Expander-implant Breast Reconstruction Research Articles

Autologous fat transplantation prior to permanent expander implant breast reconstruction enhances the outcome after two years: a randomized controlled trial.

Radiotherapy is important in breast cancer treatment. A side effect of the treatment is fibrosis that decreases the possibility for a successful breast reconstruction with expanders and with high patient satisfaction with the result. The most common option for mastectomized, irradiated women wishing for a breast reconstruction is autologous tissue transplantation. However, some patients are not suitable for flap surgery. Fifty mastectomized and irradiated women were included in a randomized controlled trial. They underwent breast reconstruction with expanders and were allocated 1:1 to either receive pre-treatment with autologous fat transplantation (AFT) or not. Primary outcomes were frequency of reoperations and complications. Secondary outcomes were number of days in hospital, number of outpatient visits to surgeon or nurse and patient reported outcome as reported with Breast Q. Follow-up time was 2 years. Fifty-two per cent of the intervention group and 68% of the controls underwent reoperations (p = 0.611). Thirty-two per cent of the intervention group and 52% of the controls had complications (p = 0.347). The median number of consultations with the nurse was four in the intervention group and six in the control group (p = 0.002). The AFT patients were significantly more satisfied with their breasts and psychosocial well-being after 2 years. They also had higher increase in satisfaction with breasts, psychosocial well-being, and sexual well-being when comparing baseline with 2 years postoperatively. This randomized controlled trial indicates benefits of AFT prior to breast reconstruction with expanders, especially on patient reported outcome even if the study sample is small.

The investigation of the relation between expansion strategy and outcomes of two-stage expander-implant breast reconstruction.

Numerous risk factors for the complications of two-stage, immediate implant-based breast reconstruction have been identified, although few studies have directly examined the impact of breast size and expansion protocols on the surgical outcomes of breast reconstruction. This study aimed to evaluate the impact of breast size, expansion velocity, and volume-related variables on postoperative complications of breast reconstruction. The cohort involved patients who underwent immediate breast expander reconstruction at a single center between 2017 and 2019. The breast size was classified into three categories according to the weight of the mastectomy specimen as small (<300 g), medium (≥300 g, ≤500 g), or large (>500 g). Multifactorial logistic regressions were used to assess the impact of variables, and receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value for predicting the complication event. Of the 174 breasts (168 patients), 51 (29.3%), 66 (37.9%), and 57 (32.6%) breasts were classified as small, medium, and large, respectively. The rate of infection (P=0.014) and expander/implant failure (P=0.007) significantly differed according to breast size, with the rate being the highest in large breasts. Multivariate logistic regression analysis showed that body mass index (BMI) [odds ratio (OR): 1.25; P=0.003], nipple-sparing mastectomy (OR: 2.82; P=0.036), sentinel biopsy (OR: 5.10; P=0.016), final expansion volume (OR: 0.99; P=0.022), and expansion velocity (OR: 0.703; P=0.024) were significant independent predictors of any complication. In the ROC analysis, breast weight >696 g could predict the possibility of revision surgery, with a sensitivity of 42.9% and specificity of 81.8%. The final expansion volume and expansion velocity have a significant negative relationship with overall complications in breast reconstruction. A standard expansion protocol needs to be established to ensure the success of two-stage breast reconstruction.

Microbiology of breast tissue expanders.

IntroductionInfection is one of the most common complications of breast reconstruction. The presence of bacterial biofilm on the implant surface does not always manifest itself clinically as an infection. Still little is known about the factors that trigger the transition from a normal to a pathological state. The aim of study: To examine a specific profile of microorganisms associated with a tissue expander, and to ascertain whether the collection of intraoperative bacteriological swabs constitutes a significant predictive factor. Material and methods: A 2-centre review of outcomes of breast cancer patients who underwent immediate 2-stage expander-implant breast reconstruction between June 2020 and September 2021 was conducted. During this period, 68 replacements of expanders with implants from 56 women were performed. A bacteriological swab was taken from each expander compartment, and microbiological culture was performed. Patients’ characteristics were taken into consideration.ResultsTissue expanders were implanted from 2 to 26 months. Seven patients had an emergency expander removed due to infection or damage to the device. Out of all 56 patients evaluated, 47 had a negative and 9 had a positive culture, 1 in both breasts. The results did not correlate closely with the clinical status.ConclusionsBacteria colonize both clinically normal and infected expanders. It is difficult to determine the specific flora associated with the pocket after expander-based reconstruction, and taking a bacteriological swab each time as a standard does not influence the success of treatment.

