Prosthesis-based Breast Reconstruction Research Articles

Effectiveness of a postoperative continuous irrigation system via a catheter following implant-based breast reconstruction

Background Implant-based breast reconstruction is a technique frequently used for breast reconstruction. Infection and inflammation are considered to be the most troublesome complications of implant-based breast reconstruction and can lead to capsular contracture or implant failure. To date, however, only a few methods have been proposed to prevent these complications. Therefore, the authors introduce a simple irrigation system using indwelling drain catheters to decrease postoperative inflammation.Methods Continuous saline irrigation was performed once per day for 3 days immediately after prosthesis-based breast reconstruction. Normal saline (500 mL) was inserted into the implant pocket through a superomedial-oriented drain catheter and drained through an inferolateral-oriented drain catheter using a suction device. Inflammatory indicators, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and postoperative complications were compared between the non-irrigation and irrigation groups.Results This study included 37 patients divided into two groups (20 non-irrigation and 17 irrigation). An analysis of inflammatory indicators revealed that the peak CRP level in the irrigation group was significantly lower than that in the non-irrigation group, while no statistically significant differences were found for the other mediators (ESR and WBC). In the immediate postoperative period, continuous irrigation effectively washed out tissue debris and blood clots within the implant pocket, which helped maintain the function of the drain catheter and decrease pro-inflammatory mediators.Conclusions This irrigation method was simple and cost-effective for decreasing inflammation within the breast pocket. Furthermore, it can also be applied to infected breast pockets in combination with antibiotics.

Outcomes Analysis of Textured Versus Smooth Tissue Expanders in Breast Reconstruction.

Because of concerns related to the correlation of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and textured implants, the use of smooth devices in breast reconstruction has been increasing. Currently, there is a paucity of literature evaluating the safety of smooth tissue expanders (STEs), which are now being used more frequently in first-stage breast reconstruction. This study sought to compare the safety and outcomes associated with STEs compared with textured tissue expanders in prosthesis-based breast reconstruction. A single-institution retrospective review of 394 patients undergoing tissue expander-based breast reconstruction (147 smooth and 247 textured) between 2015 and 2019 was conducted. Patient demographics, comorbidities, treatment characteristics, complications, and surgical outcomes were evaluated. Data analysis was performed using Fisher exact and t tests. No significant difference in demographics or complication rates were identified, including rates of hematoma, seroma, wound dehiscence, delayed wound healing, infection, tissue expander malposition, nipple necrosis, mastectomy flap necrosis, reoperation, readmission, and explantation. Average follow-up was 19 and 22 months for the smooth and textured groups, respectively. No cases of BIA-ALCL were identified in either group. With equivocal safety profiles and no demonstrated risk in BIA-ALCL associated with STEs, this study supports the safety of using STEs compared with textured tissue expanders in prosthesis-based breast reconstruction with the advantage in preventing BIA-ALCL and concludes that there is no role for textured breast expanders.

Evaluation of Xenograft Efficacy in Immediate Prosthesis-based Breast Reconstruction

