Complications In Immediate Breast Reconstruction Research Articles

ASO Visual Abstract: Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

ASO Visual Abstract: Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

Tissue expander fill medium and volume have implications for the pressure exerted on mastectomy skin flaps. This study evaluated the influence of initial fill medium (air vs. saline) on complications in immediate breast reconstruction within a propensityscore-matched cohort. Patients undergoing immediate tissueexpander-based breast reconstruction with initial intraoperative fill with air were propensity score matched 1:2 to those with saline initial fill based on patient and tissue expander characteristics. Incidence of overall and ischemic complications were compared by fill medium (air vs. saline). A total of 584 patients were included, including 130 (22.2%) with initial fill with air, 377 (64.6%) with initial fill with saline, and 77 (13.2%) with 0 cc of initial fill. After multivariate adjustment, higher intraoperative fill volume was associated with increased risk of mastectomy skin flap necrosis [regression coefficient (RC) 15.7; p = 0.049]. Propensity score matching was then conducted among 360 patients (Air: 120 patients vs. Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p > 0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p = 0.003), seroma (p = 0.004), and nipple necrosis (p = 0.03). Within a propensityscore-matched cohort, initial fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. Initial fill with air and lower fill volumes may be strategies to reducing risk of ischemic complications among high-risk patients.

ASO Author Reflections: Initial Tissue Expander Fill with Air Reduces Complications in Immediate Breast Reconstruction.

ASO Author Reflections: Initial Tissue Expander Fill with Air Reduces Complications in Immediate Breast Reconstruction.

Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery

BackgroundSkin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS. Materials and MethodsPatients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss. Results956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567). ConclusionIn this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Abstract 60: Chemotherapy Effects on Clinical Complications and Patient Reported Outcomes after Immediate Breast Reconstruction

PURPOSE: Many women undergoing immediate breast reconstruction also require pre or post-operative chemotherapy for cancer treatment. The effects of chemotherapy on breast reconstruction outcomes have not been well described. We evaluated the impact of neoadjuvant and adjuvant chemotherapies on complications and patient-reported outcomes (PROs) in immediate reconstruction. METHODS: The MROC Study prospectively assessed complications and PROs in patients undergoing immediate implant-based or autologous reconstruction at 11 centers from 2012 to 2015. Complications (total and major), and PROs (satisfaction, and physical, psychosocial and sexual well-being) were evaluated two years postoperatively, using medical records and the BREAST-Q, respectively. Mixed models compared outcomes across cohorts receiving neoadjuvant, adjuvant or no chemotherapy, controlling for clinical covariates and sites. RESULTS: Among 1881 patients, 10.6% received neoadjuvant, 35.5% adjuvant, and 53.9% no chemotherapy. Procedures included implant-based (73%) and autologous reconstructions (27%). Significant cohort differences were noted for age, laterality, lymph node management, mastectomy type, and timing of radiation. Although chemotherapy had no significant effects on complication rates for autologous reconstructions, a higher risk of major complications was seen in implant patients with adjuvant chemotherapy compared to no chemotherapy (OR 1.42, p=0.05). With the exception of sexual well-being, for which adjuvant chemotherapy was associated with significantly lower scores in implant patients (p <0.01), there were no significant chemotherapy effects on PROs. CONCLUSION: While the effects of chemotherapy on complications in immediate breast reconstruction appeared to vary by chemotherapy timing and procedure type, chemotherapy had little impact on PROs. These findings may prove useful in treatment planning and counseling for breast cancer patients.

Factors Associated With Complications in Immediate Breast Reconstruction in 1 Stage With Completely Submuscular Implants.

Immediate breast reconstruction in 1 stage using permanent implants is gaining popularity and can be performed with or without the use of acellular dermal matrices. This study aimed to investigate the results of breast implants placed submuscularly without acellular dermal matrix and assess the factors affecting surgical complications. From November 2009 to March 2018, 138 patients underwent immediate breast reconstruction with permanent submuscular implants after concomitant skin-sparing or nipple-sparing mastectomies in a single institution. All implants were covered with sufficient soft tissue under a submuscular pocket. One hundred thirty-eight patients were enrolled, and a total of 196 breasts were operated. The average age and body mass index (BMI) of the patients were 44.9 ± 8.8 years and 23.7 ± 3.6 kg/m, respectively. The majority of the mastectomies were therapeutic (81%). The average volume of implants was 389 ± 89 mL, and the mean follow-up was 33 months. The overall complication rate was 17% (n = 23), with skin necrosis being the most common complication followed by infections. Having a BMI equal to or greater than 25 kg/m was found to be a statistically significant predictor for overall complications (P = 0.002), whereas smoking history, age, and implant volume were not statistically significant. Immediate breast reconstruction in 1 stage using permanent implants can be performed with acceptable complication rates and cosmetic outcomes. Our study demonstrated that high BMI is a risk factor for overall complications. With proper patient selection and surgical technique, implants could be completely covered under a submuscular pocket.

Complications of immediate breast reconstruction after total mastectomy using conical and non-conical prostheses

Complications of immediate breast reconstruction after total mastectomy using conical and non-conical prostheses

The site of care matters: An examination of the relationship between high Medicaid burden hospitals and the use, cost, and complications of immediate breast reconstruction after mastectomy.