Inframammary Fold Approach for Second-stage Operation in Expander-Implant Breast Reconstruction.

Despite expander-based breast reconstruction being used as a reliable reconstruction method, implant removal due to wound dehiscence and infection still occurs in 0.5% to 15% of cases. This study aimed to compare the outcomes of the new inframammary fold (IMF) incision approach with previous incision in second-stage operation of expander-based 2-stage breast reconstruction. Patients who underwent expander-based 2-stage breast reconstruction between February 2014 and May 2019 were included. After expander inflation, patients undergoing second-stage reconstruction were divided into the previous incision and IMF incision groups and their outcomes were compared. Propensity score matching analysis was performed to compare postoperative 1-year results. The previous incision and IMF incision groups comprised 79 and 31 patients, respectively. There were no intergroup differences in general demographics or intraoperative data, except for total inflation volume (426.87 ± 102.63 mL in the previous incision group and 375.48 ± 94.10 mL in the IMF incision group, P = 0.017). Wound dehiscence occurred in 12 and 0 cases in the previous and IMF incision groups, respectively (P = 0.018). Implant removal was performed due to dehiscence in 9 cases (8.18%) and 0 cases (0%) in the previous and IMF incision groups, respectively (P = 0.049). In 1-to-1 propensity score matching analysis, the IMF incision group showed better results at 1-year follow-up (odds ratio: 0, 95% confidence interval: 0-1.09; P = 0.063). The IMF approach is a safe method for replacing the expander with an implant, with lower incidence of wound dehiscence and implant explantation.

Minimally invasive salvage of infected breast tissue expanders: A continuous closed irrigation technique based on surface biofilm disruption

Removal of the infected device has been the general treatment for device-associated infection in antibiotic failure. There have been anecdotal attempts to salvage infected medical devices by introducing a continuous closed irrigation system. This study examines whether continuous closed irrigation of an infected device is a successful alternative to removal in patients with recalcitrant device-associated infection. Patients who were diagnosed with recalcitrant periexpander infections during the course of expander-implant breast reconstruction from 2010 to 2018 were enrolled in a retrospective case-control study. Patients who failed antibiotics before 2017 underwent expander removal, but patients since 2017 underwent continuous closed irrigation of the infected expanders. Treatment details and clinical outcomes were compared. Rationale for expander irrigation was based on review of the current literature on biofilm research. During the study period, 21 out of the 1176 patients were diagnosed with periexpander infection recalcitrant to antibiotic therapy. Among the 21 patients, 16 underwent expander removal and five underwent expander irrigation. Clinical outcomes were comparable in terms of resolution of infection signs. The irrigation group showed fewer patients who abandoned reconstruction after infection treatment (removal=11/16, irrigation=1/5). Literature review revealed that expander irrigation might have induced hydrodynamic disruption of the biofilm structure. Expander irrigation was less invasive than removal and effective in suppressing severe recalcitrant periexpander infection. Continuous closed irrigation of infected expander devices may be a successful antibiofilm strategy in treating device-associated infections in select patients.

Postmastectomy Radiation Therapy (PMRT) before and after 2-Stage Expander-Implant Breast Reconstruction: A Systematic Review.

