Implant-based Breast Reconstruction Research Articles

Dose the Omission of Cefazolin in Irrigation Solution Affect Outcomes in Prepectoral Direct-to-Implant Breast Reconstruction?

The widely used triple-antibiotics irrigation solution, comprising cefazolin, gentamycin, and povidone-iodine solution, has been employed for preventing infection and capsular contracture in implant-based breast reconstruction. However, potential overlapping in the coverage of such antimicrobial effects and the recent emergence of cefazolin-resistant gram-positive bacteria has prompted concerns regarding the efficacy of routine use of cefazolin in irrigation solutions. This study aims to evaluate clinical safety of omitting cefazolin from the traditional triple-antibiotic irrigation solution. Patients who underwent immediate prepectoral direct-to-implant breast reconstruction between September 2020 and April 2022 were reviewed. They were divided into two groups: cases using the traditional triple-antibiotics for the former third and those using dual-antibiotics (omitting cefazolin) for the latter. Development of postoperative complications were compared by the type of irrigation solution and its independent associations with the adverse outcomes were evaluated. In total, 445 cases (126 using triple- and 319 using dual-regimen solution) were analyzed with a mean follow-up period of 12months. The two groups had generally similar baseline characteristics. Overall complications developed in 126 cases (28.3%), including 12 (2.7%) of infection and 32 (7.2%) of capsular contracture. The complication profiles did not differ between the groups. Multivariable analyses exhibited that the type of irrigation solution was not associated with the development of overall and any kind of complication including infection and capsular contracture. Omission of cefazolin from the irrigation solution may not elevate the risks of infection and capsular contracture in prepectoral direct-to-implant reconstruction. Further long-term studies would be warranted. 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 .

Streamlining outpatient prepectoral breast reconstruction: The role of polyurethane oxygen-enriched bra cups from pandemic innovation to standardized cost analysis

Background: The COVID-19 pandemic necessitated a reassessment of healthcare delivery, emphasizing on strategies to reduce hospital visits without compromising patient care. In response, plastic surgery units explored innovative approaches to ensure high-quality care and enhanced protection for vulnerable groups, such as oncologic patients undergoing mastectomy and breast reconstruction. This study evaluates the implementation of a polyurethane-polyester bra cup enriched with oxygen to diminish the need for postoperative outpatient visits. Methods: Patients who underwent mastectomy and prepectoral breast reconstruction between February 2020 and March 2021 were selected. A novel postoperative management protocol with a polyurethane-polyester bra cup was adopted, and a cost-benefit analysis evaluated the economic impact of integrating this medical device into postoperative care. Results: The polyurethane-polyester bra cup wound dressing significantly reduced the frequency of outpatient visits, enhancing patient autonomy in postoperative care. Patients reported high satisfaction levels, particularly appreciating the ability to manage the device independently, which contributed to the substantial reduction of hospital accesses. Economic analysis revealed that the devices’ utilized resulted in a notable reduction of 333.5 working hours, translating to a financial saving, ranging between €9990 and €40,020 for nursing and medical staff, respectively. The device cost was established at €20 per unit, demonstrating an effective cost-saving strategy in postoperative care. Conclusions: The adoption of polyurethane-polyester bra cup in postsurgical care for mastectomy patients undergoing implant-based prepectoral breast reconstruction proved to be a strategic measure in reducing hospital visits and maintaining high levels of patient satisfaction.

Oncoplastic Surgery with Volume Replacement versus Mastectomy with Implant-Based Breast Reconstruction: Early Post-operative Complications in Patients with Breast Cancer.

Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-days post-operative complications between these two techniques. We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications. A cohort of 8,403 breast cancer patients was analyzed. 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years (p<0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, p<0.001), exhibited a higher BMI (31.73 vs. 26.93, p<0.001), had a greater prevalence of diabetes mellitus (11.0% vs. 5.0%, p<0.001). They also had a higher ASA classification (2.33 vs. 2.15, p<0.001), shorter operative time (173.39 vs. 216.20 min, p<0.001), and a higher proportion of outpatient procedures (83.7% vs 39.5%, p<0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients, (4.2% vs. 10.9%, p<0.001), including lower rates of surgical complications (2.2% vs 8.0%, p<0.001) and wound complications (1.9% vs. 4.8%, p=0.005) compared to MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications. OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared to MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.