INTRODUCTION: The advent of acellular dermal matrix (ADM) has revolutionized prosthesis-based breast reconstruction, conferring soft tissue reinforcement to the mastectomy skin flap. However, paucity of human cadaveric tissue has resulted in limitation of supply and increased associated costs, prompting concerted effort to identify alternatives to human ADM, such as xenograft surgical adjuncts, to minimize cost burden to the patient and institution, while maintaining adequate soft tissue support. Although various studies have examined the safety of Artia, a porcine-derived ADM, in prosthesis-based breast reconstruction, few studies have evaluated its clinical efficacy as soft tissue reinforcement. This study uniquely compares clinical efficacy of Artia with AlloDerm, a commonly used human-derived ADM, by examining objective parameters of initial tissue expander (TE) fill volume at the time of mastectomy, number of TE fills, and time interval between exchange of TE for final implant. METHODS: IRB approved retrospective chart review was conducted to identify 273 consecutive TE-based procedures performed at a tertiary academic medical center between March 2017 and March 2021. Of these, 89 cases utilized Artia and 184 utilized AlloDerm. Univariate and binomial logistic regression analyses were conducted to compare patient characteristics and clinical endpoints between Artia and AlloDerm groups. RESULTS: Patients who underwent Artia-based breast reconstruction achieved comparable initial TE fill volume relative to those who underwent AlloDerm-based breast reconstruction (335 ± 198 mL versus 289 ± 158 mL, p = 0.10) and similar time interval to TE-implant exchange (232 ± 124 days versus 242 ± 131 days, p = 0.70) via univariate analysis. However, patients who underwent Artia-based reconstruction experienced fewer number of tissue expansions (3.92 ± 2.97 fills versus 4.99 ± 2.98 fills, p < 0.01). When normalizing for final implant size, which serves as a surrogate for body composition, the Artia group exhibited significantly higher perioperative fill (0.65 ± 0.34 v. 0.49 ± 0.19, p < 0.01). Rates of explantation were higher in the AlloDerm group; however, when controlling for confounding variables, no statistical significance was observed following binomial regression analysis. Otherwise, rates of post-operative complication were similar among groups. CONCLUSION: This study demonstrates efficacy of Artia as an alternative to human-derived ADM in immediate TE-based breast reconstruction. Demonstration of clinical efficacy of non-human cadaveric surgical adjuncts is of paramount importance to facilitate widespread acceptance of these materials and further decrease healthcare costs. This work, therefore, serves as a framework for future studies evaluating xenograft efficacy in breast reconstruction and can guide development of emerging biomaterials and techniques.

Evaluation of Xenograft Efficacy in Immediate Prosthesis-based Breast Reconstruction.

Background:The advent of acellular dermal matrix (ADM) has revolutionized prosthesis-based breast reconstruction. However, paucity of human cadaveric tissue has resulted in limitation of supply and increased associated costs, prompting concerted effort to identify xenograft alternatives. Although studies have examined the safety of Artia, a porcine-derived ADM, few have evaluated its clinical efficacy as soft tissue reinforcement. This study uniquely evaluates the clinical efficacy of Artia in implant-based breast reconstruction.Methods:IRB-approved retrospective chart review was conducted to identify 243 consecutive TE-based procedures performed at a tertiary academic medical center between March 2017 and March 2021. Propensity matching was conducted to minimize differences between cohorts. Efficacy metrics, defined as initial tissue expander (TE) fill volume, number of TE fills, and time interval between exchange of TE for final implant, were compared between xenograft (Artia) and allograft (AlloDerm) groups.Results:Patients who underwent Artia-based breast reconstruction achieved superior initial TE fill volume relative to those who underwent AlloDerm-based breast reconstruction via univariate analysis (317.3 ± 185.8 mL versus 286.1 ± 140.4 mL, P < 0.01) when patient and operative characteristics were well-matched. However, linear regression analysis failed to demonstrate difference in efficacy metrics, such as initial TE fill volume (P = 0.31), ratio between initial TE fill volume and final implant size (P = 0.19), and number of TE fills (P = 0.76). Complication rates were comparable between groups.Conclusion:This study suggests that Artia can be used as a safe and efficacious alternative to human-derived ADM in immediate TE-based breast reconstruction.

The effect of early arm exercise on drainage volume after total mastectomy and tissue expander insertion in breast cancer patients: a prospective study.

