Complications In Breast Reconstruction Research Articles

Intraoperative Hypothermia Versus Normothermia in Breast Reconstruction: A Systematic Review and Meta-Analysis.

Despite advancements in breast reconstruction, the precise impact of intraoperative hypothermia on postoperative complications remains unclear. Recent literature suggests that intraoperative hypothermia is a risk factor for impaired wound healing and increases the incidence of surgical site infections. This study examines the effect of intraoperative hypothermia on postoperative outcomes in breast reconstruction. We searched PubMed, Embase, and Cochrane Library for studies comparing hypothermia with normothermia in breast reconstruction. A meta-analytical method was employed to estimate the risk of postoperative complications among patients undergoing breast reconstruction. Data synthesis employed the random-effects models, presenting the results as risk ratio (RR) with corresponding 95% confidence intervals (CIs). Statistical analysis was performed using Review Manager 5.4 (Cochrane Collaboration), and heterogeneity was assessed using I2 statistics. Four studies meeting our inclusion criteria were included in the meta-analysis, comprising 871 participants. The average age and body mass index were 52.98 years and 27.76 kg/m2, with a follow-up duration of 3-6 months. In our analysis, intraoperative hypothermia was associated with an increase in the incidence of wound healing complications in breast reconstruction (RR 1.68; 95% CI 1.24 to 2.27; p = 0.0008). Despite lower incidence of infection, hematoma, seroma, and necrosis in the hypothermia group, no significant differences were observed. Our meta-analysis assessing intraoperative hypothermia in breast reconstruction indicates that hypothermia is a significant risk factor for wound healing complications.

The waist-to-hip ratio is a superior predictor of complications in breast reconstruction: A prospective pilot study

IntroductionBreast reconstruction remains common. Identifying the key risk factors for preoperative counseling is key to improving surgical outcomes. The body mass index is a commonly used measure of preoperative risk but remains controversial. We propose that the waist-to-hip ratio, a measure of central adiposity, is superior to the body mass index in predicting complications. MethodsA single surgeon’s breast reconstruction patients were prospectively analyzed from 2022-2023. Demographic data, medical comorbidities, and surgical variables were recorded, as were complications including infection, wound breakdown, and loss of reconstruction. Height, weight, waist circumference, and hip circumference were collected to calculate the waist-to-hip ratio, waist-to-height ratio, and body surface area. Statistical analysis and multivariate analysis were performed. ResultsOne hundred patients were evaluated, 50 for alloplastic and 50 for autologous, abdominally based reconstruction. For alloplastic patients, 26% had complications, with a higher waist-to-hip ratio (0.96v 0.88). On multivariate regression, the waist-to-hip was the only significant independent predictor of complications. For autologous reconstruction, again 26% had complications, with a higher waist-to-hip ratio (0.96v 0.88). On multivariate regression, the waist-to-hip was the only significant predictor of complications. For both groups, waist-to-hip did not strongly correlate with other morphometric measures. Age and other morphometric measures were not predictive of complications for either set. ConclusionThe waist-to-hip ratio is a superior predictor of surgical risk to the body mass index in our cohort and could be integrated in plastic surgery practices to improve outcomes. Level of EvidenceIV

Efficacy of Closed-Incision Negative Pressure Wound Therapy in Reducing Postoperative Complications in Breast Reconstruction After Radiotherapy: A Propensity Score Analysis.

Implant-based breast reconstruction following radiotherapy can lead to significant postoperative complications. Closed-incision negative pressure wound therapy (ciNPWT) has emerged as a potential intervention to reduce these complications. To assess the effectiveness of ciNPWT in reducing postoperative complications in patients undergoing implant-based breast reconstruction after radiotherapy. A retrospective single-center cohort study was conducted, including patients who underwent implant-based breast reconstruction after mastectomy and radiotherapy between January 1, 2015, and December 31, 2022. We utilized a procedure-level analysis model with patients contributing distinct observations for multiple procedures. Our primary outcome measures included fluid collection, infection, and wound complications. Propensity score analysis was employed to adjust for potential confounders, such as BMI, smoking history, and diabetes history, creating a balanced comparison between the ciNPWT-treated and untreated groups. In our study of 301 breast reconstructions postradiotherapy from 2015 to 2022, encompassing 218 unique patients, we found significant benefits of ciNPWT. During an average of 2.2-year follow-up, the ciNPWT group demonstrated no infections, contrasting with a 10.4% rate in the non-ciNPWT group (P < .0001). Wound complications were also significantly lower in the ciNPWT group (1.9% vs 11.2%; P = .00848). Demographic differences were adjusted using inverse probability of treatment weights. The findings suggest ciNPWT's promising role in enhancing postoperative outcomes in breast reconstruction postradiotherapy. Our study suggests that the use of ciNPWT in implant-based breast reconstruction postradiotherapy can potentially reduce postoperative complications. This intervention can improve patient outcomes and may offer cost-saving benefits in the long run.

