Implant-based Breast Research Articles

A Novel Internal Negative Pressure Delivery System in Prepectoral Breast Reconstruction-Preliminary Experience.

Background:Seroma remains a common complication after breast surgery, despite meticulous surgical technique to obliterate dead space and use of standard postsurgical drains for fluid evacuation. Therefore, novel approaches are needed. The Interi System is an internal, negative-pressure delivery system consisting of a manifold that is a silicone tubing with a central trunk and three peel-apart channeled branches connected to an external therapy unit, which simultaneously delivers continuous negative pressure of 125 mm Hg and removes excess fluid from internal tissue planes. This retrospective study evaluated the safety and effectiveness of Interi compared with standard drains in consecutive patients undergoing immediate, prepectoral, acellular dermal matrix-assisted, and implant-based breast reconstruction.Methods:Patient records were reviewed, and data on demographics, mastectomy, and reconstructive variables, postoperative complications, fluid output volume, and manifold/drain duration were retrieved and compared between the two groups.Results:Interi was used in 23 patients (38 breasts) and standard drains in 23 patients (39 breasts). Patients in both groups were well matched in all demographic, reconstructive, and mastectomy variables. Interi duration was significantly shorter than drains (16.7 versus 19.7 days; P = 0.020). There were no instances of seroma formation after removal of the manifold, edematous flap, or reconstructive failure with Interi. Seroma rate was 20.5% after drain removal (P = 0.005). All other complications were similar between the two groups.Conclusion:Interi effectively removed excess fluid from internal tissue compartments in prepectoral breast reconstruction and may offer significant improvement over current standards of care for seroma prevention in this procedure.

Commentary on “Implant-based multiplane breast augmentation—a personal surgical concept for dynamic implant-tissue interaction providing sustainable shape stability” by Vogt PM, Mackowski MS & Dastagir K

Commentary on “Implant-based multiplane breast augmentation—a personal surgical concept for dynamic implant-tissue interaction providing sustainable shape stability” by Vogt PM, Mackowski MS & Dastagir K

21. Prepectoral versus subpectoral implant-based immediate breast reconstruction: Medium-term outcome comparison from 1022 cases

21. Prepectoral versus subpectoral implant-based immediate breast reconstruction: Medium-term outcome comparison from 1022 cases

Implant-based multiplane breast augmentation\u2014a personal surgical concept for dynamic implant\u2013tissue interaction providing sustainable shape stability

BackgroundThe aesthetic long-term stability in shape, symmetry, and natural appearance of an aesthetically augmented breast remains a constant challenge. It has become clear that the results depend strongly on the technique applied and the experience of the surgeon. An ongoing controversy concerns the positioning of the implants. Subglandular, submuscular, partial submuscular, and subfascial pockets have different tradeoffs and advantages. However, secondary deformity, unnatural feel, and appearance are not addressed uniformly. The aim of the following study was to establish a standard procedure allowing for the desired and reproducible results to provide long-term stability and aesthetic quality.MethodsThe authors have developed a standardized dissection of a dynamic implant pocket. In this approach, a submuscular dissection with lower and medial release of the pectoralis muscle is combined with a wide subfascial release of the breast gland and a scoring of the deep plane of the superficial glandular fascia. In the final step, the deep layer of the glandular fascia is sutured tightly and firmly to the deep layer of the abdomino-pectoral fascia. A total of 867 patients received a 4D pocket–based breast implant by the authors. A subset of 33 patients was further analyzed for long-term results. Retrospectively, all data were analyzed from the electronic patient information system and files of patients using GraphPad 8. For comparison of multiple experimental groups, one-way ANOVA was performed where indicated.ResultsThe concept not only addresses the biplanar approach of submuscular implant placement (3D) but adds the 4th dimension (4D) of an aesthetically pleasing dynamic shape of the augmented breast providing long-term stability. Measurements—taken at 3 months, and 1, 2, 3, 5, and ≥ 7 years post augmentation—for SN-N, N-IMF, N-ML, and MC-N distances did not show any significant changes over time. In the patient cohort of 867 patients (1734 implants), the overall complication rate was < 5%. Revisions for bleeding were below 0.5%. Shape stability was observed over 7 years in more than 95% of the patients.ConclusionsOur results indicate that our technique of multiplane breast augmentation provides long-term stability and aesthetic quality. It may solve some of the existing tradeoffs of the different methods by combining the benefits of each technique supported by an additional shaping through a controlled deep fasciotomy.Level of evidence: Level IV, therapeutic study.

The Technique of Scarless Latissimus Dorsi in Immediate Breast Reconstruction.