BackgroundIn prosthesis-based breast reconstruction patients, the drain tends to be kept in place longer than in patients who undergo only mastectomy. Postoperative arm exercise also increases the drainage volume. However, to preserve shoulder function, early exercise is recommended. In this study, we investigated the effect of early exercise on the total drainage volume and drain duration in these patients.MethodsWe designed a prospective randomized trial involving 56 patients who underwent immediate breast reconstruction following mastectomy using tissue expanders. In each group, the patients were randomized either to perform early arm exercises using specific shoulder movement guidelines 2 days after surgery or to restrict arm movement above the shoulder height until drain removal. The drain duration and the total amount of drainage were the primary endpoints.ResultsThere were no significant differences in age, height, weight, body mass index, or mastectomy specimen weight between the two groups. The total amount of drainage was 1,497 mL in the early exercise group and 1,336 mL in the exercise restriction group. The duration until complete removal of the drains was 19.71 days in the early exercise group and 17.11 days in the exercise restriction group.ConclusionsExercise restriction after breast reconstruction did not lead to a significant difference in the drainage volume or the average time until drain removal. Thus, early exercise is recommended for improved shoulder mobility postoperatively. More long-term studies are needed to determine the effect of early exercise on shoulder mobility in prosthesis-based breast reconstruction patients.

Antibiotic Prophylaxis in Alloplastic Breast Reconstruction: Regimens and Outcomes.

Surgical site infections (SSI) in prosthesis-based breast reconstruction can have a significant impact on patient outcome. Despite current CDC (Centers for Disease Control and Prevention) guidelines recommending 24 hours of postoperative antibiotics, various perioperative antimicrobial regimens are reported in the literature. Consensus on the optimal duration of antibiotics remains unclear. In this study, the aim is to compare the incidence of surgical site infections following different antibiotic durations in alloplastic breast reconstruction. In this retrospective cohort study, all consecutive patients who underwent expander/implant-based breast reconstruction between January 2009 and December 2014 at a tertiary centre were included. Data on patient demographics, risk factors, operative time, choice and timing of antibiotic used before surgery, and the duration of postoperative antibiotic use were collected. The primary outcome, SSI, is defined according to CDC criteria. A total of 507 consecutive expander/implant-based cases were included. Minimum follow-up time was 1 year. The overall infection incidence was 14% (95% CI: 11%-17%), and the rate of subsequent explantation was 8%. Of the infected cases, 80% (45/56) received 1 week of postoperative antibiotic, while 20% (11/56) had a prolonged course of antibiotics (2-3 weeks; P = .003, odds ratio [OR] = 2.9; 95% CI: 1.4-5.8). Most infections were superficial (65%). Prior history of radiation treatment was identified as a risk factor for developing surgical site infection (P = .02). Overall infection rate and risk factors for infections are in keeping with current literature. Prescribing one week of postoperative antibiotic was found to be associated with a higher incidence of SSI compared to a more prolonged antibiotic regimen.

Abstract P6-14-10: A retrospective study of peri-prosthesis infection after prosthesis based breast reconstruction in a single breast center in east China and impact of an evidence-based protocol