Role of Qualitative and Quantitative Indocyanine Green Angiography to Assess Mastectomy Skin Flaps Perfusion: A Prospective Monocentric Experience.

Mastectomy skin flap (MSF) necrosis remains a significant complication in breast reconstruction. This study aims to identify a correlation between the qualitative and quantitative analysis of the MSF perfusion grade and the skin necrosis rate 1 month after surgery using indocyanine green angiography (ICGA), focusing on lag time and perfusion metrics. Consecutive women scheduled for nipple/skin-sparing/skin-reducing mastectomy between May 2020 and October 2022 were prospectively enrolled. Patients were divided into Group 1 in the absence of superficial and full-thickness necrosis (SN; FTN) and Group 2 in the presence of both. Demographic data, lag time T1 (time between ICG injection and the initial perfusion of the least perfused MSF area), ICG-Q1, and ICG-Q% (absolute and relative perfusion values of the least vascularized area) were collected. 76 breasts were considered. FTN was reported in 8 breasts (10.5%) and SN in 4 (5.2%). The 2 groups statistically differ in T1 (Group2 > Group1), ICG-Q1, and ICG-Q% (Group1 > Group2) (P < 0.05). T1 longer than 170 seconds, body mass index, previous chemo/radiotherapy, arterial hypertension, breast weight, type of surgery, and ICG quantitative values can help in predicting MSF necrosis. MSF qualitative and quantitative perfusion evaluation can be helpful to prevent MSF necrosis. However, it should be considered together with the patient's characteristics, the type of surgery, and T1. In this way, it is possible to predict the risk of MSF necrosis and plan the best reconstructive strategy.

Reconstructive plastic surgery in combined treatment of breast cancer: Predictive risk factors of complications and reconstruction failure.

e12594 Background: Breast reconstruction after mastectomy must consider potential complications from surgical techniques as well as additional complications of oncologic treatment such as radiation or systemic therapy. But the consensus is lacking regarding the optimal reconstruction plan for patients requiring adjuvant radiation therapy. Objective: To determine the impact of risk factors on the development complications of breast reconstruction for postmastectomy radiotherapy. Methods: This study included patients diagnosed with breast cancer who received combination treatment from 2016 to 2021 at the FSBI “N.N. Petrov National Medical Research Center of Oncology” of the Russian Ministry of Health. The patients were divided into 3 groups: immediate reconstruction (158 people), immediate-delayed (210 people) and delayed (98 people). Results: Every fourth patient (24.0%, 112/466) may encounter a complication after mastectomy with reconstruction and adjuvant radiation therapy. According to the analyzed data, there was no correlation between potential risk factors depending on the general status of patients (age, obesity, diabetes mellitus, hypertension, history of smoking) and the occurrence of complications after combination treatment. Conclusions: The analysis of complications and reconstructive failures showed that immediate breast reconstruction at the FSBI "N.N. Petrov National Medical Research Center of Oncology" of the Ministry of Health of Russia is the safest method of reconstruction in the combined treatment of breast cancer with the lowest incidence of severe complications (9.5%, 15/158, z&gt;1.96), which plays a key role in the development of reconstructive failures (Pearson Correlation=0.861, p&lt;0.001). However, these surgeries are associated with a significant number of capsular contractures (15.2%, 24/158, z&gt;1.96, Pearson Correlation=0.230, p&lt;0.001), which requires finding ways to minimize these risks to optimize treatment in each individual case in short and long term results.