Managing Asymmetry in Breast Reconstruction After Mastectomy—A Systematic Review and Highlight of Clinical Pearls

Background/Objectives: As breast reconstruction techniques continue to progress, patient satisfaction with aesthetic outcomes has become an increasingly important marker of success. Obtaining optimal symmetry often requires secondary procedures whether reconstruction is unilateral or bilateral, implant-based or autologous, immediate or delayed. Consequently, determining the ideal method to achieve symmetry, particularly in challenging scenarios, such as the radiated breast, is nuanced and requires experienced decision-making. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines, including the PubMed, Cochrane Library, and Embase bibliographic databases, to identify original articles addressing asymmetry in both implant-based and autologous breast reconstruction. Studies based on benign breast disease or oncoplastic reconstruction for partial mastectomy/lumpectomy defects were excluded. Results: The search initially yielded a total of six hundred and fifty unique articles. After complete assessment of inclusion and exclusion criteria, a total of forty-one articles were included in total. Conclusions: This article provides a systematic review of the current literature available to guide surgeons on managing asymmetry in breast reconstruction and highlights case examples of frequently encountered clinical challenges. A novel treatment algorithm was then generated to serve as a comprehensive decision-making guide for both patients and surgeons.

Performance of Artificial Intelligence Chatbots in Answering Clinical Questions on Japanese Practical Guidelines for Implant-based Breast Reconstruction.

Artificial intelligence (AI) chatbots, including ChatGPT-4 (GPT-4) and Grok-1 (Grok), have been shown to be potentially useful in several medical fields, but have not been examined in plastic and aesthetic surgery. The aim of this study is to evaluate the responses of these AI chatbots for clinical questions (CQs) related to the guidelines for implant-based breast reconstruction (IBBR) published by the Japan Society of Plastic and Reconstructive Surgery (JSPRS) in 2021. CQs in the JSPRS guidelines were used as question sources. Responses from two AI chatbots, GPT-4 and Grok, were evaluated for accuracy, informativeness, and readability by five Japanese Board-certified breast reconstruction specialists and five Japanese clinical fellows of plastic surgery. GPT-4 outperformed Grok significantly in terms of accuracy (p < 0.001), informativeness (p < 0.001), and readability (p < 0.001) when evaluated by plastic surgery fellows. Compared to the original guidelines, Grok scored significantly lower in all three areas (all p < 0.001). The accuracy of GPT-4 was rated to be significantly higher based on scores given by plastic surgery fellows compared to those of breast reconstruction specialists (p = 0.012), whereas there was no significant difference between these scores for Grok. The study suggests that GPT-4 has the potential to assist in interpreting and applying clinical guidelines for IBBR but importantly there is still a risk that AI chatbots can misinform. Further studies are needed to understand the broader role of current and future AI chatbots in breast reconstruction surgery. 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

The protocol for BROWSE-P (breast reconstruction outcomes with Strattice™ or Artia™ – pre-pectoral): a cohort study to assess long-term outcomes of immediate pre-pectoral implant based breast reconstruction with Strattice™ or Artia™

Introduction: Techniques in implant-based breast reconstruction (IBBR) have evolved over the last 15 years due to the introduction of mesh or acellular dermal matrices (ADMs). Traditionally, total submuscular coverage progressed to upper pole muscle cover with lower pole ADM and now total or anterior ADM cover in the pre-pectoral plane. Data is scarce to support the pre-pectoral technique but, it is suggested to result in less postoperative pain, more natural cosmesis and avoidance of animation deformity. The BROWSE study concluded that subpectoral with Strattice™ IBBR resulted in better cosmesis and lower rates of capsular contracture when compared to the total submuscular technique. The BROWSE-P study aims to assess the safety profile of Artia™ a porcine derived ADM and review the long-term outcomes of pre-pectoral IBBR with Strattice™ and Artia™. Methods and analysis: BROWSE-P is a single center cohort study. Consecutive patients who have undergone immediate pre-pectoral IBBR with Strattice™ or Artia™ from January 2017 to December 2022 will be included. Demographic, operative, oncology, complication, and further surgery data with be collected to assess the rate of revision surgery and safety profile of Artia™. Those who have their implant reconstruction in situ will be invited for clinical assessment to assess for capsular contracture. Participants will also be asked to complete a BREAST-Q post-reconstruction module, to assess patient satisfaction and quality of life, and have medical photographs taken for an assessment of aesthetic outcome by a blinded panel using the 10-point Visser scale. We aim to collect data on 500 reconstructions and complete clinical assessment, patient reported outcomes and aesthetic assessment for 250 patients.

