Patients Undergoing Reduction Mammoplasty Research Articles

Efficacy of Serratus Posterior Superior Intercostal Plane Block on Postoperative Pain and Total Analgesic Consumption in Patients Undergoing Reduction Mammoplasty Surgery: An Evidence Based Report.

Serratus posterior superior intercostal plane block (SPSIPB) is a novel technique that provides analgesia in shoulder, hemithorax and in the back of the neck. In this study, the efficacy of this block on postoperative pain and quality of recovery is reported in ten consecutive patients who had undergone reduction mammoplasty. Blocks were performed bilaterally with 30 ml 0.25 % bupivacaine for each side, at the end of surgery. Cumulative tramadol consumption and numerical rating scale (NRS) scores during rest (static) and coughing (dynamic) were assessed within the first postoperative 24 hours. Mean total tramadol consumption was 39 ±9.94 mg. NRS scores above 4 were observed in 5 patients in the dynamic NRS assessment at the postoperative 1st hour, while static and dynamic NRS scores were ≤4 at other durations. SPSIPB may play a part in postoperative multimodal analgesia following mammoplasty in the future and may reduce total analgesic consumption. Key Words: Serratus posterior superior intercostal plane block, Reduction mammoplasty, Breast surgery, Postoperative analgesia.

Evaluation of nipple vascularity using superb microvascular imaging in patients with reduction mammoplasty.

We aimed to investigate the effect of the chosen pedicle on nipple vascularity by evaluating changes in the microvascular circulation of the nipples in patients undergoing reduction mammoplasty through superb microvascular imaging study (SMI). 70 nipples were included in this retrospective study. There were 15 patients (30 nipples) in Group A using the inferior pedicle and 20 patients (40 nipples) in Group B using the superomedial pedicle. The vascular index (VI) of each nipple were evaluated preoperatively and at the third postoperative month using SMI. The mean VI in Group A was 1.25 (0.5-3.6) preoperatively and 1.3 (0.4-3.2) at the third postoperative month (P > .05). The mean VI in Group B was 1.65 (0.7/2.9) preoperatively and 1.15 (0.2/1.9) at the third postoperative month (P < .05). While the VI increased by 11.3% in Group A, it decreased by 30.6% in Group B (P < .001). The changing of the VI was analyzed between comparable groups, and decreasing microvascular circulation of the nipple with use of the superomedial pedicle was detected by quantitative values, which can be useful in at-risk patient groups, the planning of surgical procedures, and early revisions at postoperative month 3.

A Look at the Other Side: High-Risk Lesions and Occult Contralateral Malignancy in Symmetry Procedures for Patients Undergoing Oncoplastic Breast-Conserving Surgery.

The incidence of occult breast cancer among patients undergoing reduction mammoplasty or risk-reducing mastectomies ranges from 1% to approximately 10%, respectively. Identification of incidental cancer often mandates subsequent mastectomy due to ambiguous margins. This study aimed to determine the incidence of contralateral malignancy among patients undergoing oncoplastic breast-conserving surgery (OBCS) with concurrent symmetry procedures. The authors reviewed their prospectively maintained institutional database of patients with unilateral breast cancer who underwent OBCS. Patients who underwent excisional biopsy on the contralateral breast were analyzed separately. Patient demographics, pathologic features, and subsequent disease management were evaluated. Between March 2018 and July 2022, 289 patients underwent OBCS with a symmetry procedure, and 100 patients yielded contralateral breast tissue specimens. For 14 patients, a planned excisional biopsy was performed with their symmetry procedure, and five lesions (36%) were found to be malignant. Of the remaining 86 patients, 92% underwent preoperative breast magnetic resonance imaging (MRI). Four patients (4.7%) had occult malignancies identified on the contralateral breast pathology; three patients with ductal carcinoma in situ and one patient with invasive lobular carcinoma. Three patients had undergone preoperative MRI without suspicious findings. No patients required mastectomy for treatment of the contralateral breast cancer. The incidence of occult malignancy among OBCS symmetry procedures approaches 5%. The final pathology of excisional biopsies had a higher upgrade rate than previously reported. All identified malignancies were early-stage disease. The higher incidence of occult breast cancer in this population warrants the routine orientation of all specimens, which allows patients with incidental early-stage cancer the option of breast preservation.

