been administered since the 1990s and is now one of the major treatments for breast cancer. It can achieve extremely positive results in some patients. Whether NAC affects immediate breast reconstruction (IBR) using an expander, however, remains unclear. A retrospective study was performed at Tokyo Medical and Dental University (TMDU) hospital. Seventy-five cases of immediate breast reconstruction using an expander were performed in 69 patients between January 2001 and January 2007. The patients were evaluated for tumor size, histological type, sites of invasion, staging, lymph node metastasis, NAC regimen, response to NAC, type of immediate breast reconstruction (IBR), complications, and prognosis. In patients treated with an expander, there was no significant difference in the complication rate between those who underwent NAC and those who did not. NAC did not increase the complication rate after IBR using an expander. However, for reconstruction using autologous tissue, more data are needed.

One stage placement of permanent implant compared to two stage tissue expander reconstruction

With the advent of the skin sparing mastectomy, immediate breast reconstruction with placement of the definitive prosthesis at the time of mastectomy is possible. The question remains: does single-stage prosthetic reconstruction result in greater numbers of complications or rates of re-operation, compared to two-stage tissue expander reconstruction? A retrospective cohort study of a single centre?s experience with these techniques was carried out. From 2004 to 2012, 54 cases of immediate breast reconstruction with implant were identified, and 108 cases of immediate breast reconstruction using a tissue expander were identified. Gathered preoperative data included tumour, prior exposure to radiation, preoperative chemotherapy, smoking, and comorbidities. Complication rates, as well as the rate of secondary operations, were examined. There were no significant increased risks in the rate of post-operative complications (p = .910, odds ratio = 0.9) nor in the rate of re-operation (p = 0.421, odds ratio = 1.4) associated with the insertion of a definitive prosthesis at the time of skin sparing mastectomy. However, previously radiated breasts experienced a 100% rate of wound complications in our subset of 9 breasts that underwent one stage breast reconstruction with immediate final prosthesis placement. Our study suggests that patients with early stage disease can undergo single stage breast reconstruction without increased risk of complications nor need for secondary operations. While the mean time to completion of the reconstructive process is shortened by 5 months with the single stage technique, implant based breast reconstruction requires careful counseling and patient selection in radiated patients.

Abstract: Assessing the Association Between Seroma and Surgical Site Infection in Immediate Breast Reconstruction

PURPOSE: Several preoperative and intraoperative risk factors have been implicated in infectious complications of immediate breast reconstruction, however the link between common postoperative sequelae and surgical site infection (SSI) remains largely anecdotal. Published rates of seroma and SSI often trend in parallel, and authors have hypothesized that seroma formation may independently promote infectious complications.1,2 The current study aims to assess and quantify the postulated association between seroma and the risk of SSI in immediate breast reconstruction. METHODS: A retrospective review of the Tracking Outcomes and Operations in Plastic Surgery data registry was conducted to identify all cases of immediate breast reconstruction (IBR) between 2009–2012. Cohort characteristics and 30-day outcomes were compared between cases with and without seroma using Pearson’s chi-squared for categorical variables and student t-tests for quantitative variables. Multivariate logistic regression analysis was performed to control for confounding variables while assessing the association between seroma formation and the risk of SSI. RESULTS: Of the 6,729 cases of IBR identified in the study period, 4489 were classified as prosthetic and 2240 as autologous, with 717 pedicled TRAM flaps, 611 latissimus flaps, and 912 free flaps. Acellular dermal matrix (ADM) was used in 17.2% of cases. The seroma rate was 2.9 percent and the SSI rate was 1.9 percent. Bivariate analysis showed that seroma was associated with a 3.6 percent increase in absolute risk of surgical site infection (p<0.0001). Multivariate analysis confirmed that the presence of seroma independently increased the likelihood of SSI in both prosthetic and autologous IBR (odds ratio 7.195,p=0.015; odds ratio, 4.496, p=0.013, respectively). Of note, ADM usage was not associated with SSI when confounding variables were accounted for. CONCLUSION: This study is the first to quantify the independent and statistically significant association between seroma and surgical site infection in immediate breast reconstruction. Seroma is associated with a seven- and four-fold increased likelihood of SSI in prosthetic and autologous reconstruction, respectively. Irrespective of whether postoperative seroma represents an independent nidus of infection or an indicator of aberrant wound healing, our results indicate that a seroma in the setting of recent mastectomy has a greater propensity for infection, and thus we advocate for more attentive surveillance and thoughtful management of seroma following immediate breast reconstruction. REFERENCES: 1. Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of post-operative complications. Plast Reconstr Surg 2010;125:429–36. 2. Ganske I, Verma K, Rosen H, et al. Minimizing complications with the use of acellular dermal matrix for immediate implant-based breast reconstruction. Ann Plast Surg. 2013 Nov;71(5):464–70