Background: In dealing with the inferior pole coverage of an implant or a tissue expander in the partial submuscular technique, various surgical strategies have been introduced over the years. Among them, ADM and synthetic meshes were intensively studied and performed in order to obtain a good aesthetic result with satisfactory lower pole contouring, create a strong support of the implant and offer flexibility in adapting the volume of a tissue expander to the remaining mastectomy flaps (1,2). However, the viability of the skin from the mastectomy flaps is not always optimal. Vascular impairment and subsequent necrosis can occur at various extent in the mastectomy flaps (3). The necrosis of the mastectomy flaps is unpredictable and sometimes occurs with no obvious cause (4). Implant exposure and extrusion, ADM or mesh exposure are serious complications which can lead to the reconstructive failure. Methods: The scarless latissimus dorsi flap technique was introduced and observed in patients eligible for skin sparing and nipple sparing mastectomy with implant-based submuscular breast reconstruction. The keypoints of the surgical steps are described. Results: The main priorities of the outcome of the reconstructive process were stability and good definition of the lower pole of the reconstructed breast. The good vascularized underlying muscular tissue totally covering the implant increases chances in avoiding exposure or extrusion of the implant. In the advent of partial mastectomy flap necrosis, the healing by secondary intention provided good and stable results. Also, this technique decreases the morbidity and risks related with the change of the patient position during the procedure, improves the aesthetic results, by avoiding additional incisions for harvesting the flap. Conclusions: The scarless latissimus dorsi flap in implant based breast reconstruction is a valuable option for stable results and viable alternative to the use of ADM.

Effects of latissimus dorsi (LD) flap harvest on shoulder function in delayed breast reconstruction. A long-term analysis considering the acromiohumeral interval (AHI), the WOSI, and BREAST-Q questionnaires

The latissimus dorsi (LD) flap is reliable and versatile with many indications and low donor site morbidity. The aim of this study is to evaluate the long-term effects of LD flap on the shoulder function in patients undergoing delayed breast reconstruction. This case-control study enrolled women who underwent implant-based (IB) breast reconstruction, radical lymphadenectomy, and radiotherapy between 2006 and 2016. The study group included 72 women, with a history of severe capsular contracture, who received a secondary LD flap reconstruction. The control group consisted of a matched cohort of 80 patients with IB breast reconstruction. Shoulder function was assessed using the acromiohumeral interval (AHI) measurement in standard X-rays. The validated Western Ontario Shoulder Instability (WOSI) and BREAST-Q questionnaires were used to assess outcomes one year postoperatively and data were analyzed using Fisher's exact test and the Mann-Whitney test. Out of 72 patients from the study group, 40 had valuable pre- and postoperative X-rays to measure the AHI. An AHI reduction was recorded only in 7/40 patients. From the WOSI analysis, no significant differences in shoulder function and back pain between the two groups were registered. BREAST-Q scores in the LD group were higher in most domains, including satisfaction with breasts and psychosocial well-being. However, the Mann-Whitney test showed no significant difference between the two groups (p > 0.05). LD flap, with detachment of its insertions from the humerus, does not seem to have a negative impact on back and shoulder function and is correlated with high patient satisfaction in breast reconstruction following radiotherapy.

Pre-pectoral implant-based immediate breast reconstruction with Braxon Porcine Acellular Dermal Matrix: Is it safe with radiotherapy?

Pre-pectoral implant-based immediate breast reconstruction with Braxon Porcine Acellular Dermal Matrix: Is it safe with radiotherapy?