SP05. A Novel, Patient-specific, Organotypic 3D Platform for Modeling Cell Behavior in the Setting of Malignancy

PURPOSE: With the advent of personalized cancer treatments, patient-specific in vitro models of the breast malignancies are critical for modeling the complex in vivo milieu and to better assess therapeutic efficacy. A primary challenge to developing such platforms is isolating and successfully co-culturing the many primary cell types that constitute the tumor microenvironment. In addition, optimizing for cost-effectiveness of such platforms is critical to making the technology translational. Using patient-derived cells and machine learning-based image analysis, we have developed a low-cost 3D biomimetic platform that allows for the study of cell behavior in a highly organotypic model of breast malignancy. METHODS: Stromal vascular fraction, organoids and mature adipocytes were isolated from breast tissue obtained from healthy female patients undergoing reduction mammoplasty. Isolated cells were embedded in non-ribosylated collagen, creating a biomimetic milieu that approximates the patient-specific in vivo cellular environment (“biomimetic collagen”). 3D collagen constructs consisting of a bottom layer of plain collagen or collagen embedded with RFP-tagged MDA-231 tumor cells followed by a layer of plain or biomimetic collagen were built in a 96-well plate. GFP-tagged human umbilical vascular endothelial (HUVEC) cells were plated in a monolayer layer on top of the collagen to mimic the endothelial barrier. Constructs were imaged with confocal microscopy on days 0 and 7 to assess for endothelial cell organization and migration. Image analysis was completed in Imaris. ANOVA tests for statistical significance were completed in R Studio. RESULTS: Confocal microscopy at day 0 revealed ~800μm thick constructs with distinct tumor and non-tumor collagen layers and a robust HUVEC top monolayer. Confocal images at day 7 were notable organization of the HUVEC layer into 2D tubular networks with some HUVEC below the top monolater indicating migration through the collagen matrix. Our machine-learning based approach was able to reliably and reproducibly parse HUVEC cells from the surrounding cells and collagen, allowing for quantification of cell migration in the Z-axis. Statistical analysis revealed a significant difference in migration across treatment groups (p < 0.01), with endothelial cells in the tumor and biomimetic collagen platform migrating 20-40 microns further than endothelial cells in the other construct designs, a finding retained on intergroup pairwise comparison (p < 0.01). CONCLUSION: This biomimetic platform design and image analysis allows for reliable, reproducible study of discrete endothelial cell interactions with the tumor microenvironment. The finding of enhanced HUVEC migration in the platform with both tumor and biomimetic cells is consistent with the hypothesis that stromal cells, adipocytes and malignant cells enhance the angiogenic capacity of endothelial cells. Importantly, this utilization of patient-derived stromal vascular fraction and mature adipocytes in this platform makes it inherently personalized, a vital component of any future clinically-relevant in vitro cancer platform.

A Systematic Review of the Impact of Patient Factors on BREAST-Q Outcomes After Reduction Mammoplasty.

As reduction mammoplasty rises in popularity, it will become increasingly important to understand the patient-reported outcome measurements associated with a successful operation. There has been a growing body of literature on BREAST-Q outcomes for patients undergoing reduction mammoplasty, but meta-analyses of patient factors and BREAST-Q Reduction Module scores are lacking. This study sought to ascertain which patient factors were associated with improvements in BREAST-Q scores compared with preoperative levels. A literature review through August 6, 2021, was conducted using the PubMed database to select publications using the BREAST-Q questionnaire to evaluate outcomes after reduction mammoplasty. Studies examining breast reconstruction, breast augmentation, oncoplastic reduction, or breast cancer patients were excluded. BREAST-Q data were stratified by comorbidities, age, body mass index (BMI), complication rate, and resection weight. Among 14 articles and 1816 patients, the mean age ranged from 15.8 to 55 years, mean BMI ranged from 22.5 to 32.4 kg/m2, and bilateral mean resected weight ranged from 323 to 1845.96 g. Overall complication rate was 19.9%. On average, satisfaction with breasts improved by 52.1 ± 0.9 points (P < 0.0001), psychosocial well-being improved by 43.0 ± 1.0 points (P < 0.0001), sexual well-being improved by 38.2 ± 1.2 points (P < 0.0001), and physical well-being improved by 27.9 ± 0.8 points (P < 0.0001). The mean age was positively correlated with preoperative sexual well-being (Spearman rank correlation coefficient [SRCC]: 0.61, P < 0.05). Body mass index was negatively correlated with preoperative physical well-being (SRCC: -0.78, P < 0.01) and positively correlated with postoperative satisfaction with breasts (SRCC: 0.53, P < 0.05). The mean bilateral resected weight was significantly positively correlated with postoperative satisfaction with breasts (SRCC: 0.61, P < 0.05). No significant correlations were observed between complication rate and preoperative, postoperative, or mean change in BREAST-Q scores. Reduction mammoplasty improves patient satisfaction and quality of life as reflected by the BREAST-Q. Although preoperative or postoperative BREAST-Q scores may be individually influenced by age and BMI, these variables demonstrated no statistically significant effect on the average change between these scores. This literature review suggests that reduction mammoplasty delivers high satisfaction across a diverse range of patient populations, and additional prospective cohort or comparative studies gathering robust data on other patient factors would benefit this area of research.