Comparative analysis of comorbidity indexes in implant-based breast reconstruction

Recent studies have used comorbidity indexes to stratify postsurgical complication risk across multiple surgical fields, including plastic surgery. However, such studies are lacking in implant-based breast reconstruction (IBBR). Understanding how comorbidity scores affect postsurgical outcomes in IBBR can help identify patients who may require additional medical surveillance after surgery. We conducted a retrospective analysis of adult female patients who underwent IBBR between January 2017 and December 2022 using the Merative™ Marketscan® Research Databases. ICD-10 diagnosis codes were used to calculate patients' scores on four different comorbidity indexes. Chi-squared tests were performed for demographic analysis, and multivariable logistic regression controlling for demographic and surgical variables, was conducted to determine associations between comorbidity indexes and adverse outcomes. Among 16,287 IBBR patients, 3145 (19.3%) experienced a complication within 90 days. On regression analysis, the Modified Frailty Index 5-Item (mFI-5) demonstrated the strongest associations with complications (odds ratio=1.25 [1.18, 1.32]), compared to the Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Modified Frailty Index 11-Item. Further regression analysis revealed that four out of the five mFI-5 comorbidities were independent risk factors for postsurgical complications. This study highlights important associations between comorbidity indexes and adverse postoperative outcomes in IBBR. mFI-5 demonstrated superior performance in postoperative risk stratification compared to the other indexes analyzed. These findings suggest that using mFI-5 in clinical settings may help identify high comorbidity patients who may benefit from additional monitoring and prophylactic measures. Further research is needed to understand how to mitigate the increased postoperative complication risk in these patients.

Red Breast Syndrome—Where Has It Gone?

Background Red breast syndrome (RBS) has been noted in past literature as a possible complication of implant-based breast reconstruction (IBBR) with the use of acellular dermal matrices (ADMs). Since its first appearance in 2009, RBS has drawn growing medical attention with reported incidence ranging from 7%–9%. There has been a noted decrease in the emergence of RBS despite its inclusion among the analyzed complications in a number of studies. This systematic review aims to evaluate the trend in reported RBS incidence over time and appropriately determine an accurate incidence of RBS from reported literature since the emergence of the phenomena. Methods A systematic literature review was performed in July 2023 that analyzed the incidence of RBS among retrospective cohort studies on complication rates of IBBR with ADM. Patient demographics, RBS incidence rates, and all-cause complications were captured. The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and Methodological Index for Nonrandomized Studies criteria was used to assess study quality. Results From 2009 to 2023, a total of 48 studies (n = 6251) met inclusion criteria of which 35 studies from 2017 to 2023 were not already included in a prior systematic review (n = 5246). The mean incidence of RBS in the unreported studies was 2.88% with a weighted mean of 3.22%. Analysis of the trend in RBS over time shows an increasing reported incidence rate from 2009 with a peak in incidence between 2016 and 2017, followed by a steady decline through 2022. Twenty-six of the studies were published from 2016 to 2019. Conclusions The incidence of RBS among prior studies and systematic reviews has fluctuated significantly since its initial emergence in 2009. Reported incidence rates have been on the decline since 2018 with a true weighted incidence of 3.22% from analysis of recent reported studies. Potential causes for the decline in incidence include practice changes in ADM preparation, changes in the ADM brand used for IBBR, and improved categorization of RBS compared to cellulitis/infection. Despite more robust criteria for diagnosis, no consensus for management has yet been established.

Real-world data of perioperative complications in prepectoral implant-based breast reconstruction: a prospective cohort study.