Use of negative pressure wound therapy with instillation to salvage infected breast reconstruction implant pockets: a retrospective review of cases

"Introduction: Periprosthetic breast implant infections are a well-known but devastating complication of breast reconstruction, occurring in up to 35 per cent of patients postoperatively. Historically, surgical washout and explantation was common practice to control infection, often sacrificing the reconstruction. Methods: After successfully using negative-pressure wound therapy with instillation (Veraflo, Intermed, Auckland) on lower leg wounds, we transferred the use of this technology to infected breast pockets. Results: In the first year using NPWTi, our department managed seven patients (8 breast reconstructions) presenting with breast device infection at an average of 15.3 days postoperatively. The average length of stay for treatment was 7.4 days with 2.5 operations over this period. Four patients had attempted salvage of their reconstructive pocket and all were discharged with a breast expander in situ. Conclusion: Attempted salvage using negative-pressure wound therapy with instillation may improve rates of reconstruction salvage after periprosthetic infection. We present our current management algorithm for periprosthetic infections."

In hospital outcomes of autologous and implant-based breast reconstruction in patients with diabetes mellitus: A population-based study of 2015-2020 national inpatient sample.

Breast reconstruction encompasses autologous (ABR) and implant-based breast reconstruction (IBR) each with its own sets of potential complications. Diabetes mellitus (DM) is associated with breast reconstruction complications, although most of the studies did not differentiate between the reconstruction procedures. This study conducted a population-based study examining impact of DM on inhospital outcomes in ABR and IBR. Patients underwent ABR or IBR were identified in National Inpatient Sample from Q4 2015 to 2020. A 1:2 propensity score matching was used to address differences in demographics, hospital characteristics, primary payer status, comorbidities, and reconstruction staging between DM and non-DM patients. In hospital outcomes were assessed separately in ABR and IBR. There were 997 (7.68%) DM and 11,987 (92.32%) non-DM patients in ABR. Meanwhile, 1325 (7.38%) DM and 16,638 (92.62%) non-DM patients underwent IBR. DM cohorts in ABR and IBR were matched to 1930 and 2558 non-DM patients, respectively. After matching, DM patients in both ABR and IBR had higher risks of renal complications (ABR, 3.73% vs. 1.76%, p<0.01; IBR, 1.83% vs. 0.78%, p=0.01) and longer length of stay (ABR, p=0.01; IBR, p=0.04). In ABR, DM patients had higher respiratory complications (2.82% vs. 1.19%, p<0.01), excessive scarring (2.72% vs. 1.55%, p=0.03), and infection (2.42% vs. 1.14%, p=0.01), while in IBR, DM patients had higher hemorrhage/hematoma (5.40% vs. 3.40%, p<0.01) and transfer out (1.52% vs. 0.78%, p=0.04). DM was associated with distinct sets of inhospital complications in ABR and IBR, which can be valuable for preoperative risk stratification and informing clinical decision-making for DM patients.

Surface Topography, Microbial Adhesion, and Immune Responses in Silicone Mammary Implant-Associated Capsular Fibrosis.

Breast cancer is the most common cancer in women globally, often necessitating mastectomy and subsequent breast reconstruction. Silicone mammary implants (SMIs) play a pivotal role in breast reconstruction, yet their interaction with the host immune system and microbiome remains poorly understood. This study investigates the impact of SMI surface topography on host antimicrobial responses, wound proteome dynamics, and microbial colonization. Biological samples were collected from ten human patients undergoing breast reconstruction with SMIs. Mass spectrometry profiles were analyzed for acute and chronic wound proteomes, revealing a nuanced interplay between topography and antimicrobial response proteins. 16S rRNA sequencing assessed microbiome dynamics, unveiling topography-specific variations in microbial composition. Surface topography alterations influenced wound proteome composition. Microbiome analysis revealed heightened diversity around rougher SMIs, emphasizing topography-dependent microbial invasion. In vitro experiments confirmed staphylococcal adhesion, growth, and biofilm formation on SMI surfaces, with increased texture correlating positively with bacterial colonization. This comprehensive investigation highlights the intricate interplay between SMI topography, wound proteome dynamics, and microbial transmission. The findings contribute to understanding host-microbe interactions on SMI surfaces, essential for optimizing clinical applications and minimizing complications in breast reconstruction.

The Usage of Mesh and Relevant Prognosis in Implant Breast Reconstruction Surgery: A Meta-analysis.