Reduction Mammoplasty in the Pediatric Population: An Analysis of Pediatric NSQIP Data From 2012 to 2019

Introduction: Reduction mammoplasty is becoming more commonly performed in the pediatric population yet the risk factors for complications have not been well-studied. The purpose of this study was to assess the relationship between preoperative patient characteristics and postoperative complications in a large population of pediatric patients undergoing reduction mammoplasty. Methods: Pediatric patients undergoing reduction mammoplasty were identified within the 2012 to 2019 National Surgical Quality Improvement Program database for cross-sectional study. The predictor variables were age, body mass index (BMI), diabetes, chronic steroid use, time under anesthesia, and operative time, and the primary outcome was a 30-day postoperative surgical site-related complication. Multivariate logistic regression was performed to identify a relationship between predictor variable and primary outcome. Results: A total of 1216 pediatric patients were identified with a mean age of 16.6 years and mean BMI of 30.8 kg/m2. The incidence of overall postoperative complications was 4.6%. Superficial surgical site infection (SSI) was the most common complication (29/1216; 2.4%). BMI was significantly associated with superficial SSI (odds ratio: 1.03, 95% confidence interval: 1.00-1.05, P = .02) . Sixteen patients (1.32%) underwent a second operation, most commonly to address hematoma/seroma (7/16; 43.8%). Conclusion: In a large series of patients, pediatric reduction mammoplasty is a safe procedure with a low complication rate. BMI was significantly associated with the incidence of superficial SSIs with the most common cause for reoperation being a hematoma/seroma. This study can help guide the discussion between physicians and patients regarding potential risks associated with pediatric reduction mammoplasty.

Improving symmetry of nipple–areola complex (NAC) position in reduction mammoplasty using laser level projection

Symmetrical height of the nipple-areola complex (NAC) is a key factor in the perception of breast symmetry. For preoperative markings, we mainly rely on conventional anthropometric measurements of distances in correlation to anatomical landmarks. In this study, we evaluated whether the use of a class 2 laser projection water level would lead to better symmetry of nipple height in reduction mammoplasty procedures when used for preoperative planning. We analysed 100 patients undergoing reduction mammoplasty with a supero-medial pedicle and wise-pattern skin resection. We compared the bilateral differences in nipple height of the last 50 reduction mammoplasty procedures before using the laser projection water level (group A; no laser) with the first 50 reduction mammoplasties after implementation of this device (group B; laser). The follow-up period was 12 months. A total of 48 patients were included in group A and 44 patients in group B. Patient demographics, mean resection weight and complications did not differ statistically significantly. Nipple height differences were significantly lower in group B (laser), measuring 0.22±0.20cm (0-0.9; n=44), than those in group A (no laser; p < 0.001), measuring 0.61±0.28cm (0.2-1.2; n=49). Using laser level projection helped improve nipple height symmetry in reduction mammoplasty. We consider a difference of more than 1 cm in nipple height to be unacceptable in aesthetic reduction mammoplasty. This simple tool facilitates preoperative markings, and we find it to be safe, quick to install and very helpful in daily practice.

Predictive risk factors of complications in reduction mammoplasty-analysis of three different pedicles.

BackgroundReduction mammoplasty can be performed in several different techniques. Understanding the complication profile and risk factors in different reduction methods can help in choosing a technique, which serves the patient best. The authors present their experience of three different reduction techniques [superomedial pedicle (SMP), superior pedicle (SP) and inferior pedicle (IP)] with an emphasis on predictors of complications.MethodsA retrospective review of a prospectively maintained database of breast reductions between 2014 and 2020 was performed. Patient’s demographics [age, body mass index (BMI), comorbidities, smoking, nipple to sternal notch distance (N-SN)], operative details (pedicle, tissue resected, drains, operating surgeon) and complications according to Clavien-Dindo classification were assessed. Study variables were compared against overall complication rates for the three techniques.ResultsIn total, 760 patients underwent reduction mammoplasty, including 578 (76%) bilateral and 182 (24%) unilateral operations. Of patients, 477 (63%) were operated with SMP, 201 (26%) with IP and 82 (11%) with SP. An average weight of resected tissue per breast was 460 g. Overall complication rate was 38%. The rate was higher in IP group (50%) compared to SMP (36%) and SP (22%) groups (P<0.001). Complications were mainly minor and related to delayed wound healing. The rate for major complications was 4%. Multivariable analysis showed that complications were associated independently with IP [odds ratio (OR) 1.89, 95% confidence interval (CI): 1.33–2.69], age <50 years (OR 1.87, 95% CI: 1.32–2.65), bilateral operation (OR 1.67, 95% CI: 1.00–2.76) and resected tissue weight ≥650 g per breast (OR 2.02, 95% CI: 1.36–2.99). Each factor contributed 1 point in the creation of a risk-scoring system. The overall complication rate was increased as the presence of statistically significant risk factors (IP, age <50, bilateral operation and/or resected tissue ≥650 g per breast) increased (31%, 38%, 59% and 90% for number of 1, 2, 3 and 4 risk factors respectively, P<0.001).ConclusionsThe rate of complication can be predicted by a risk-scoring system. In increasing variety of patients undergoing reduction mammoplasty, careful consideration of the best operation technique is important to prevent complications and costs.