To analyze complications and potential risk factors associated with immediate prepectoral direct-to-implant breast reconstruction (DTIBR). 295 patients (326 operated breasts) with DTIBR between March 2021 and December 2023 were included in this prospective study. Postoperative complications (postoperative bleeding, seroma, infection, necrosis, wound dehiscence, implant exchange/loss) were analyzed for potential risk factors by descriptive and logistic regression analyses. The implant was covered by TiLOOP® Bra Pocket in 227 breasts (69.6%), by "dual-plane" technique in 20 breasts (6.1%), by acellular dermal matrix (ADM) in 1 breast (0.3%). No additional support was used for 78 breasts (23.9%). The use of mesh did not increase the risk for complications. Major complications requiring surgical revision occurred due to postoperative bleeding in 22 (6.7%), seroma in 2 (0.6%), infection in 13 (4.0%), necrosis in 10 (3.1%), and wound dehiscence in 10 (3.1%) breasts. Thirteen (4.0%) implants were exchanged, and 5 (1.5%) were explanted without substitution. One patient had to switch to autologous reconstruction due to skin necrosis. The main reasons for the removal/exchange of implants were infections (11 breasts, 3.4%) and necrosis (4 breasts, 1.2%). The risk for necrosis, infection, and wound dehiscence was mainly associated with the type of incision, especially skin-reducing incisions, and body mass index (BMI) ≥ 30kg/m2. Severe complications occurred primarily in patients with a BMI ≥ 30kg/m2 and when skin-reducing surgical techniques were performed. This study was retrospectively registered at the German Clinical Trials Register (DRKS) on 20.06.2024. DRKS00034493. https://drks.de/search/de/trial/DRKS00034493 .

“The Use of Cortiva® Allograft Dermis in Two-Staged Breast Reconstruction: A Matched-Comparison and Cost Analyses Study”

BackgroundAcellular Dermal Matrices (ADM) are an adjunct in implant-based breast reconstruction. While clinical outcomes have generally been equivocal between brands, a cost analysis between brands has not been completed. This study reports a single, academic institution’s experience with two ADM brands in breast reconstruction and provides data on clinical and financial outcomes. MethodsA retrospective chart review of patients who underwent two staged breast reconstruction with Cortiva® Allograft Dermis ® were matched with a cohort who received AlloDerm RTU. Comparison of clinical outcomes, such as complications and revision surgeries, in addition to a cost analysis was completed. ResultsThe study cohort included 24 patients who received Cortiva® and 24 patients who received AlloDerm. There were no statistical differences between the cohorts in demographics or breast specific characteristics. Major complications were not statistically increased [HR 1.78 (0.421-7.66)] with Cortiva® use, but the rate of revision following second stage reconstruction trended towards significance with Cortiva® use [3.41 (0.99 – 11.80), p = 0.05]. The material base cost and total cost following surgeries were lower for Cortiva® (44% of the AlloDerm costs) but the incremental costs did not display significant difference secondary to comparable complication and revision rates. ConclusionsThe use of Cortiva® Allograft Dermis was shown to have a decreased cost in base material and total cost associated with surgery while also displaying comparable clinical outcomes and complication rate. Additional studies examining patient reported outcomes would complement the growing literature comparing ADM brands.

Decellularized porcine dermal hydrogel enhances implant-based wound healing in the setting of irradiation

Acellular Dermal Matrix (ADM) provides mechanical and soft tissue support in implant-based breast reconstruction, and has shown to modulate the healing response. However, skin flap necrosis, edema, and previous radiation therapy can hinder ADM integration. Effective biomaterial integration requires regulating the immune response, fibrosis, and adipocyte-driven functionalization. Extracellular matrix (ECM) hydrogels have demonstrated utility in tissue regeneration, and decreasing inflammation and fibrosis in various tissues. Therefore, we hypothesized that a Decellularized Porcine Dermal (DPD) hydrogel to support ADM integration would prevent excessive fibrosis, regulate the macrophage response, and promote adipogenesis. Exploration of DPD hydrogel during ADM implantation in mice (healthy and radiated) revealed long-term effects of irradiation on implant wound healing. DPD hydrogel rescued radiation-induced fibrosis, restoring capsule thickness of healthy mice, and did not increase the fibroblast migration into the ADM. As a modulating soft tissue filler, DPD hydrogel also promoted adipocyte infiltration in healthy and irradiated mice. Detailed macrophage analysis showed that radiation led to the increase in pro-inflammatory, transition, and reparative markers. Despite relatively subtle effects on individual macrophage phenotype markers, multidimensional flow cytometry analysis revealed that DPD hydrogel temporally regulated two subpopulations. he presence of DPD resulted in significantly reduced CD9HiArg1HiCD301bLo and CD163HiCD38HiCD301bHi macrophages in healthy mice at one week, and a significant increase in CD9High macrophages with low expression of other markers at 6 weeks in irradiated mice. DPD hydrogel promotes a decreased fibrotic, and adipocyte-promoting coordination of wound healing in healthy and irradiated wound beds while not disrupting the immunomodulatory effects of ADM. Statement of significanceAcellular Dermal Matrix (ADM) provides mechanical and soft tissue support in post-mastectomy implant-based breast reconstruction, and positively affects wound healing. Following breast reconstruction, skin flap necrosis, edema, and previous radiation therapy can hinder ADM integration. Effective wound healing and biomaterial integration requires regulating the cellular immune response. Extracellular matrix hydrogels have demonstrated utility in tissue regeneration and decreasing inflammation and fibrosis in various tissues, but has yet to be utilized in the setting of breast reconstruction. Here, we demonstrated that a decellularized dermal hydrogel as an adjunct to ADM, decreases fibrosis and promotes adipogenesis during the coordination of wound healing in healthy and clinically relevant microenvironments that have received radiation therapy while not disrupting the immunomodulatory effects of implanted ADM.