Abstract Purpose To investigate the status of surgical site infection after prosthesis-based breast reconstruction in a single center and evaluate the role of an evidence-based protocol in infection control in immediate prosthesis-based breast reconstruction. Method Two cohorts are included in our study. In the first cohort, a retrospective analysis of consecutive post-mastectomy prosthesis-based reconstructions performed between June of 2010 and April of 2018 at Affiliated Hangzhou First People's Hospital Zhejiang University School of Medicine was performed. We reviewed clinicopathological information and the surgical outcomes through the medical record and questionnaire. Then we developed an evidence-based perioperative infection prevention protocol marked by preoperative decolonization and sterility optimization according literatures. In the second cohort, patients had undergone prosthesis-based breast reconstruction after protocol implementation between July of 2018 and April of 2019. We compared the surgical outcomes between this two cohort. In this study a patient was considered to have infection if she had any of these: (1) local inflammatory symptoms in breast that requires intravenous antibiotics or surgical intervention, (2) purulent drainage, (3) pathogenic culture positive. Infections requiring surgical intervention were defined as severe infections. T test was used to analyze quantitative data, Fisher’s two-tailed exact test was used to compare qualitative data. A multi-factor logistic regression analysis was used to analyze risk factors. Results In the first cohort,108 reconstruction procedures were performed among 93 patients. Median follow-up time was 17.5 months. The infection rate was 23.1%(25/108). Three prosthesis were explanted at postoperative 30 days, 50 days and 15 months respectively. The prosthesis salvage rate and total explantation rate were 88%(22/25), 2.8%(3/108) respectively. Culture was performed in only 17 patients with 24 samples. Pathogens were found in 4 samples: S.aureus(n=2), enterococci(n=1) and serratia marcescens(n=1). The average duration of prophylactic antibiotics was 5.4±3.9 days. Cephalosporin was the main prophylactic antibiotics. Therapeutic antibiotics for infected patients were mainly based on empirical agents, with vancomycin widely used. A multi-factor regression analysis indicated that large volume prothesis (V&amp;gt;400CC) was an independent risk factor of severe infection (p&amp;lt;0.05). After the protocol was implemented, 48 breasts were reconstructed among 45 patients. Median follow-up time was 6.5 months. Only one patient was considered as infection for tissue expander exposure following nipple necrosis. Overall, the rate of infection reduced significantly from 23.1% (25/108) to 2.1%(1/48) (P = 0.001). Conclusions Our single center data indicated that incidence of peri-prosthesis infection seems high in medium-sized hospitals in eastern China, but explantation rate is still very low. The evidence-based protocol was associated with a significant decline in infection rates among prosthesis-based breast reconstruction patients. In addition, there are many urgent problems such as inadequate application of prophylactic antibiotics, poor awareness of bacterial culture. We will continue to use this protocol in our practice to control infection. Table 1. Schematic of evidence-based protocolPreoperativeIntraoperativePostoperative*nasal swab culture*intravenous cefazolin(swab negative)or vancomycin(swab MRSA)* prophylactic antibiotics for 24 hours* chlorhexidine* chlorhexidine prep*drain removal in 3 weeks after surgery*intranasal mupirocin*glove change*re-draping*prosthesis minimal touch*betadine and antibiotics (cefazolin, gentamicin) irrigation* betadine and antibiotics rinse pocket*dermabond dressing for incision and drains Citation Format: Liu Jian, Guo Jufeng, Hu Shufang, Nie Shijiao, Chen Qiong, Wang Shuying. A retrospective study of peri-prosthesis infection after prosthesis based breast reconstruction in a single breast center in east China and impact of an evidence-based protocol [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-10.

Ultrasonic dissection versus electrocautery for immediate prosthetic breast reconstruction.

BackgroundUltrasonic dissection devices cause less thermal damage to the surrounding tissue than monopolar electrosurgical devices. We compared the effects of using an ultrasonic dissection device or an electrocautery device during prosthetic breast reconstruction on seroma development and short-term postoperative complications.MethodsWe retrospectively reviewed the medical records of patients who underwent implant-based reconstruction following mastectomy between March 2017 and September 2018. Mastectomy was performed by general surgeons and reconstruction by plastic surgeons. From March 2017 to January 2018, a monopolar electrosurgical device was used, and an ultrasonic dissection device was used thereafter. The other surgical methods were the same in both groups.ResultsThe incidence of seroma was lower in the ultrasonic dissection device group than in the electrocautery group (11 [17.2%] vs. 18 [31.0%]; P=0.090). The duration of surgery, total drainage volume, duration of drainage, overall complication rate, surgical site infection rate, and flap necrosis rate were comparable between the groups. Multivariate analysis revealed that the risk of seroma development was significantly lower in the ultrasonic dissection device group than in the electrocautery group (odds ratio for electrocautery, 3.252; 95% confidence interval, 1.242–8.516; P=0.016).ConclusionsThe findings of this study suggest that the incidence of seroma can be reduced slightly by using an ultrasonic dissection device for prosthesis-based breast reconstruction. However, further randomized controlled studies are required to verify our results and to assess the cost-effectiveness of this technique.