Use of Absorbable Dermal Stapler in Reduction Mammoplasty: Assessing Technical, Quality-of-Life, and Aesthetics Outcomes.

Introduction:Reduction mammaplasty is a mainstay in the treatment of symptomatic macromastia, with a well-described positive impact on patient quality-of-life (QoL). Absorbable dermal staplers have the potential to improve the efficiency of skin closure in reduction mammoplasties, but a more comprehensive assessment of its impact on key outcomes has not been fully elucidated.Methods:A retrospective review of patients undergoing reduction mammoplasty between November 2018 and December 2020 was conducted. Patients were included if they had undergone a wise-pattern reduction with a superomedial pedicle and completed 3 months of follow-up. Patient demographics, operative information, clinical and aesthetic outcomes, and QoL were compared between patients that had INSORB stapler-assisted and suture-only closures.Results:Seventy-five patients met the inclusion criteria, with 34 patients (45%) in the stapler cohort. Total procedure time was significantly reduced with the use of the dermal stapler (stapler: 154 vs. suture: 170 minutes; p = 0.003). The incidence of major complications was similar between cohorts (stapler: 8.8% vs. suture: 12%; p = 0.64), as was the incidence of minor complications (stapler: 44% vs. suture: 41%; p = 0.82). Regardless of closure technique, patients demonstrated significant increases in all QoL domains (p <0.001). Lastly, 10 independent raters found no difference in the cosmetic appearance of breasts from either cohort, when judging overall breast appearance, shape, scars, volume and the nipple-areolar complex (all p > 0.05).Conclusions:The dermal stapler improves efficiency of closure during reduction mammoplasty without increasing the incidence of wound healing complications. Additionally, cosmetic outcomes are not affected, and patients demonstrate similar post-operative satisfaction with the result regardless of closure technique.

Evaluation of Factors Related to Postoperative Complications in Patients Who Underwent Reduction Mammoplasty.

This study aimed to investigate whether there was an increase in the number of postoperative complications in patients undergoing reduction mammoplasty depending on the technique used (i.e., pedicle type, skin incision pattern), existence of concomitant diseases, and presence of other risk factors. A total of 186 patients who underwent breast reduction between 2013 and 2018 (bilateral, n = 170; unilateral, n = 16) were included in the study. A retrospective review of the data of patients who underwent reduction mammoplasty, which was performed by the same surgical team in a single institution over a 6-year period, was carried out. Superomedial, superior, and inferior pedicles were used in 99, 55, and 32 patients, respectively. The median follow-up period was 4 years. The median patient age was 45 (range: 16-75) years. The median total reduction weight was 2,194 (range: 80-4,800) grams. The median distance between the sternal notch and nipple was 31 cm (range: 24-45 cm) for the right breast and 30 cm (range: 22-45 cm) for the left breast. The overall complication rate was 6.9%. The complication rates in patients with and without any concomitant diseases were 10.2% and 4.6%, respectively. The overall complication rate was significantly higher in patients with smoking habit, accessory breasts, progesterone use, cerebrovascular disease, morbid obesity (Body Mass Index ≥40 kg/m2), and thalassemia. Our analysis shows that the presence of concomitant diseases increases the risk for postoperative complications in patients who underwent reduction mammoplasty. Our findings do not suggest that any of the techniques have significant superiority to each other in terms of pedicle safety and overall complication rate.