The Impact of Complication Timing on the Outcomes of Implant-based Breast Reconstruction.

The National Surgical Quality Improvement Program (NSQIP) database provides an important resource for determining complication rates and risk factors for surgical procedures. However, NSQIP is limited to 30-day follow-up, and it is unclear whether this is reliable for evaluating prosthetic breast reconstruction outcomes. A single-institution, cross-sectional, retrospective review was performed for patients undergoing mastectomy with immediate, prepectoral tissue expander reconstruction. Timing of complications was stratified as early (within 30 days of operation) versus late (after 30 days). Categorical variables were compared using χ2 (or Fisher exact) tests, and continuous variables were analyzed using Kruskal-Wallis or Wilcoxon rank-sum tests. There were 301 patients (509 reconstructed breasts) included with a median follow-up time of 11 months. Of them, 176 patients (58%) experienced a postoperative complication-140 patients (47%) experienced an early complication and 36 patients (12%) experienced a late complication. Patients with late complications had a significantly higher rate of reconstructive failure compared with the early complication group (17% versus 10%; P = 0.001) and were more likely to require a flap (28% versus 7%; P = 0.001) for final reconstruction. Revision surgery rates after final implant placement were higher in the late complication group (36% versus 64%; P = 0.285). Late complications after prepectoral breast reconstruction have a more prominent impact on reconstructive failure and revisions than early complications. This finding may inform strategies to revise national databases such as NSQIP to include more detailed information and longer capture periods.

Perioperative antibiotic prophylaxis in implant breast reconstruction

Implant infection is the most common and serious complication in implant-based breast reconstruction. To prevent infection, many surgeons have adopted a perioperative antibiotic prophylaxis regimen for managing patients. However, there has been considerable debate regarding the duration of antibiotic prophylaxis. After reading this article, plastic surgeons should manage their patients with an understanding of the evidence supporting perioperative antibiotic prophylaxis.

Breast implant illness in women with implant-based reconstruction after breast cancer

Abstract Background This study investigated the association between silicone breast implants and health symptoms (Breast Implant Illness (BII)) in women with implant-based breast reconstruction after breast cancer. While there is increasing evidence of an association with BII in cosmetic breast augmentation cases, for women with implant-based breast reconstruction this is unknown. Methods Retrospective cohort study of 254 women who underwent implant-based reconstruction after breast cancer and a control group of 487 women who underwent breast-conserving therapy or simple mastectomy. We linked Dutch Breast Implant Registry data (2015-2019) and general practice electronic health records data (2014-2022) to study the occurrence of thirteen BII-related health symptoms in general practice and the number of consultations for these symptoms one year before to three years after breast surgery. Results Over the three years following implantation, no significant differences in symptom occurrence were observed compared to both the year before implantation and the control group. Women with breast implants did not have more consultations compared to the control group during follow-up. However, there was an increased likelihood of multiple consultations in the first and second years post-implantation compared to before implantation (≥3 consultations first year OR = 2.10, p = 0.005; second year OR = 1.70, p = 0.048; ≥5 consultations first year OR = 2.57, p = 0.02). Conclusions This study found no evidence for BII in women with implant-based reconstruction after breast cancer. Despite certain limitations in examining BII in this specific patient group, these findings add valuable information to the decision-making process of breast cancer patients considering reconstructive options. Key messages • This is the first study on BII that focused solely on women with breast implants for reconstruction after breast cancer. • No evidence of BII was found in this patient group.