Abstract QS4: Outcomes in Breast Reconstruction: Does Race Play a Role? An Analysis of 51,362 Patients from the ACS-NSQIP

PURPOSE: Racial disparities in postoperative complications are widely observed in various surgical specialties. The influence of race is particularly evident and often described in current vascular, orthopedic, and spine surgery literature. Although disparities in access to plastic surgery are well described, the effect of race on plastic surgical outcomes remains largely undefined. This study aims to clarify the influence of race on reconstructive breast surgery outcomes. METHODS: The NSQIP was queried for all female patients undergoing reconstructive breast surgery between 2008 and 2016. Surgical outcomes of patients of white race were compared to those of African-American, Asian, or other races (composite of American Indian, Alaska Native, Native Hawaiian or Pacific Islander). Logistic regression was performed to control for variations between all groups with a priori selected variables ‘Age’, ‘BMI’, ‘COPD’, ‘Hypertension’, ‘Diabetes’, ‘Smoking status’, ‘Steroid use’, ‘Operating Time’, and ‘Type of procedure’. Racial differences in outcomes were further stratified and analyzed within four different types of breast reconstruction: delayed or immediate autologous breast reconstruction and delayed or immediate prosthesis-based breast reconstruction. RESULTS: In total, 51,362 patients were included in the analysis of which 43,864 (85.4%) were white, 5,135 African-American (10.0%), 2,057 Asian (4.0%), and 332 of other races (0.6%). Patients of African-American race had larger body mass indices (31.3 ± 7.0 versus 27.6 ± 6.3, p-value <0.001) in addition to higher rates of diabetes (12.3% vs 4.6%, p-value <0.001) and hypertension (44.7% versus 23.4%, p-value <0.001) when compared to white patients. Both univariate and multivariate analysis showed no differences in overall complication rate. When modeling for overall complication rate, the odds ratios (OR) of being of a minority race were not significantly different compared to being white (OR 0.980, 95% CI 0.877–1.095; p-value =0.720, OR 1.035, 95% CI 0.848–1.263; p-value =0.734, OR 0.674, 95% CI 0.395–1.149; p-value =0.147 for African-American, Asian, and other respectively). Moreover, when sub-stratified into different types of reconstruction, no differences were observed. CONCLUSION: Among the four types of reconstructive procedures, differences in surgical outcomes do not seem to be based on race. Racial disparities in outcomes appear to be less apparent in reconstructive breast surgery compared to the current literature within other surgical specialties.

Evaluation of Acellular Dermal Matrix Efficacy in Prosthesis-Based Breast Reconstruction

Background Although many studies have examined the safety of acellular dermal matrix in immediate prosthetic breast reconstruction, few studies have evaluated efficacy. This study examined initial tissue expander fill volume as a marker of efficacy, comparing patients after staged prosthetic breast reconstruction assisted with acellular dermal matrix versus breast reconstruction not assisted with acellular dermal matrix. Number of fill visits and time interval to implant exchange were examined as secondary endpoints. Methods An institutional review board-approved retrospective chart review was conducted to identify consecutive staged prosthetic reconstruction cases over 12 years. Results Mean initial tissue expander fill volume was significantly higher in the acellular dermal matrix group compared with the non-acellular dermal matrix group (180.8 ± 150.0 versus 45.8 ± 74.4; p = 0.00). Normalizing for final implant size, the acellular dermal matrix group exhibited significantly higher perioperative fill (0.33 ± 0.24 versus 0.11 ± 0.16; p = 0.00). A collinear trend was observed between acellular dermal matrix use and direct-to-implant reconstruction procedures during the study period. Conclusions These results suggest that acellular dermal matrix use is more efficacious in achieving greater initial fill volume, fewer visits for expansion, and a shorter time interval to implant exchange compared with non-acellular dermal matrix procedures. The authors also describe a collinear relationship between acellular dermal matrix use and transition to direct-to-implant procedures at their institution. This work serves as a framework for future studies evaluating acellular dermal matrix efficacy, and guides innovation of biomaterials to support breast reconstruction. Clinical question/level of evidence Therapeutic, III.