Abstract PS1-37: Reduction mammoplasty in the setting of neoadjuvant chemotherapy

Abstract Background: Oncoplastic reduction mammoplasty is an accepted method of breast conserving surgery that also allows for potentially improved symmetry and aesthetics compared to other techniques and allows for larger tissue volumes to be removed with acceptable cosmetic outcomes. Neoadjuvant systemic chemotherapy (NAC) is increasingly used for the treatment of patients with breast cancer. While there is some data that oncoplastic reduction may delay timing of adjuvant radiation, we sought to examine this in our patients, and specifically to compare complications and time to radiation in patients who received NAC to those that didn’t. Methods: A retrospective analysis was done of all patients with DCIS or invasive cancer who underwent a reduction mammoplasty and received adjuvant radiation at our single institution from 2009-2018. Patients who received NAC were compared to those that did not. Results: A total of 114 patients underwent reduction mammoplasty as part of their oncologic surgery and received adjuvant radiation at our institution. Of those, 40.4% received neoadjuvant chemotherapy and 49.1% received no neoadjuvant treatment. A total of 38 patients (33.3%) had some postoperative complication with 8.8% having a serious complication that required intervention. Adjuvant radiation started after 8 weeks in 74.6% of patients and after 12 weeks in 38.6% of patients, with the majority of these delays due to non-clinical factors. A total of 29.4% of patients had a delay due to wound healing issues. There was no association between NAC and delayed radiation due to wound healing (p=0.18). Discussion: Oncoplastic reduction mammoplasty is a safe option for breast-conserving surgery in patients who have received NAC. The receipt of NAC in itself does not delay timing of adjuvant radiation or lead to increases in delayed wound healing. We are additionally examining other factors and their possible interaction with NAC, including diabetes, smoking, BMI and breast reduction size. In those with larger tumors receiving NAC who would otherwise not be candidates for breast conserving surgery, oncoplastic reduction should be considered as an appropriate option for surgical management. Reduction also allows for wider excision which may mitigate the impact of the longer time from surgery to radiation. Citation Format: Kelly Hewitt, Susan Wu, Laura Barnes, Joanna Yang, Merisa Piper. Reduction mammoplasty in the setting of neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-37.

Preoperative estimation of breast resection weight in patients undergoing inferior pedicle reduction mammoplasty: the Bilgen formula

Background/aimSymptomatic breast hypertrophy has a significant impact on the quality of life of women. The amount of tissue to be excised may be preoperatively estimated by an experienced surgeon. However, this remains a subjective assessment. Accurate quantification of the amount of breast tissue to be resected in the preoperative period will be a guide for both patient information and the surgeon during the operation. The aim of this study is to develop a new method based on simple measurements that can accurately estimate the resection weight in the preoperative period in a wide range of patients undergoing reduction mammoplasty.Materials and methodsThe study was carried out between December 2016 and September 2018. With the determined drawing and measurement methods, a triangle was obtained by measuring the distances among the sternal notch (A) - right nipple areola midpoint (B), sternal notch (A) - left nipple areola midpoint (C) and both internipple areola (B-C). The height of this triangle (h) was found by measuring the distance between the sternal notch and the midpoint of both nipple areola levels. The amount of breast tissue to be resected for each breast was calculated by multiplying the distance between the sternal notch–nipple areola and the height of the large triangle. The formula may be expressed as AB × h for the right breast and AC × h for left breast.ResultsWhen the t values ​​and significance levels of the beta coefficients of the independent variables were examined, the preoperative values ​​were determined to be in accordance with the actual values ​​after surgery (P < 0.05). The values ​​calculated before were calculated as the percentage of the actual values (91%). In other words, the R2 value showed that the calculated values were compatible with the actual values (R2 = 0.910).ConclusionsWith the formula described herein, one may accurately estimate the amount of tissue to be resected in a wide range of patients undergoing reduction mammoplasty whose sternal notch–nipple distances are between 28–42 cm. Additionally, because measurements for each breast are performed separately, breast asymmetry does not affect the results. In conclusion, the formula we devised is simple, applicable, and has a high accuracy rate.

Impact of Reduction Mammoplasty on Cosmetic Outcomes and Delivery of Hypofractionated Radiotherapy for Breast Cancer Patients Undergoing Reduction Mammoplasty as a Component of Breast-Conserving Surgery

Impact of Reduction Mammoplasty on Cosmetic Outcomes and Delivery of Hypofractionated Radiotherapy for Breast Cancer Patients Undergoing Reduction Mammoplasty as a Component of Breast-Conserving Surgery

Incidental breast carcinoma: incidence, management, and outcomes in 4804 bilateral reduction mammoplasties.