Although mesh-based implant breast reconstruction surgery is emerging as the primary surgical procedure for breast reconstruction, mesh use remains controversial in implant breast reconstruction surgery, especially in terms of how to select the ideal mesh. Our aim is to elaborate relevant prognosis in the mesh-based implant breast reconstruction surgery. Relevant studies were identified from PubMed, Web of Science, EMBASE, and Cochrane library searches. Extracted data included study type, basic characteristics, mesh information, complications, etc. We analyzed the included cohort studies and randomized controlled trials that reported mesh-related implant breast reconstruction complications and breast quality scale scores. A total of 32 studies including 7475 subjects were included. The results showed that the overall complication rate was 2.07 times higher in the biological mesh group than in the synthetic mesh group (risk ratio [RR]: 2.07, 95% CI 1.14-3.78). The risk of seroma was 4.50 times higher in the biological mesh group than in the synthetic mesh group (RR: 4.50, 95% CI 2.27-8.95). In terms of comparing breast quality scale scores, the mesh group had scores that were 1.49 (95% CI 0.19-2.78) higher than the non-mesh group for "physical well-being" and 2.05 (95% CI 0.08-4.02) higher for "sexual well-being." Our study found that the risk of total complications was higher with biological mesh than with synthetic mesh in implant breast reconstruction surgery. Based on short-term cost, healthcare burden, and healthcare benefits, synthetic meshes are superior to biological meshes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Role of Adipose-derived Stem Cell in Breast Reconstruction with Fat Grafting: A Literature Review

Adipose-derived stem cells (ADSC) are a biological development that provides new hope regarding tissue engineering and regenerative therapy. Due to its potential paracrine activity, compounding, paracrine activity and immunomodulatory function, ADSC-based cell-assisted lipotransfer has emerged as a promising cell therapy technology and significantly improves fat graft retention. Initially used for breast augmentation as a cosmetic function, currently ADSC-based cell-assisted lipotransfer has potential utility for breast reconstruction in breast cancer patients. Post-fat grafting complications of 10.9% were reported and considered major, including hematoma, seroma, fat necrosis, dermatitis, cellulitis, and infection. In this review, we summarize the latest research and aim to provide an overview of ADSC in fat grafting, so that in the future research can be found to avoid post-fat grafting complications in breast reconstruction and provide satisfactory breast reconstruction results.

Does the dominant hand’s use affect the complication rates in prosthetic breast reconstruction?

Background Numerous studies have investigated risk factors for unfavorable outcomes in prosthetic breast reconstruction, such as obesity, perioperative radiotherapy, and acellular dermal matrix use. However, no reports have explored whether the use of the dominant hand influences complications in breast reconstruction. To address this gap in the literature, analyzed complication rates between the dominant and non-dominant sides after reconstruction.Methods We retrospectively reviewed the charts of 160 patients (170 breasts) who underwent breast reconstruction from February 2017 to March 2022. We analyzed the complications between beasts on the dominant and non-dominant sides according to the reconstruction method.Results During prosthetic breast reconstruction, the drainage volume and duration on the dominant side exceeded those on the non-dominant side after reconstruction (duration: 9.79 days on the dominant side vs. 9.12 days on the non-dominant side, P=0.196; volume: 771.1 mL on the dominant side vs. 654.3 mL on the non-dominant side, P=0.027). The incidence of complications such as wound dehiscence, mastectomy flap necrosis, and infection was significantly higher in the dominant hand group (infection: 6 vs. 0, P=0.014; dehiscence: 15 vs. 4, P=0.009; flap necrosis: 13 vs. 4, P=0.024).Conclusions Complications including seroma, infection, and mastectomy skin flap necrosis following prosthetic reconstruction were common in breasts on the dominant-hand side. Therefore, meticulous management and restriction of shoulder movement can aid in preventing seroma-related complications in prosthetic breast reconstruction, especially on the side of the dominant hand.

Frail but Resilient: Frailty in Autologous Breast Reconstruction is Associated with Worse Surgical Outcomes but Equivalent Long-Term Patient-Reported Outcomes.

Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction. We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort. We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011). Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.