Diminished use and worse outcomes after immediate breast reconstruction (IBR) have been documented for Medicaid beneficiaries. However, to the authors' knowledge, the contribution of patient clustering at hospitals with a high percentage of Medicaid patients to these inequalities in IBR delivery is unknown. A cross-sectional analysis of patients undergoing IBR after mastectomy using the 2007 to 2011 Nationwide Inpatient Sample database was performed. Hospital Medicaid status was calculated as the percentage of all patients with Medicaid as a primary payer. Tertile groupings were generated to enable statistical analysis. Hierarchical regression models were used to investigate the link between Medicaid status and IBR use, outcomes, and costs. A subgroup of patients undergoing IBR for noninvasive cancer or those with increased genetic risk were used to study IBR use. A total of 30,086 IBR cases in 1199 hospitals were analyzed. Hierarchical regression analysis demonstrated an association between high Medicaid burden hospitals and significantly decreased odds of IBR among patients with in situ disease and/or an elevated risk of cancer (odds ratio, 0.64; 95% confidence interval [95% CI], 0.507-0.806). Increasing age, obesity, being nonwhite, having more comorbid conditions, and having government insurance were found to be associated with diminished odds of IBR (P<.001 in all instances). In-hospital surgical and medical complication rates were comparable across the 3 strata of hospital Medicaid status. Log-adjusted costs of care were found to be positively associated with a higher hospital Medicaid burden status (coefficient of 0.038 [95% CI, 0.011-0.066] for medium Medicaid burden hospitals and coefficient of 0.053 [95% CI, 0.015-0.093] for high Medicaid burden hospitals). High Medicaid burden hospital status is associated with an attenuation of IBR use and increased total inpatient costs. Structures of care such as hospital resources partially explain disparities in IBR delivery. Cancer 2018;124:346-55. © 2017 American Cancer Society.

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

Complications in immediate breast reconstruction using Strattice™

Introduction Immediate breast reconstruction (IBR) is becoming increasingly popular. Implant-based IBR has a lot of benefits over autologous IBR but also carries the disadvantages associated with implant use. Acellular dermal matrix, such as Strattice™, has been used as an alternative approach to provide implant coverage.

Complications in immediate breast reconstruction after mastectomy

Immediate post-mastectomy breast reconstruction (IBR) is a procedure that has proven advantages, but it also entails risks. The aim of this study was to identify risk factors for reconstruction failure. A review was made of all the IBR carried out at a general hospital from 2002 to 2009. Retrospective information was obtained about postoperative complications and the characteristics of patients and treatments applied. The minimum follow-up period was 9 months. Cox's regression analysis was performed on the variables related to the reconstruction failure requiring the removal of the prosthesis, with an explanatory model in which all the study variables were introduced and a predictive model that contained only the variables known before the intervention. A total of 115 IRB interventions carried out on 112 women with breast cancer were analyzed. The mean follow-up period was 25.5 months. In sixty cases (52.2 percent), there were no complications; in sixteen cases (13.9 percent) minor complications appeared, and in 39 (33.9 percent) the complications were moderate. In twenty-six cases (22.6 percent), a reconstruction failure occurred. Cox's regression model revealed that the reconstruction failures were related to the patient's age (Hazard Ratio 1.08), to neoadjuvant chemotherapy (HR 6.24) and to postoperative tamoxifen (HR 3.10). The predictive model included the age of the patient (HR 1.05) and the use of neoadjuvant chemotherapy (HR 5.11). A significant proportion of the patients receiving IBR developed reconstruction failure. Multivariate analysis identified three variables related to this complication, two of which were known before the intervention.

Intraoperative Perfusion Mapping with Laser-Assisted Indocyanine Green Imaging Can Predict and Prevent Complications in Immediate Breast Reconstruction

Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability. Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed. In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors. This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.

Complications analysis of 266 immediate breast reconstructions

The purpose of this study was to describe the complications of immediate breast reconstruction, to compare their rates with respect to the surgical procedure and to patient's characteristics, in order to improve surgical indications and patient information. We carried out a retrospective study of 266 immediate breast reconstructions (249 women) over a 12-year period (latissimus dorsi myocutaneous flap with implant 61%, autologous latissimus dorsi myocutaneous flap 15%, subpectoral implant 24%). Mean age was 48 and the median follow-up was seven years (2-14). The overall complication rate was 49% (128), and there were 10 reconstruction failures. The most frequent complications were dorsal seroma 26% (70), capsular contracture 10% (27), skin necrosis 8.3% (22), and haematoma 5.6% (15). The complication rate for immediate breast reconstruction with implant alone (39%) was lower than that associated with latissimus dorsi with or without implant (51%), but the difference was not significant (Chi-square: p=0.07). The risk factors for complications were smoking (skin necrosis, Fisher: p=0.02), obesity (infection, Fisher: p=0.004), and radiotherapy (capsular contracture, Chi-square: p=2.6 x 10(-5)). Smoking was found as the only risk factor of reconstruction failure (Fisher: p=0.015). Capsular contractures were more frequent when implants were used alone (25%) as well as when used along with a flap (6.8%) (Chi-square: p=2 x 10(-5)). Infections were also higher in the non-flap group than in the flap group (Fisher: p=0.02). In our opinion, latissimus dorsi myocutaneous flap with or without an implant is a good compromise between complication risk and necessity of good cosmetic result requirement. These results have led us to delay or contraindicate reconstruction in the case of obesity or heavy smoking. In the case of probable post-operative radiotherapy, we prefer to delay the breast reconstruction.