Bilateral reduction mammoplasty is one of the most common plastic surgery procedures performed in the U.S. This study examines the incidence, management, and prognosis of incidental breast cancer identified in reduction specimens from a large cohort of reduction mammoplasty patients. Breast pathology reports were retrospectively reviewed for evidence of incidental cancers in bilateral reduction mammoplasty specimens from five institutions between 1990 and 2017. A total of 4804 women met the inclusion criteria of this study; incidental cancer was identified in 45 breasts of 39 (0.8%) patients. Six patients (15%) had bilateral cancer. Overall, the maximum diagnosis by breast was 16 invasive cancers and 29 ductal carcinomas in situs. Thirty-three patients had unilateral cancer, 15 (45.5%)of whichhad high-risk lesions in the contralateral breast. Twenty-one patients underwent mastectomy (12 bilateral and nine unilateral), residual cancer was found in 10 in 25 (40%) therapeutic mastectomies. Seven patients did not undergo mastectomyreceived breast radiation. The median follow-up was 92months. No local recurrences were observed in the patients undergoing mastectomy or radiation. Three of 11 (27%) patients who did not undergo mastectomy or radiation developed a local recurrence. The overall survival rate was 87.2% and disease-free survival was 82.1%. Patients undergoing reduction mammoplasty for macromastia have a small but definite risk of incidental breast cancer. The high rate of bilateral cancer, contralateral high-risk lesions, and residual disease at mastectomy mandates thorough pathologic evaluation and careful follow-up of these patients. Mastectomy or breast radiation is recommended for local control given the high likelihood of local recurrence without either.

National Surgical Quality Improvement Program Analysis of 9110 Reduction Mammaplasty Patients: Identifying Risk Factors Associated With Complications in Patients Older Than 60 Years.

The purpose of this study was to identify preoperative risk factors in patients undergoing reduction mammoplasty as well as identify any increased complication risk in patients older than 60 years undergoing reduction mammoplasty. The American College of Surgeons National Surgical Quality Improvement Program data from years 2013-2015 was reviewed. Patients were identified using Current Procedural Terminology code 19318 specific for reduction mammoplasty. Only patients undergoing bilateral procedures were included, and no reconstructive procedures were included. Patient demographics, comorbidities, and 30-day complications were analyzed. Comparative analysis was performed between patients younger than 60 years and patients 60 years and older, identifying risk factors associated with complications in the geriatric population. A total of 9110 patients undergoing reduction mammoplasty were identified. Of these 1442 (15.83%) were patients older than 60 years. Mean age of all patients was 42 years (range, 18-85 years). Eighty hundred fifty-nine patients were active smokers. Four hundred eighty-two patients were diabetic. Overall, 798 complications occurred with an incidence of 8.7%. Group 1 (<60 years) mean age was 39 years (range, 18-59). Group 2 (>60 years) mean age was 66 years (range, 60-85 years). The geriatric population showed a higher risk of cerebral vascular accidents (P < 0.00006), myocardial infarction (P < 0.02), and readmission (P < 0.03). Smoking was found to be a statistically significant risk factor for superficial surgical site infection, and deep space infection. Diabetes was found to be a statistically significant risk factor for readmission. Reduction mammoplasty is a common surgical procedure. It is not uncommon for patients older than 60 years to undergo elective reduction mammoplasty (15.83% incidence), resulting in a cumulative complication rate of 11.65% in the geriatric population compared with 8.89% in the group of patients younger than 60 years. Smoking and diabetes were found to be independent risk factors for complications, regardless of age.

Abstract 140: Discrepancies In Opioid Prescription And Utilization Following Breast Reduction

PURPOSE: To examine opioid prescribing patterns after reduction mammoplasty and to assess percentage of pills that are actually consumed. Background: Prescription opioids are a major contributor to the opioid epidemic. Data to inform surgeons regarding inpatient pain control protocols are improving, but data describing the appropriate outpatient opioid regimen is lacking. METHODS: We evaluated 247 cases of reduction mammoplasty performed from 6/2015 to 2/2018 at a single institution with four surgeons. Postoperative opioid prescriptions, prescribers, and refill data were tabulated. A phone survey was conducted to determine the percentage of opioid pills consumed. RESULTS: There was a wide variation in the number of opioid pills prescribed to patients undergoing reduction mammoplasty at a single institution. The mean number (and range) prescribed was 38 (10–60) pills. The mean (and range) of morphine equivalents prescribed was 230.5 (75–675). 78% of patients consumed 25% or less of the pills prescribed. 14% of patients took no narcotics or never filled their prescription. Approximately 15% of patients obtained refills. Average refill prescription was for 35 pills. There is a large variation in prescribing habits among providers for the same procedure. Only one of the 12 prescribing providers prescribed the same number of morphine equivalents routinely. We identified the number of pills that suffice the opioid needs of 80% of patients undergoing reduction mammoplasty to be 20 pills. Compared to the current average 38 pill prescription, this would be a 47% reduction of opioid pills prescribed. CONCLUSION: We demonstrate wide variability of discharge opioid prescribing habits within a single institution. In many cases, excess pills are prescribed initially at discharge and again with refill prescriptions. Using our ideal number, plastic surgeons can decrease the number of opioids prescribed for this common procedure.