Risk factors of mastectomy skin flap necrosis in immediate breast reconstruction using low abdominal flaps

Background: The purpose of this study was to determine the risk factors associated with mastectomy skin flap necrosis during immediate reconstruction with TRAM or DIEP flaps.Methods: This study reviewed 1116 cases of immediate breast reconstruction over 10 years. Patients ranged in age from 29–76 years (average = 45.1 years), and had an average follow-up period of 65.6 months. Thirteen factors (age, BMI (body mass index), smoking habits, diabetes ptosis grade, midclavicle-to-nipple distance, neoadjuvant chemotherapy, free or pedicled flap, mastectomy method, surgeon, stage, axillary dissection, mastectomy weight) known to be associated with mastectomy flap necrosis were retrospectively analysed. The odds ratios of the risk factors were calculated using logistic regression analyses.Results: Mastectomy skin flap necrosis occurred in 247 cases (22.1%). Univariate regression analysis showed that the odds ratio of age, BMI, ptosis grade, midclavicle-to-nipple distance, free flap, mastectomy method, surgeon, stage, and mastectomy weight were significant and the odds ratios determined using multivariate analysis were significant for mastectomy method, surgeon, and mastectomy weight.Conclusion: During breast reconstruction using abdominal tissue, the independent risk factors that affect mastectomy skin flap necrosis include the mastectomy method, surgeon, and the weight of the mastectomy specimen. Awareness of the impact of each risk factor will lead to the modification and individualisation of surgical techniques and continually improve outcomes.

Methylene blue dye-induced skin necrosis in immediate breast reconstruction: evaluation and management.

BackgroundFor early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported.MethodsImmediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation.ResultsSix cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction.ConclusionsThe complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.

Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction

BackgroundThe quality and viability of mastectomy flaps remain a central challenge in reconstructive surgery, particularly for immediate breast reconstruction. Insufficient perfusion in tissue flaps is a leading cause of early complications following reconstructive procedures, and clinical judgment alone is not completely reliable for the assessment of flap viability. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis, thereby allowing for maneuvers to improve tissue flap viability.MethodsThis study evaluates the use of intraoperative laser angiography using the SPY System (LifeCell Corp., Branchburg, NJ) for the assessment of perfusion in mastectomy flaps for immediate breast reconstruction. The SPY System uses the contrast agent indocyanine green, which has an excellent safety profile and pharmacokinetics that allow for repeat evaluations during the same surgical procedure. In recent work, the SPY System has demonstrated high sensitivity and specificity for detection of tissues at risk for ischemia and necrosis during reconstructive surgery. Using a retrospective, chart-review design, the authors compared consecutive cases of immediate breast reconstruction using a prosthesis, before and after implementation of the SPY System.ResultsNinety-one subjects were included in the analysis: 52 prior to SPY (Pre-SPY) and 39 after implementation of SPY (Post-SPY). Baseline characteristics were similar between the groups. Both groups had high rates of comorbidities, chemotherapy, and radiation therapy. The rate of postoperative complications was two-fold higher in the Pre-SPY group compared to the Post-SPY group (36.5% vs. 17.9%); this difference was of borderline significance (P = 0.0631). However, mean number of repeat visits to the OR per patient was significantly higher in the Pre-SPY group (1.21 ± 1.47 vs. 0.41 ± 0.71; P = 0.0023). Of the seven patients with complications in the Post-SPY group, five were identified by SPY as having poor flap perfusion; none were identified by clinical judgment alone.ConclusionsThis study suggests that the SPY System can contribute to reduced ischemia-related complications in a population of women undergoing immediate breast reconstruction following mastectomy for breast cancer.