A short follow-up of prosthesis-based breast reconstruction using TiLOOP® Bra surgical mesh.

A new approach for prosthesis-based breast reconstruction is the use of a titanium-coated polypropylene mesh TiLOOP® Bra. However, the safety and outcomes are currently unclear in Chinese breast cancer patients. A retrospective study of patients undergoing prosthesis-based breast reconstruction using TiLOOP® Bra was carried out. Complications were divided into minor complications (require conservative treatment) and major complications (require surgical intervention). The influence of patient- and surgery-related characteristics on complications was analyzed. Postoperative hematoma and seroma were respectively found in one and two breasts and could be treated conservatively. In three breasts skin infection occurred immediately after surgery resulting in skin necrosis of two breasts and wound dehiscence of one breast. These three breasts were treated with mesh removal, and revisionary surgery. Increased risk of mesh removal and implant explantation were observed in case of skin infection (P = 0.011) and skin necrosis (P = 0.033). Neither patient-related characteristics including age >50 years, BMI >25 kg/m2, and postoperative radiotherapy/chemotherapy, nor surgery-related characteristics including sentinel lymph node biopsy or axillary dissection alone, and curative/prophylactic surgery were significantly correlated with minor and major complications. Ultrasound evaluation showed a well-incorporated mesh into surrounding tissue. This titanium-coated polypropylene mesh showed acceptable complications and could be used safely in prosthesis-based breast reconstruction by stabilizing the implant pocket. Longer follow-up data and more randomized trials are necessary to determine the clinical use of this mesh.

“Evaluation of Acellular Dermal Matrix Efficacy in Prosthesis-Based Breast Reconstruction.”

“Evaluation of Acellular Dermal Matrix Efficacy in Prosthesis-Based Breast Reconstruction.”

Antibiotic Prophylaxis after Immediate Breast Reconstruction: The Reality of Its Efficacy

Numerous techniques are used to prevent infection after immediate implant-based breast reconstruction. Postoperative antibiotic prophylaxis is commonly prescribed to decrease the risk of reconstructive failure, despite conflicting evidence regarding its effectiveness. The authors studied whether postoperative antibiotic prophylaxis decreases the risk of infection-related explantation in the setting of immediate prosthesis-based breast reconstruction. Using Truven MarketScan databases, the authors identified all patients who underwent immediate implant reconstruction between January of 2010 and June of 2014 with at least 6 months of follow-up. Postoperative antibiotic prophylaxis was defined as any oral antibiotic course to be taken postoperatively based on prescriptions filled within 14 days preoperatively through 24 hours after discharge. Reconstructive failure, defined as explantation because of infection, was the primary outcome. Secondary outcomes of interest included wound complications, infection, and readmission for infection. Multivariable regression analyses controlled for demographic variables/comorbidities. Of the 7443 patients, 6049 (81 percent) filled prescriptions for postoperative antibiotic prophylaxis. These patients were equally likely to develop a wound complication (OR, 0.93; 95 percent CI, 0.71 to 1.23) or infection (OR, 0.89; 95 percent CI, 0.70 to 1.14), undergo explantation because of infection (OR, 0.82; 95 percent CI, 0.57 to 1.18), or require readmission for infection (OR, 1.21; 95 percent CI, 0.82 to 1.78) compared with those who did not receive antibiotics. There was no significant difference in the risk of infection-related outcomes based on postoperative antibiotic prophylaxis duration. Postoperative antibiotic prophylaxis was not associated with a reduced risk of infection or explantation following prosthesis-based breast reconstruction. Given rising rates of antibiotic resistance, focusing instead on technical considerations and the management of comorbid conditions may more effectively enhance the safety of breast reconstruction. Therapeutic, III.