Breast Reduction Using the Superomedial Pedicle- and Septal Perforator-Based Technique: Our Clinical Experience.

Adequate tissue removal must be performed for symptom relief following reduction mammoplasty. However, this is not always possible in patients with gigantomastia because the pedicle is planned wider and the breast cannot be sufficiently reduced to prevent compromising the blood supply to the pedicle. To maximize blood circulation to the nipple-areola complex in our patients, the pedicle was planned to include the internal thoracic artery branches coming from both the second and third interspaces and the intercostal artery branches coming from the fourth and fifth intercostal spaces. A total of 185 patients underwent reduction mammoplasty with the superomedial pedicle- and septal perforator-based technique. The mean weight of excised tissue was 928.77g from the right breast and 899.92g from the left, whereas the mean distance of nipple-areola transfer was 11.52cm on the right breast and 11.27cm on the left. Complications developed in 11 patients (5.94%): hematoma occurred in three patients, partial loss of areola and fat necrosis in five patients, and wound dehiscence in three patients. The pedicle included vessels of both superomedial and septum origin without any disruption in circulation. Consequently, the blood supply of the nipple-areola complex was preserved. Furthermore, in cases where the pedicle was long, intercostal perforators were identified and the pedicle was narrowed thoroughly; thus, the breast was reduced to the desired volume while minimizing the risk of 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 .

Abstract: Octyl-2-Cyanoacrylate and Adhesive Mesh Closure System Versus Subcuticular Suture Closure in Reduction Mammoplasty: A Randomized, Controlled Trial

INTRODUCTION: An ideal wound closure system is one that is effective, consistent, and efficient. The commonly-used subcuticular suture is time-consuming, operator-dependent, and inflammatory in nature. Recent studies have demonstrated the efficacy of octyl-2-cyanoacrylate and mesh system (Dermabond Prineo, Ethicon, Inc.) in the closure of surgical wounds. This study compared the use of Prineo to subcuticular suture closure in patients undergoing reduction mammoplasty. METHODS: A prospective, randomized, controlled, single-blind study of patients undergoing bilateral reduction mammoplasty was performed. Power analysis was done to determine the minimum sample size of seven breasts per group. Each breast per patient was randomized to layered closure with Prineo or subcuticular sutures for the final layer. The incision length and time to closure were measured and recorded for each breast. Incisions were assessed at 2 weeks, 6 weeks, 6 months, and 1 year for scar quality and complications. Subjects completed the Patient Observer Scar Assessment Scale (POSAS) for each breast and two blinded plastic surgeons evaluated scar quality using the Vancouver Scar Scale (VSS) at each time point. RESULTS: Twenty-one patients participated in the study. On average, Prineo closure took 58.38 seconds (2.50 s/cm) while subcuticular closure took 444.76 seconds (18.94 s/cm). Prineo closure was approximately 6.8 times faster (p=0.000) than subcuticular closure, saving an average of 6.4 minutes per incision. VSS scores were significantly better in patients with Prineo closure at 2 weeks (p=0.026), although there was no difference in POSAS and VSS scores at all other time points. No differences were found in wound complication or infection rates between the two groups and no adverse reactions were observed in either group. Cost analysis of our results estimated an average cost saving of approximately $127.75 per surgery when Prineo was used instead of subcuticular suture. CONCLUSION: In reduction mammoplasty, Prineo closure results in equivalent scar quality and lower operative cost without increased complications when compared to subcuticular closure. The Prineo system is significantly faster than subcuticular closure and represents an effective, consistent, and efficient alternative to standard suture techniques.