Preoperative Venous Thromboembolism Risk as a Predictor of Free Flap Complications in Breast Reconstruction

Preoperative Venous Thromboembolism Risk as a Predictor of Free Flap Complications in Breast Reconstruction

Breast Reconstruction Complications After Postmastectomy Proton Radiation Therapy for Breast Cancer

Our purpose was to report complications requiring surgical intervention among patients treated with postmastectomy proton radiation therapy (PMPRT) for breast cancer in the setting of breast reconstruction (BR). Patients enrolled on a prospective proton registry who underwent BR with immediate autologous flap, tissue expander (TE), or implant in place during PMPRT (50/50.4 Gy +/- chest wall boost) were eligible. Major reconstruction complication (MRC) was defined as a complication requiring surgical intervention. Absolute reconstruction failure was an MRC requiring surgical removal of BR. A routine revision (RR) was a plastic surgery refining cosmesis of the BR. Kaplan-Meier method was used to assess disease outcomes and MRC. Cox regression was used to assess predictors of MRC. Seventy-three courses of PMPRT were delivered to 68 women with BR between 2013 and 2021. Median follow-up was 42.1 months. Median age was 47 years. Fifty-six (76.7%) courses used pencil beam scanning PMPRT. Of 73 BR, 29 were flaps (39.7%), 30 implants (41.1%), and 14 TE (19.2%) at time of irradiation. There were 20 (27.4%) RR. There were 9 (12.3%) MRC among 5 implants, 2 flaps, and 2 TE, occurring a median of 29 months from PMPRT start. Three-year freedom from MRC was 86.9%. Three (4.1%) of the MRC were absolute reconstruction failure. Complications leading to MRC included capsular contracture in 5, fat necrosis in 2, and infection in 2. On univariable analysis, BR type, boost, proton technique, age, and smoking status were not associated with MRC, whereas higher body mass index trended toward significance (hazard ratio, 1.07; 95% CI, 0.99-1.16; P = .10). Patients undergoing PMPRT to BR had a 12.3% incidence of major complications leading to surgical intervention, and total loss of BR was rare. MRC rates were similar among reconstruction types. Minor surgery for RR is common in our practice.

Increased Complication Rates with Proton Therapy in Breast Cancer Patients with Immediate, Implant-Based Reconstruction: Single-Institution Comparative Effectiveness Analysis

To compare the impact of protons vs. photons on breast reconstruction complications, for patients (pts) receiving postmastectomy radiation (PMRT) with either single-stage direct-to-implant (DTI) or two-staged expander/implant (TE/I). We reviewed the charts of 578 pts who underwent immediate reconstruction followed by radiation at our institution between 2010 and 2020. Pts with implant-based reconstruction using either TE/I or DTI and PMRT delivery in the presence of the prosthesis were included. Pts enrolled in active ongoing clinical trials were excluded from the analysis. The photon group received 3D conformal or IMRT/VMAT treatment with a median dose of 50-50.4 Gy in 25 to 28 fractions. For proton pts, treatment was delivered mainly with pencil beam scanning technique (PBS); few pts received passively scattered proton spread-out Bragg peak (SOBP). The complications were defined as infection/skin necrosis (I/N) requiring operative debridement, capsular contracture (CC) necessitating capsulotomy, and overall implant failure (ORF) as the removal of the permanent implant irrespective of replacement outcomes (i.e., with and without salvage reconstruction). We fit inverse-probability weighted cumulative incidence curves to adjust for confounding and non-random loss to follow-up. Various sensitivity analyses were conducted. Four hundred ninety-five pts were available for the final analysis with an overall median follow-up of 55 months. 66 (13%) received protons, of which14 were treated with SOBP protons. 137 (28%) and 256 (56%) received photons with and without chest wall boost (CWB), respectively. The 5-year inverse probability-weighted risk of CC post-PMRT was 31% for protons vs. 10% for photons (RR:3.09, 95% CI: 1.77, 5.40). The 5 years ORF risk was 35.6% in protons compared to 22.7% in photons pts (RR: 1.57; 95% CI 1.0, 2.48). Hazard ratios from the adjusted Cox models were 3.79 (p<0.001) for CC and 2.05 (p<0.01) for ORF. No difference in I/N was noted between protons and photons pts. Sensitivity analysis showed that protons significantly increased CC risk vs photons both with CWB (HR:3.56, P<0.001) and without CWB (HR:3.9, p<0.001). Similar outcomes were observed with ORF, where protons increased the rate of ORF compared to photons, irrespective of CWB (HR 1.8, p = 0.038 with CWB; HR 2.4, p = 0.004 without CWB). No differences between PBS and SOBP proton techniques were noted. Compared to photons, proton therapy increases the risk of capsular contracture requiring surgical intervention and hence overall reconstruction failure. This data should inform discussions about the risks and benefits of protons in patients with reconstruction, while awaiting mature data from ongoing clinical trials (RADCOMP) utilizing protons for breast cancer.