Background: In those undergoing treatment for breast cancer, evidence has demonstrated a significant improvement in survival, and a reduction in the risk of local recurrence in patients who undergo postmastectomy radiation therapy (PMRT). There is uncertainty about the optimal timing of PMRT, whether it should be before or after tissue expander or permanent implant placement. This study aimed to summarize the data reported in the literature on the effect of the timing of PMRT, both preceding and following 2-stage expander-implant breast reconstruction (IBR), and to statistically analyze the impact of timing on infection rates and the need for explantation. Methods: A comprehensive systematic review of the literature was conducted using the PubMed/Medline, Ovid, and Cochrane databases without timeframe limitations. Articles included in the analysis were those reporting outcomes data of PMRT in IBR published from 2009 to 2017. Chi-square statistical analysis was performed to compare infection and explantation rates between the two subgroups at p < 0.05. Results: A total of 11 studies met the inclusion criteria for this study. These studies reported outcomes data for 1565 total 2-stage expander-IBR procedures, where PMRT was used (1145 before, and 420 after, implant placement). There was a statistically significant higher likelihood of infection following pre-implant placement PMRT (21.03%, p = 0.000079), compared to PMRT after implant placement (9.69%). There was no difference in the rate of explantation between pre-implant placement PMRT (12.93%) and postimplant placement PMRT (11.43%). Conclusion: This study suggests that patients receiving PMRT before implant placement in 2-stage expander–implant based reconstruction may have a higher risk of developing an infection.

Inhibition Mechanism of Acellular Dermal Matrix on Capsule Formation in Expander-Implant Breast Reconstruction After Postmastectomy Radiotherapy.

Capsular contracture is one of the most common complications of expander-implant breast reconstruction. Recently, clinical reports have shown that use of an acellular dermal matrix (ADM) to cover breast implants decreases incidence of capsular contracture, but the underlying mechanism is unclear. Here, we examine how ADM reduces capsular formation in expander-implant breast reconstruction and identify cellular and molecular mechanisms of ADM-mediated reduction of capsular contracture in nonirradiated and irradiated patients. Thirty patients who underwent immediate two-stage implant-based breast reconstruction were included; 15 received radiotherapy. While the tissue expander was changed to permanent silicone implant, biopsies of the subpectoral capsule and ADM capsule were performed. Capsule thickness, immunohistochemistry of α-smooth muscle actin (αSMA), vimentin, CD31, F4/80 expression, αSMA and CD31 coexpression, and relative gene expression levels of transforming growth factor (TGF)-β1 and platelet-derived growth factor (PDGF)-B were investigated. Irradiated submuscular capsules were thicker than nonirradiated submuscular capsules, but the thickness of ADM capsules did not significantly differ between nonirradiated and irradiated groups. Levels of myofibroblasts, fibroblasts, vascularity, EndoMT, and macrophages were significantly lower in ADM capsules than in submuscular capsules. With the exception of EndoMT, all others were increased in irradiated submuscular capsules compared with nonirradiated submuscular capsule, while none significantly differed between nonirradiated and irradiated ADM capsules. Use of ADM reduced myofibroblasts, vascularity, fibroblasts, and EndoMT in capsule tissues. Moreover, ADM use decreased macrophages, a key regulator of tissue fibrosis, as well as TGF-β1 and PDGF-B expression. We hope that these results provide basic concepts important for prevention of capsular contracture.

Prepectoral Immediate Direct-to-Implant Breast Reconstruction with Anterior AlloDerm Coverage.

Staged subpectoral expander-implant breast reconstruction is widely performed. Disruption of the pectoralis major origin and the frequent occurrence of animation deformity and functional discomfort associated with subpectoral reconstruction remain ongoing concerns. Prepectoral single-stage direct-to-implant reconstruction resolves many of these issues. In this study, the authors explored the rationale for prepectoral single-stage implant-based breast reconstruction with anterior AlloDerm coverage as an alternative to the staged approach. Seventy-three breasts in 50 patients were reconstructed using a single-stage direct-to-implant prepectoral approach with total anterior AlloDerm coverage during a 24-month period. The decision to proceed with single-stage reconstruction was predicated upon the adequacy of mastectomy skin flap blood flow based on indocyanine green fluorescence perfusion assessment. The patients were followed up for a maximum of 32 months. Ninety-seven percent of patients achieved complete healing within 8 weeks. There were 2 implant losses (2.7%) due to infection. Major seroma rate requiring repeated aspiration and drain insertion was 1.2%. There were no full-thickness skin losses. Capsular contracture was 0% in nonradiated patients. There were no cases of animation deformity. The authors were unable to establish significant correlation between complications and any of the usually stated risk factors, such as smoking, obesity, and large mastectomy weights, presumably due to the rigorous application of intraoperative skin perfusion assessment. Single-stage direct-to-implant reconstruction using a prepectoral approach appears to be a safe and effective means of breast reconstruction in many patients, assuming adequate skin perfusion is present.

Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study.

Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions. A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed. A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511). A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.

Abstract: Use of Negative Pressure Wound Therapy with Instillation in Acute Post-Surgical Breast Reconstruction Infections—Retrospective Review

INTRODUCTION: In recent years, combining instillation of a topical wound solution with negative pressure wound therapy (NPWT) has facilitated wound cleansing. Furthermore, published studies have positively reported on the use of a NPWT system with automated instillation and a dwell time (NPWTi-d) that provides a method of cyclically instilling and dwelling topical solutions to help improve healing outcomes of acute and chronic wounds. Our purpose was to analyze our outcomes of patients who received adjunctive NPWTi-d with a polyhexanide solution to address surgical site occurrences (SSO) following first stage expander-implant breast reconstruction. METHODS: A retrospective record review was conducted. Patient data were extracted from the electronic medical record by means of manual review and stored in a database. Adult patient records were included for analysis if the patient underwent a mastectomy followed by immediate or delayed expander reconstruction, had infection of at least one pocket confirmed via culture, had received oral and systemic antibiotics for at least one week, and subsequently received NPWTi-d. All procedures were completed between January 1, 2016 and February 1, 2017. Demographics, surgical approach, comorbidities and expander salvage rate were recorded and analyzed. Six female patients with a median age of 50.8 were included in the analysis. Five of 6 patients had undergone sub-pectoral expander reconstruction and one patient received pre-pectoral expander reconstruction. Antibiotics were also continued based on specific cultures. All surgical site infections were thoroughly debrided and irrigated. Adjunctive NPWTi-d was initiated: instillation of a polyhexanide solution with a 20-minute dwell time, followed by 3.5 hours of -125 mmHg negative pressure. Duration of therapy ranged from 1–3 days. RESULTS: Salvage of the expander was achieved in all 6 patients. None of the pockets showed signs of infection after application of NPWTi-d. Healthy granulation tissue was present in all NPWTi-d treated pockets. All breast incisions were successfully closed with good cosmetic results and without further sequelae. CONCLUSION: Tissue expanders could be salvaged in all 6 patients with SSOs in this series who received NPWTi-d. This small sample size does not allow for a reliable extrapolation to the general population. Although further studies are needed, the results from these 6 patients suggest that NPWTi-d may represent an important new adjunctive therapy option in device salvage for breast reconstruction patients.

Estimating Implant Volume and Mastectomy-Specimen Volume by Measuring Breast Volume With a 3-Dimensional Scanner.

Conventional 2-stage expander-implant breast reconstruction is frequently performed. However, direct to implant reconstruction should be considered if indicated and if circumstances allow. One difficulty in breast reconstruction postmastectomy is selection of the appropriate implant size prior to surgery. The ability to estimate implant volume and mastectomy-specimen volume from the preoperative breast volume using a 3-dimensional (3D) scanner would greatly facilitate reconstruction. We investigated the relation between preoperative breast volume, mastectomy-specimen volume, and implant volume. Forty-eight women who underwent 2-stage expander-implant reconstruction between April 2014 and September 2015 were included in this study. A 3D scanner (Kinect V1; Microsoft Corporation, Redmond, Wash) was used for measuring preoperative breast volume. We evaluated the relation of the measured preoperative breast volume, the mastectomy-specimen volume, and the implant volume using the Pearson correlation coefficient. A strong correlation existed between preoperative breast volume, mastectomy-specimen volume, and implant volume. The following formulae were calculated:Mastectomy-specimen volume (mL) = 1.01 × preoperative breast volume (mL) + 9.91Implant volume (mL) = 0.90 × preoperative breast volume (mL) + 65.42Implant volume (mL) = 0.68 × mastectomy-specimen volume (mL) + 68.26This study shows that preoperative breast volume, as measured by a 3D Kinect scanner, can provide useful assistance in the preoperative choice of implant size.