Abstract 3376: Reprogramming the estrogen signaling network is a potential mechanism for human breast tumorigenesis

Abstract Background: The estrogen receptor (ER) is expressed in approximately 70% of sporadic breast cancers and is known to activate genes driving cell proliferation. Much work in the field has characterized the mechanisms of ER signaling behind cancer progression and eventual metastasis, and therapeutic targeting of the ER signaling pathway has proven effective. However, little is known regarding the role of ER in the initial process of transformation. Since ER possesses pro-differentiation roles in normal breast development yet becomes one of the drivers of breast cancer, altered ER function is then likely a crucial early step. We seek to investigate the role of ER from the perspective of the normal breast to allow for mechanistic insights into breast tumorigenesis. Methods: To model the normal breast epithelium, viable tissue specimens from patients undergoing reduction mammoplasty were obtained and enriched for breast epithelial cells via fluorescence-activated cell sorting (FACS). Fresh-frozen ER+ breast tumor samples were then obtained for comparison. RNA-seq, ChIP-seq for ER, and genome-wide CRISPR screening in the presence of estrogen stimulation in both normal breast and breast tumor were performed. These various modalities of genomic data were then integrated and analyzed to identify patterns in breast tumorigenesis. Results: Gene expression profiling via RNA-seq of breast epithelial cells from seven reduction mammoplasties reveals a drastically different and muted normal response to estrogen stimulation. Genes that promote cell cycling and cell proliferation were down-regulated in normal breast but were up-regulated in breast cancer cells. Furthermore, differential ER binding alone via ER ChIP-seq is capable of segregating ten primary breast tumors from seven normal breast tissues with very few overlapping sites. Deeper motif analysis reveals the enrichment of novel transcription cofactor GRHL2 in the binding sites most closely associated to ER+ breast cancer. Further findings via genome-wide CRISPR screens reveal GRHL2 as an essential gene in luminal ER+ breast cancer with predictive ability in cancer risk and prognosis. Conclusions: Cellular reprogramming of the ER signaling network may alter the functioning phenotype of normal mammary epithelial cells and offer insights into the series of events necessary for developing breast cancer. Notably, ER activation does not promote cellular proliferation in normal mammary epithelial cells, and the interaction with transcriptional cofactors such as GRHL2 can be a driving mechanism for breast tumorigenesis. Unraveling the differential ER signaling in normal mammary epithelium and breast cancer will enhance our understanding of breast cancer and aid the development of more effective prevention strategies and targeted therapeutics. Citation Format: David Chi, Hari Singhal, Lewyn Li, Henry W. Long, Judy E. Garber, Myles A. Brown. Reprogramming the estrogen signaling network is a potential mechanism for human breast tumorigenesis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3376. doi:10.1158/1538-7445.AM2017-3376

The Sternum-Nipple Distance is Double the Nipple-Inframammary Fold Distance in Macromastia.

Reduction mammaplasty is one of the most commonly performed plastic surgery operations. For a majority of techniques, the most common long-term complication is pseudoptosis. It has previously been proposed that upper breast suspensory ligaments (SL) are weaker than lower breast SL. We tested this hypothesis through anthropometry of the proxies for upper and lower SL strength: the sternal notch-nipple (SN-N) distance and the nipple-inframammary fold (N-IMF) distance, respectively. An institutional review board-approved retrospective review of patients undergoing reduction mammoplasty in an academic faculty practice between 2008 and 2015 was conducted. Patient demographics included age, race, and body mass index (BMI); patient comorbidities included smoking status, diabetes, and hypertension. Breast anthropometric measurements included SN-N and N-IMF. Sternal notch-nipple was used as the primary metric of the upper SL strength, whereas N-IMF was used as the primary metric of the lower SL strength. Intraoperative details included reduction technique and resection mass. Postoperative complications were recorded, including nipple areola complex necrosis and hematoma. Linear regression analysis was performed with the primary endpoint of the relationship between SN-N and N-IMF distance in macromastia. Data from 208 patients, totaling 400 individual breast measurements, were collected. The mean SN-N length was 35.1 cm, mean N-IMF length was 16.0 cm, and mean resection weight was 1094 g. Linear regression found that N-IMF distance could be predicted as 45% of the SN-N distance (N-IMF = 0.454 * SN-N). This was a strong relationship, demonstrated by univariate analysis of SN-N and N-IMF (R, 0.624; P < 0.001). A Wise pattern was used in 89.9% of cases; an inferior pedicle was used in 83.7% of cases. Nipple areola complex necrosis occurred in 15 breasts (3.75%). Sternal notch-nipple (R, 0.127; P = 0.011) and N-IMF (R, 0.119; P = 0.017) were both predictive of nipple areola complex necrosis (Table 4). In our series, the N-IMF distance increased 0.45 cm for every 1 cm increase in the SN-N distance. This relationship strengthens our primary hypothesis that the lower pole ligaments stretch at a significantly slower rate than the upper pole ligaments. Taking this into consideration, we suggest that surgeons seeking to minimize pseudoptosis rates should favor techniques that minimally disrupt the lower SL.