Near-Surface Dose Avoidance in Patients with Implant-Based Reconstruction Receiving Post-Mastectomy Proton Irradiation

Dose to the near-surface region may contribute to toxic effects and breast reconstruction complications in patients receiving post-mastectomy irradiation. Here we report the acute and chronic toxic effects in patients with implant-based reconstruction receiving post-mastectomy proton irradiation with prospective near-surface dose avoidance. We reviewed the charts of patients with breast cancer who underwent a mastectomy with implant-based reconstruction and a first course of pencil beam scanning proton irradiation at a single institution from 2017-2022. Patients were evaluated weekly on-treatment, 3- and 12-months post-completion, and then annually. Baseline demographics, treatment details, acute and chronic toxicities (CTCAE v.4), unplanned reconstructive surgery, and implant failure were recorded. Inverse probability weighting was used to generate a balanced cohort receiving post-mastectomy photon irradiation. Logistic regression was used for comparison. Sixteen patients with implant reconstruction at the time of treatment completed proton irradiation with a median follow up of 1.6 years. Nine (56%) underwent direct-to-permanent implant reconstruction and seven (44%) underwent two-stage reconstruction via tissue expander; of these, five (71%) completed permanent implant exchange prior to irradiation. Implant placement was pre-pectoral in twelve (75%). All patients received a dose of 50 Gy in 25 fractions; fifteen (94%) received a sequential boost to the mastectomy scar of a median 10 Gy. Fifteen (94%) used a near-surface contour (bound by the chest wall CTV, the skin surface, and the skin-3mm contour) for plan optimization to avoid dose to the near-surface region with a median value of the mean dose of 46.8 Gy. Acute grade > 2 radiation dermatitis was present in thirteen (81%) patients. Two (13%) experienced moist desquamation and ten (63%) experienced grade > 2 chest wall pain. Three (19%) underwent unplanned reconstructive surgery at a median time of 1.6 years post-treatment: all were capsulectomies due to capsular contracture. One (6%) patient experienced implant failure. A matched cohort of 59 patients who received photon irradiation was identified with a weighted median follow up of 2.5 years. The cohorts were similar with respect to rates of grade ≥2 radiation dermatitis, grade ≥2 chest wall pain, and unplanned reconstructive surgery. Proton irradiation resulted in statistically significant decreases in rates of moist desquamation (OR 0.01, 95% CI 0.0002-0.182) and implant failure (OR 0.01, 95% CI 0.0001-0.997). Post-mastectomy proton irradiation with prospective avoidance of the near-surface region in patients with implant-based reconstruction is feasible and well-tolerated; it results in low rates of unplanned reconstructive surgery and implant failure.

Comparison between Pre-Pectoral and Post-Pectoral Implant Reconstruction and Different Radiation Modalities on Breast Reconstruction Complications