Predictors of 30-day Hospital Readmission after Autologous vs. Implant-based Breast Reconstruction: A 16-year Analysis of 175,474 Patients

Predictors of 30-day Hospital Readmission after Autologous vs. Implant-based Breast Reconstruction: A 16-year Analysis of 175,474 Patients

Race and Ethnicity Impacts Patient-Reported Outcomes in Implant-Based Breast Reconstruction.

Addressing social determinants of health is critical in achieving health equity, and of the many determinants, race and ethnicity are key contributors in postmastectomy breast reconstruction. The purpose of this study was to investigate the impact of race and ethnicity on patient-reported outcomes (PROs) after implant-based breast reconstruction (IBBR) and to provide reference values for each cohort. We identified all patients who underwent IBBR between January 2017 and August 2022 and completed the BREAST-Q longitudinally. Race and ethnicity were self-categorized as White, Asian, Black, or Hispanic. Reference values were established. Outcomes of interest were BREAST-Q scores preoperatively, and 6months, 1year, and 2years postoperatively. Generalized estimating equation (GEE) modeling was performed to assess race and ethnicity as independent predictors of BREAST-Q scores. Overall, 3281 patients were included, of whom 2479 (75.6%) were White, 296 (9.0%) were Asian, 239 (7.3%) were Black, and 267 (8.1%) were Hispanic. There were significant differences in Physical Well-being of the Chest at all timepoints; Satisfaction with Breasts and Psychosocial Well-being at preoperative, 6months, and 1year; and in Sexual Well-being at 1year. GEE modeling showed that relative to White patients, Asian subjects scored significantly lower on all BREAST-Q domains, while Black and Hispanic patients scored significantly lower on the Physical Well-being of the Chest domain. Racial and ethnic disparities persist within IBBR, with minority patients scoring lower on the BREAST-Q than White patients. This study suggests that more work is needed to understand and improve these PROs in minority patient populations. Individualized reference values may prove beneficial in assessing outcomes over time.

Revision Surgeries After Proton vs Photon Postmastectomy Radiation Therapy in Prepectoral Implant-Based Breast Reconstruction.

Postmastectomy radiation therapy (PMRT) improves disease-free survival in breast cancer but reduces aesthetic satisfaction. Proton PMRT has gained popularity due to fewer systemic complications. There is a lack of data regarding revision surgeries for pre-pectoral implant-based breast reconstruction (PP-IBBR) following radiation. To compare the revision surgeries in PP-IBBR with photon versus proton PMRT. A single-institution retrospective cohort study included breast cancer patients undergoing mastectomy and PP-IBBR with PMRT (January 2020-October 2022) The mean follow-up duration for the cohort was 1056.4 days (2.89 years). Revision surgeries evaluated were fat grafting, conversion to autologous flaps, implant replacement, implant removal, capsulectomy, and scar revision. 116 PP-IBBR were divided into two cohorts: photon (75, 64.66%) and proton (41, 35.34%) radiation cohorts. Overall corrective surgeries were higher with photon (27.5% overall; 32.4% photon vs 19.5% proton, p=0.132). The odds of any revision surgery were nearly double with photon (OR=1.98), and the conversion to an autologous flap was significantly more likely with photon (OR=4.55, p=0.025). Multivariable analysis showed an increased tendency for photon therapy patients to require any revision surgeries (OR=1.62, p=0.359), autologous flaps (OR=5.97, p=0.049), fat grafting (OR=1.52, p=0.664) and scar revision (OR=4.51, p=0.273). Compared to proton therapy, traditional photon therapy has a higher conversion rate to autologous flaps with PP-IBBR. Photon therapy had higher rates of overall revision surgeries, however not statistically significant. Proton therapy is safer, with fewer revision surgeries, warranting larger studies and broader utilization.

Outcomes of ADM-Assisted Implant-based Breast Reconstructions According to Division Types of the Pectoralis Major Muscle.