Analysis of factors influencing drain amount, time to drain removal, and seroma formation in patients undergoing immediate expander-implant breast reconstruction

Background: Placement of a closed suction drain is a common cause of patient complaints, such as postoperative pain or discomfort following immediate expander-implant breast reconstruction. This study aims to identify factors that affect drainage volume, time to drain removal, and seroma formation.Methods: A retrospective chart review of prospectively collected data was conducted on patients who underwent immediate expander-implant breast reconstructions following nipple-sparing or skin-sparing mastectomy without skin excision (nipple areolar complex excision only) between February 2010 and April 2015. Daily drainage volume was measured until the drain was removed. Eight independent variables, including acellular dermal matrix (ADM) usage and inflation ratio (the rate of initial inflation volume to mastectomy weight) were analysed by univariable and multivariable analyses.Results: A total of 162 breasts in 148 patients were included in this study. The inflation ratio did not influence the drain amount or days to drain removal. Although the use of ADM was significantly associated with increased drainage during the first 5 postoperative days (p = 0.015), it was not significant when adjusted for time. Old age, larger expander size, and larger drain amount on the first postoperative day were predictors for longer days to drain removal (p < 0.001). Old age had a trend toward higher risk of seroma formation that approached statistical significance (p = 0.057).Conclusions: The use of ADM and initial inflation ratio do not influence days to drain removal or seroma formation. A longer period of drain placement is expected when a larger expander is used or in elderly patients.

Novel Approach to Intractable Pectoralis Major Muscle Spasms Following Submuscular Expanderimplant Breast Reconstruction

Implant-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. Placement of the tissue expander and implant under the pectoralis major muscle is believed to minimize the incidence of capsular contracture, provide adequate soft tissue coverage, and minimize implant visibility and palpability. However, utilization of the submuscular pocket can be associated with discomfort, which may originate from stretching of the cutaneous envelope, distension of the underlying muscle or, rarely, from spasms of the pectoralis major muscle. A case of intractable and involuntary pectoralis major spasms following submuscular implant-based breast reconstruction is presented. An ultrasound-guided pectoral intrafascial plane block is shown to be an effective diagnostic modality, implicating the medial and lateral pectoral nerves in these spasms. The clinical anatomy literature pertaining to the course and branches of the medial and lateral pectoral nerves is reviewed.

Risk Factors for Complications in Immediate Expander-Implant Breast Reconstruction for Non-obese Patients: Impact of Breast Size on Complications.

Although obesity is a well-known risk factor for complications in immediate expander-implant breast reconstruction, no studies have identified risk factors for non-obese patients. The purpose of this study was to identify risk factors for complications in non-obese patients. A retrospective analysis of prospectively collected data from 397 consecutive immediate expander-implant breast reconstructions in 367 non-obese patients at a single institution over a 5-year period was conducted. Univariable and multivariable analysis were performed to determine the influence of six patient-related and eight procedure-related characteristics on complications. Mean BMI was 21.7 ± 2 kg/m(2) and median mastectomy weight was 298.0 g (range: 40-1164 g). Multivariable analysis showed that neither BMI nor the use of acellular dermal matrix was a predictor for complications. Adjuvant radiation (odds = 3.12, p < 0.001) and mastectomy weight (p < 0.001) were independent risk factors for complications. A 100 g increase in the mastectomy weight was significantly associated with a 23 % increase in the odds of overall complications (p = 0.003), major complications (p = 0.004), and skin flap complications (p = 0.007), as well as a 28 % increase in the odds of seroma (p = 0.044), but was not associated with reconstruction failure. Adjuvant radiation (p < 0.001) and hypertension (p < 0.001) were risk factors for reconstruction failure. Breast size was an independent risk factor for complications in non-obese patients while BMI was not. In the reconstruction of large breasts, greater attention and additional adjunctive procedures would be needed to prevent complications. 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.

Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy

Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

Outcomes of protective lipofilling on post-mastectomy radiotreated patients in immediate expander-implant breast reconstruction

Outcomes of protective lipofilling on post-mastectomy radiotreated patients in immediate expander-implant breast reconstruction

Body mass index as a continuous predictor of outcomes after expander-implant breast reconstruction.