Single Stage direct to implant (DTI) is a rising reconstruction approach. It has been speculated that prepectoral implant placement reduces reconstruction complications as well as using newer postmastectomy radiation (PMRT) modalities as protons. Largest series in this topic included 350 DTI patients with less than 30 patients receiving PMRT. We reviewed the charts of 2,187 patients (pts) who underwent mastectomy and reconstruction at our institution between 2000 and 2020. Pts only receiving DTI with and without PMRT were included. PMRT was delivered either with 3D conformal photon +/- chest wall electron boost (CWB) or proton therapy mainly with pencil beam scanning. All pts received conventional fractionation (50-50.4 Gy in 25-28 fractions). Patients on active protons clinical trials were excluded. Primary endpoints were reconstruction complications defined as infection/necrosis (I/N) requiring debridement; capsular contracture (CC) requiring capsulotomy and overall reconstruction failure (ORF: removal of permanent implant for any complication with and without salvage reconstruction). Subgroup analysis for pts receiving PMRT was done to explore impact of proton and photons on complications. Logistic and cox regression were used. Eight hundred nine pts received DTI, with an overall median follow-up of 6.2 years. Among the entire cohort, 78/809 (9.7%) had prepectoral implants while the rest had subpectoral implants with and without alloderm support. Of the entire cohort 391/809 (48.5%) received PMRT, among those 43/391 (11%) received protons. The 5 years cumulative incidence of CC was 8.5% and 6.6% among prepectoral vs subpectoral implants (HR = 1.2, p = 0.7). The 5 years cumulative incidence of ORF was 32.2% and 28.2% among prepectoral vs subpectoral implants (HR 1.1, p = 0.6). For pts receiving PMRT, the 5 years cumulative incidence of CC were 26.0% and 8.6% among protons vs photons (HR 3.7, p < 0.0005). The 5 years cumulative incidence of ORF were 38.2% and 30.1% among protons vs photons (HR 1.4, p = 0.2). Multivariable logistic regression analysis accounting for BMI, smoking history, diabetes, and PMRT showed no significant difference between prepectoral implants versus subpectoral coverage for CC (OR = 0.7, p = 0.5), and for ORF (OR = 0.9, p = 0.8). Subgroup multivariable analysis for those receiving PMRT only showed protons compared to photons significantly increased the risk of CC (OR = 5.3, p < 0.0001) and ORF (OR = 2.1, p = 0.03). No significant difference in I/N was noted between photons and protons or between prepectoral and subpectoral pts. For breast cancer patients receiving single stage direct to implant reconstruction with and without PMRT, prepectoral implant placement did not reduce the risk of complications. Proton therapy compared to photons significantly increased the risk of capsular contracture requiring capsulotomies and significantly increased overall reconstruction failures with implants removal.

Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction.

Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prostheticinfection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction. A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes. A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy. Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bovine Acellular Dermal Matrix-Based Breast Reconstruction in Previously Irradiated Breasts: Complications and Outcomes From a Single-Center Experience.

Radiation therapy is considered today an integral part of the management of breast cancer. However, radiotherapy significantly increases the incidence of total complications in breast reconstruction. Several procedures have been adopted to reduce complication rates in irradiated fields, including the use of acellular dermal matrices (ADMs). We conducted a retrospective analysis of our single-center experience with ADM-assisted implant-based reconstruction or revision surgeries for capsular contracture treatment in irradiated breasts. We divided our population into 4 groups based on prior surgical history: group A (previous quadrantectomy), group B (previous mastectomy and expander reconstruction), group C (previous mastectomy and implant reconstruction), and group D (prior quadrantectomy followed by mastectomy and implant reconstruction). At the European Oncology Institute in Milan, Italy, between June 2017 and April 2019, we identified 84 patients for a total of 86 irradiated breasts reconstructed with implant and ADM. We observed a total of 12 reconstructive failure, with the highest rate of failure in group B (16.6%) and in group D (15.38%). Overall, we recorded 22 total complications (24.4%): 12 major complications and 10 minor complications. The most common complication was infection, with 9 cases (10.4%), 6 of which were classified as severe and required implant removal. In group B, we observed the highest complication rate, both major and minor, with 7 of 42 patients (16.6%) experiencing each. Before reconstruction with ADM, the Baker grade ranged from 3 to 4, with a mean of 3.25. At the 2-year follow-up, the Baker grade ranged from 1 to 4, with a mean of 1.9. Surgeons were highly satisfied with the aesthetic result in 72.1% of cases, moderately in 8.1% and unsatisfied in 5.81%, and in 13.9%, the outcome was not assessable because of reconstructive failure. The worst aesthetic result was in group B. We observed significant reduction in capsular contracture in revision surgeries despite a moderately high rate of complications in previous quadrantectomy and radiotherapy. In our experience, breast reconstruction with implant and ADM is not the primary surgical indication in case of prior irradiation, but it can be considered as a valid alternative with reasonable safety profile, to be used in selected cases.

Postmastectomy Radiation Modalities (Protons, Chest Wall Boost, Skin Bolus, Fractionation, and Timing) and Breast Reconstruction Complications: The Role of Radiation Oncologist

Postmastectomy Radiation Modalities (Protons, Chest Wall Boost, Skin Bolus, Fractionation, and Timing) and Breast Reconstruction Complications: The Role of Radiation Oncologist