Abstract 86: Antibiotic Prophylaxis After Immediate Breast Reconstruction: The Reality of Its Efficacy

PURPOSE: Although postoperative antibiotic prophylaxis (PAP) is thought to minimize the risk of infection after implant-based reconstruction, the efficacy of this practice remains unclear. The goal of this study was to determine whether PAP effectively prevents failure of immediate prosthesis-based breast reconstruction due to infection. METHODS: Using Truven MarketScan data, we identified all patients who underwent immediate reconstruction between 2009–2013 with at least 6 months of follow-up. PAP included any oral antibiotic prescription filled within 7 days prior to surgery through 24 hours post-discharge. The primary outcomes were infection and explantation due to infection. Multivariable regression analyses controlled for demographic variables and comorbidities. RESULTS: Of the 10,784 patients who underwent immediate prosthesis-based reconstruction, 5,516 (51%) filled antibiotic prescriptions. These patients were equally likely to develop an infection (OR 1.0 95%CI(0.85–1.18); p=0.98) or require explantation (OR 0.96 95%CI(0.80–1.15); p=0.64) compared to those who did not. There was no difference in the likelihood of infection or explantation based on duration of antibiotics of 1–5 days (OR 0.85 95%CI(0.59–1.08); p=0.08), 6–10 days (OR 1.01 95%CI(0.90–1.14); p=0.84), or greater than 10 days (OR 0.97 95%CI(0.81–1.16); p=0.74). Comorbidities significantly increased the risk of infection and explantation (p<.05). CONCLUSION: In this population-based study, PAP did not reduce the risk of infection following prosthesis-based reconstruction. Given rising rates of antibiotic resistance, focusing on management of comorbid conditions may be more valuable.

Risk of infection is associated more with drain duration than daily drainage volume in prosthesis-based breast reconstruction: A cohort study.

In prosthesis-based breast reconstruction, drains are used to prevent seroma formation and to reduce the risk of infection. However, prolonged drainage increases the risk of ascending infection. Although the volume often accepted for drain removal is ≤30 mL per day, the optimal timing to remove the drain for best clinical outcome remains controversial.We did a retrospective cohort study of 569 patients of prosthesis-based breast reconstruction with infection rate as the outcome variable; drain duration and last daily drainage volume as the main independent variables. Data on age, smoking history, diabetes mellitus history, body mass index, breast weight, tissue expander size, drain size, number of retrieved lymph nodes, tumor size, number of metastatic lymph nodes, tumor stage, mastectomy type, reconstruction type, submuscular implantation, skin defect, operative time, duration of antibiotics use, chemotherapy, and radiotherapy were collected as covariates. Multivariable logistic regression analysis was used to control for confounding.The total infection rate was 5.1% (29/569). The daily drainage volume ≥30 mL/d at the time of drain removal was not found associated with increased infection rate (P = 0.32). Of the various cutoff values of last daily drainage volume, none was found to be a determinant for drain removal where the risk of infection was concerned. By contrast, drain duration over 21 days significantly increased infection rate (P = 0.001). The multivariable logistic regression analysis showed an increase of 76.2% in the infection rate with each additional week of drain retention (P = 0.001). Breast weight also had a significant influence on risk of infection. Chemotherapy and drain size showed borderline effect on risk of infection whereas the last daily drainage volume was not associated with risk of infectionIn summary, our study revealed that drain duration, rather than the last daily drainage volume, significantly affects the infection rate in prosthesis-based breast reconstruction. We recommend that the drain is better removed no longer than 3 weeks postoperatively and can be removed as early as postoperative day 7, even when the drainage is over 30 mL in a 24-hour period.