Studies show that obesity is a risk factor for complications after expander/implant breast reconstructions. However, reports vary on the precise threshold of body mass index (BMI) as a predictor of heightened risk. We endeavored to link BMI as a continuous variable to overall complications in a single-surgeon series of expander-implant reconstructions. From 399 patients undergoing expander-implant reconstruction, 551 breasts were stratified to normal weight, overweight, and obese groups for analysis and comparison with previous studies. Logistic regression was performed to predict changes to risk profile per increment of BMI. Complication rates for obese and overweight patients were significantly greater than for normal weight patients, that is, 21.1% and 24.0% versus 10.4%, respectively (P < 0.005). A unit increase in BMI predicted a 5.9% increase in the odds of a complication occurring, and 7.9% increase in the odds of reconstruction ending in failure. By expanding the analysis of BMI to include patients who do not meet the traditional definition of obesity (BMI ≥ 30 kg/m), we demonstrated that simply overweight patients (25 ≤ BMI < 30 kg/m) had an elevated complication rate. Moreover, through regression analysis, we established that BMI as a continuous variable predicts outcomes from expander-based breast reconstruction.

Tracking the aesthetic outcomes of prosthetic breast reconstructions that have complications

Background Aesthetic results following breast reconstruction have been shown to be a major contributor to patient satisfaction. While many presume that complications after reconstruction impact final aesthetic results, little data exist to substantiate this putative relationship. Objective To track and evaluate aesthetic outcomes following implant reconstructions with complications. Methods A chart review was conducted on a series of consecutive expander-implant breast reconstructions performed by the senior author between 2004 and 2012. Included patients completed their prosthetic reconstruction or converted to autologous methods and had a minimum follow-up period of 130 days. Four blinded members of the division of plastic surgery independently rated postoperative anterior photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains: breast mound volume, contour, placement, scarring and inframammary fold. Results Of the 172 patients who met the inclusion criteria, 36 experienced a complication. The tissue expander in one-half of these patients was salvaged and the remaining patients converted to autologous reconstruction. The average aesthetic scores for each domain did not differ significantly between patients who experienced a complication and retained their expander and those who did not experience a complication. Patients who converted to autologous tissue reconstruction after experiencing a complication had the highest aesthetic scores. Discussion The ability to obtain aesthetic results following a complication that were not statistically different from results in those without complications may reflect the surgeon's refined attempt to salvage the initial implant reconstruction; in other circumstances, the improved cosmesis was achieved through conversion to an autologous tissue-based method. Conclusion The present study quantitatively assessed the impact of complications on aesthetic outcomes following implant breast reconstruction. Continuance of prosthetic reconstruction and conversion to autologous reconstruction serve as viable options to obtain adequate aesthetic scores following a complication. Information gained from the present analysis will help manage patient expectations.

Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q

Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2%. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.

Outcome Analysis of Expander/Implant Versus Microsurgical Abdominal Flap Breast Reconstruction: A Critical Study of 254 Cases

Expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are currently the two most frequent breast reconstruction techniques performed in the United States. The aim of this study was to compare outcomes between EIBR and MAFBR in order to help future breast cancer patients to be more knowledgeable and better informed in choosing their optimal reconstruction option. Medical records of 795 patients who underwent breast reconstruction at Stanford Hospital from 2007 to 2011 were reviewed. We found 254 patients to be candidates for both MAFBR and EIBR preoperatively and included them in the study. Patients demographics, postoperative clinic visits, length of hospital stay, postoperative complications, and follow-up time were compared. Logistic regression analysis was used to determine risk factors for major complications. MAFBR patients had 8.7 clinic visits postoperatively, while 14.6 visits were needed for EIBR patients. Length of hospital stay was 4.8±1.32days for MAFBR and 2.1±0.9days for EIBR. Complication occurred in 21.3% of MAFBR versus 37.4% for EIBR patients. Follow-up duration was 24.7±17.2months for EIBR and 30.1±18.5months for MAFBR. On multivariate analysis, EIBR and a body mass index of ≥30kg/m(2) were the only significant predictors of major complication. For patients eligible for both options, MAFBR has a lower incidence of major complications and fewer postoperative visits, but it has a longer initial hospital stay compared to EIBR. Patients should be informed of not only short-term but also long-term possible risks and benefits in order to make an informed decision.