Surgical techniques, biomaterials, and patient variables that impact peri-operative nipple necrosis in nipple-sparing mastectomy.

152 Background: Nipple sparing mastectomy is for treatment of early stage breast cancer and risk reduction in patients at high risk for breast cancer. A high rate of nipple loss after NSM (10% to 30%) has slowed incorporation of NSM into clinical practice. No study has evaluated whether clinical and technical factors contribute to nipple loss by decreasing blood supply to the nipple areola complex (NAC). The objective here was to determine the impact of patient variables and surgical factors on survival of the nipple following NSM and to compare rates of complications of NSM to those of SSM. Methods: We evaluated 233 cases of immediate breast reconstruction following mastectomy at MD Anderson Cancer Center between September 2003 and May 2011. 113 NSM procedures were randomly matched to 120 SSMs based on stage, comorbidities, and age. The NSM group was analyzed for variables that correlated with partial or total nipple loss. Results: In the NSM group, the complication rate was 28%, compared to 27% in SSM (p &gt; 0.99). The nipple loss rate in NSM was 20%. In SSM, axillary node dissection increased complications compared to sentinel lymph node biopsy (p = 0.01). Body mass index, breast ptosis, breast cancer pathology, distance of the lesion to the NAC and use of neoadjuvant chemo or radiation therapy had no effect on nipple loss. Vascular comorbidities and smoking lead to increased nipple loss, with borderline p values (p = 0.09 and p = 0.08, respectively). When compared to A- and B-cup breasts, larger breasts had higher nipple loss (6% and 34%, respectively; p=0.003). Surgical incision location did not affect nipple loss, neither did number of prior NSM procedures performed by the breast surgeon (p = 0.86). Axillary lymphadenectomy (p = 0.13), separate axillary incision (p = 0.25), type of breast reconstruction (p = 0.23), and application of bioprosthetic sling (p = 0.27) may have impacted nipple loss if a larger sample size was studied. Conclusions: Patient variables and surgical technique can alter the rate of nipple loss with NSM. This study helps to define patient populations that may be at risk for necrosis and informs surgeon’s as to the best techniques for reconstruction to decrease the occurrence of nipple loss.

Immediate breast reconstruction does not lead to a delay in the delivery of adjuvant chemotherapy

Immediate breast reconstruction (IBR) has been considered by some to lead to a delay in the delivery of adjuvant chemotherapy. Our aim was to determine whether IBR led to a delay when compared to conservation surgery and non-reconstructive mastectomy. Ninety-five cases of IBR receiving chemotherapy were reviewed. These were compared to 95 consecutively treated patients undergoing conservation surgery and 95 undergoing non-reconstructive mastectomy.Our data shows that IBR does not lead to a delay in the delivery of adjuvant chemotherapy when compared to standard non-reconstructive surgery and should not adversely affect breast cancer outcome.

Radiation therapy after immediate breast reconstruction with implants.

The use of implants in immediate breast reconstruction is presently a common option. However, the practice should be evaluated in consideration of possible adjuvant therapies needed to control disease and to rule out negative interactions. This article discusses the effects of radiotherapy on breast implants with regard to the final cosmetic result. Six out of 124 cases of immediate breast reconstruction with implants were followed and evaluated in terms of capsular contracture and final aesthetic result after adjuvant radiotherapy and compared with the results of 118 patients who did not require irradiation. All of the patients who received irradiation demonstrated poor to fair results, with grade III to IV capsular contracture. Two patients received radiation therapy for local recurrences, which worsened their capsular contracture, emphasizing the deleterious effect of irradiation on breast implants. Statistical analysis of the results demonstrated a significant difference between the two groups in terms of capsular contracture and breast symmetry. In the selection of patient candidates for immediate breast reconstruction with implants, adjuvant radiation therapy must be considered as a contraindication, at least from an aesthetic point of view.