In implant-based breast reconstruction (IBR), several surgical techniques are based on the implant insertion planes. Ideal location for breast implants has become a popular topic in IBRs because each technique has advantages and disadvantages. Herein, we report the outcomes of three different division types of the pectoralis muscle and suggest an algorithm for selecting the division types. Charts of patients who underwent IBRs between October 2017 and December 2020 were retrospectively reviewed. The patients were classified into three groups (prepectoral, high subpectoral, and subpectoral) according to the division types of the pectoralis muscle. Aesthetic outcomes were assessed in terms of animation deformity, rippling deformity, and visibility of the upper implant border. Total 104 cases were included. 25, 38, and 41 were in the prepectoral, high-subpectoral, subpectoral IBR groups, respectively. Animation deformities frequently appeared in the subpectoral group. Nipple displacement was most prominent in the subpectoral group. Skin rippling at rest was mostly detected in the prepectoral group, whereas ripping during contraction was commonly observed in the subpectoral group. Visibility of upper border was more prominent in the prepectoral group than the other groups. We propose an algorithm for selecting the division types of the pectoralis muscle. If the pectoralis muscle is thick, prepectoral plane is most preferred to avoid the animation deformity. In cases with thin pectoralis muscle, thickness of the mastectomy flap is considered next. If it is thicker than 1cm, prepectoral plane is better than the subpectoral plane; otherwise, high-subpectoral plane is preferable for better aesthetic outcomes. 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.

Management of the Infected Tissue Expander.

Tissue expander (TE) infection is a critical postoperative complication in two-stage implant-based breast reconstruction (IBBR). We assessed risk factors associated with TE infection and reconstructive loss and examined reconstructive salvage rates. We retrospectively reviewed patients who underwent IBBR with TE placement from 2017 to 2022. Included were patients with TE infection treated with admission and IV antibiotics, interventional radiology (IR) drainage, and/or operative management (washout with or without TE removal and TE replacement, TE removal and replacement with implant, and/or TE removal without replacement). Reconstructive success was defined as maintenance of breast reconstruction for 1 year after TE placement. Of 4,498 patients who underwent IBBR, 305 (338 TEs) met the inclusion criteria. Cox modeling showed higher body mass index, hypertension, radiation, bilateral TEs, acellular dermal matrix use, increasing mastectomy weight, and nipple sparing mastectomy were associated with increased hazard of TE infection. Patients with TE infection had a 54% reconstructive failure rate within 1 year; Cox modeling showed Black race and gram-negative cultures were associated with increased hazard of reconstructive failure within 1 year. Patients who underwent TE replacement with an implant had the most favorable success rate following infection. Overall, 46% of patients admitted with a periprosthetic infection had successful salvage. Patients with TE infection should be started on IV antibiotics with a low threshold for operative intervention based on exam and culture data. While IR can guide operative intervention of periprosthetic infections, our practice has shifted away from IR drainage towards definitive operative management.

Microbiology of periprosthetic infections following implant-based breast reconstruction surgery: a multicentric retrospective study.

Implant-based breast reconstruction (IBR) is the predominant breast reconstruction technique post-mastectomy, with bacterial infections being a significant complication affecting patient recovery and quality of life. The following study aimed to determine the microbiological features of the causative agents responsible for breast implant infections, with more attention paid to the comparative analysis of Gram-positive and Gram-negative bacteria and their presentation. We conducted a retrospective analysis of 214 patients who presented with periprosthetic infection and underwent implant removal following implant-based breast reconstruction at Humanitas Research Hospital and Istituto Europeo di Oncologia between January 2018 and March 2024. The study revealed that Gram-positive bacteria were more prevalent, with Staphylococcus species, particularly Staphylococcus aureus, being the most isolated pathogen in both institutions (∼39.96%). In contrast, Gram-negative bacteria were less frequent, with a higher proportion of these pathogens being multi-resistant strains. A significant difference was observed (p = 0.007), indicating that individuals with normal BMI have a higher prevalence of Gram-positive infections (88.46%), whereas obese and overweight patients had higher proportions of Gram-negative infections (23.53% and 28.89%, respectively). In addition, smoking status was also significantly associated with pathogen distribution (p = 0.032), with active and past smokers being related to higher percentages of polymicrobial infections. Furthermore, positive prophylactic MSSA/MRSA swabs were significantly more associated with Staphylococcus aureus infections compared to those with negative results (p = <0.001). Gram-positive bacteria, especially Staphylococcus species, dominate the microbiological landscape of implant-based breast reconstruction (IBR) infections. Our findings provide insights into this critical issue, facilitating a more precise choice of empiric antibiotic treatment and prevention strategies. This analysis underscores the necessity for prophylactic protocols and therapeutic approaches tailored to the predominant bacterial groups. Further research is needed to explore long-term trends and resistance mechanisms to improve patient management.