Abstract P2-13-06: Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction

Abstract Introduction: The innovation of fenestrated allograft (acellular dermal matrix, ADM) has improved patient outcomes in two-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap and has enhanced the efficiency of the reconstructive experience. We present a follow-up study of one- and two-stage breast reconstruction with a more refined, standardized method of surgeon-designed fenestration of ADM. Methods: We conducted a retrospective review of 52 patients (91 breasts) having undergone one- and two-stage breast reconstruction using fenestrated ADM at our institution from 2013 to 2014. Results: Mean intra-operative fill volume (IOFV) measured 402cc (SD=118cc), and IOFV as a percent of tissue expander size averaged 79.1% (SD=16.7%). Ten breasts were expanded to 100% and completed reconstruction in one stage with implant placement. IOFV as a percentage of total fill volume at completion of expansion averaged 73.6% (SD=16.6%). Two-stage reconstruction patients underwent 1.8 post-operative expansions on average (range 0-4) and averaged 81.2cc (SD=29.3cc) per in-office expansion. Days to full expansion averaged 45.1 days, while days to exchange averaged 137.8 days (Table 1). Mean days to exchange between our first 24 breasts to complete reconstruction vs. our last 23 breasts to complete reconstruction differed significantly, with 205 ± 43.8 days vs. 137.7 ± 138.1 days, respectively (p=0.03). Table 1. Fill volume characteristics for 91 breasts after immediate reconstruction with fenestrated ADM. Data on tissue expander size was excluded.CharacteristicMinimumMaximumMeanSDTE size300700512.6108.3Intra-op fill (cc)150650402.1118Intra-op/TE size (%)44.1108.379.116.7Total fill (cc)31082537.6120.3Intra-op/Total fill (%)34.110073.616.6Total fill/TE size (%)76.9141.310813.2# of post-op expansions041.81.1Office fill per expansion (cc)31.322581.229.3Days to full expansion020445.141.8Days to exchange0554142117.9Implant size (cc)335800547.3126.9 The major complication rate requiring re-operation within 30 days post-operatively was 11.0%. Four breasts experienced partial mastectomy flap necrosis requiring re-operation with implant salvage (4.4%). Six breasts (6.6%) underwent explantation due to: infection (three), flap necrosis (two), and patient preference (one) (Table 2). Table 2. Complication rates in 91 breasts after immediate reconstruction with fenestrated ADM.Complicationsn%Minor 30-day complication22.2Major 30-day complication1011.030-Day take back for necrosis with salvage44.430-Day explant66.6Explant due to infection33.2Explant due to necrosis22.2Explant due to patient preference11.1Total 30-day complication1213.2 Conclusion: Our fenestrated technique is demonstrated to increase intra-operative fill volume, decrease number of post-operative expansions and time to full expansion, and improve expansion rate with subjectively less pain. We believe our patients benefited from improved cosmetic outcomes with better shape, maintenance of breast footprint, and enhanced comfort due to the decreased number of intra-office fills and increased intra-operative expansion. Citation Format: Daar DA, Bourgeois JM, Mowlds DS, Wirth GA, Paydar KZ. Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-06.

Comparison of immediate postoperative pain in implant-based breast reconstructions

Implant-based techniques represent the most common form of breast reconstruction. However, substantial postoperative pain has been associated with implant-based breast reconstruction. The objective of this study is to evaluate immediate postoperative pain in implant-based breast reconstruction. We reviewed 378 patients who underwent implant-based reconstruction between January 2004 and December 2012. Each patient's visual analog scale (VAS) score, pain medication, and patient-controlled analgesia (PCA) attempts were used to assess in-hospital postoperative pain. We evaluated timing of reconstruction post mastectomy, tissue expander (TE) designed fill volume, TE initial fill volume, and single-stage immediate implant (II) versus TE reconstruction. No significant differences in pain parameters were noted between the immediate and delayed postmastectomy reconstruction cohorts. TEs with larger (>300cc) designed volumes required significantly more narcotic use (p=0.02) and PCA attempts (p<0.01). Narcotic use was higher in the larger (>250-cc) TE initial fill group starting on postoperative day 2, but overall differences in VAS score and PCA attempts were not significant. Morphine equivalence (p<0.01) and non-opioid oral analgesic use (average p=0.03) of the TE cohort were significantly higher than those of the II cohort. Patients undergoing TE-based implant reconstruction show greater analgesic use than those with single-stage II-based reconstruction. This may indicate a higher immediate postoperative pain in TE procedures than in II procedures. Furthermore, higher initial fill and designed volume of TE require more morphine equivalence postoperatively. These findings may warrant further preoperative discussion for better pain management and patientsatisfaction.

P308 Comparison of implant-based immediate breast reconstruction with and without vicryl mesh

P308 Comparison of implant-based immediate breast reconstruction with and without vicryl mesh

O-74 Comparison of the incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gy in 15 fractions

O-74 Comparison of the incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gy in 15 fractions

Comparison of Resource Costs Between Implant-Based and TRAM Flap Breast Reconstruction

Resource costs, as measured by hours of time in the operating room, days of stay in the hospital, and other costs of care, were evaluated for 240 patients who underwent mastectomy with immediate breast reconstruction using either TRAM flaps or breast implants at The University of Texas M. D. Anderson Cancer Center. To make costs comparable, only patients who completed reconstruction of the nipple were included. As expected, the initial resource costs of implant-based reconstruction were much lower than those of TRAM flap reconstruction. After correcting for patients whose reconstructions were unsuccessful and including the costs of surgery subsequent to the initial reconstruction, however, the cost advantage of implant-based reconstruction disappeared. If current trends continue, it is likely that with increased follow-up, the long-term resource costs of implant-based reconstructions will continue to increase, while those of autogenous tissue reconstructions will not. Autogenous breast reconstruction with the TRAM flap therefore appears to be more cost-effective, in terms of time as well as dollars, in the long run than reconstruction based on prosthetic implants.