The effect of skin expansion on acellular dermis in an experimental model

Objective: Although acellular dermis is widely used in prosthesis-based breast reconstruction, there is no study evaluating its expandability and histological, ultra-structural related changes. The purpose of this study is to determine whether acellular dermis could be expanded and whether the histological changes occurring in the skin with tissue expansion is different from normal when acellular dermis is used.Methods: Twenty-two male Wistar rats were used in this study. In group 1 (n = 6), a rectangular-shaped tissue expander with final volume of 35 ml was placed subcutaneously. In group 2 (n = 6) tissue expander was placed submuscularly. In group 3 (n = 6), a 4 × 5 cm, acellular dermis was inserted and sutured in place, tissue expander was placed underneath acellular dermis. Group 4 (n = 4) was control, no procedure was done after creation of a pocket. After day 30, tissue expanders were inflated with 2 ml every 2 days with saline solution. On day 66, midvertical, midhorizontal surface expansion measurements were recorded. Samples were examined macroscopically. Biopsies were taken from mid-point of the expanded full-thickness flap. Histological evaluation, total skin thickness, epidermal thickness, and the amount of vascularisation were measured.Results: There was no expansion noted on the acellular dermis; however, acellular dermis increased vascularity and decreased the thinning of the overlying skin and thickening of the epidermis when compared to other groups.Conclusion: Acellular dermis use can be beneficial in implant-based breast reconstruction in terms of morbidity and its tissue support.

Indocyanine green-based fluorescent angiography in breast reconstruction.

Fluorescent angiography (FA) has been useful for assessing blood flow and assessing tissue perfusion in ophthalmology and other surgical disciplines for decades. In plastic surgery, indocyanine green (ICG) dye-based FA is a relatively novel imaging technology with high potential in various applications. We review the various FA detector systems currently available and critically appraise its utility in breast reconstruction. A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken. In comparison to the old fluorescein dye, ICG has a superior side effect profile and can be accurately detected by various commercial devices, such as SPY Elite (Novadaq, Canada), FLARE (Curadel LLC, USA), PDE-Neo (Hamamatsu Photonics, Japan), Fluobeam 800 (Fluoptics, France), and IC-View (Pulsion Medical Systems AG, Germany). In breast reconstruction, ICG has established as a safer, more accurate tracer agent, in lieu of the traditional blue dyes, for detection of sentinel lymph nodes with radioactive isotopes ((99m)-Technetium). In prosthesis-based breast reconstruction, intraoperative assessment of the mastectomy skin flap to guide excision of hypoperfused areas translates to improved clinical outcomes. Similarly, in autologous breast reconstructions, FA can be utilized to detect poorly perfused areas of the free flap, evaluate microvascular anastomosis for patency, and assess SIEA vascular territory for use as an alternative free flap with minimal donor site morbidity. ICG-based FA is a novel, useful tool for various applications in breast reconstruction. More studies with higher level of evidence are currently lacking to validate this technology.

A New Approach to Minimize Acellular Dermal Matrix Use in Prosthesis-based Breast Reconstruction.

Background:Acellular dermal matrices (ADMs) are often used to improve lower-pole contour, as well as allow for single-stage reconstruction, but numerous studies have shown an increased complication rate using ADM. As such, our group has developed a minimal-ADM-use technique to lower complications while effectively recreating lower-pole contour.Methods:A total of 380 postmastectomy prosthesis-based breast reconstructions were performed in 265 patients by a single surgeon. One hundred eight reconstructions were performed using the traditional ADM technique, with a large piece of ADM along the entire inferior and lateral borders. Two hundred twenty-five reconstructions were performed with the minimal-use technique, patching only the lateral area of the reconstruction. Thirty-five reconstructions were performed without the use of any ADM for high-risk reconstructions, most often in morbidly obese patients.Results:Comparing the traditional technique with the minimal-use technique, the seroma rate dropped from 3% to 0%. The rate of infection and reconstruction loss fell from 9% to 1%. Upon greatly reducing or eliminating the use of ADM use in obese patients, the seroma rate decreased from 15.4% to 5.7%, and the reconstruction loss rate decreased from 38% to 9%.Conclusions:This article describes a new surgical approach to minimize the amount of ADM necessary to create an aesthetically pleasing breast reconstruction. We believe that this approach helps avoid the complications of seroma, infection, and loss of the reconstruction. In certain obese patients, total avoidance of ADM may be the better choice.

Trans-axillary approach for breast implant exchange in high risk cases of irradiated or attenuated skin

Breast reconstruction with implants after tissue expansion is one of the most common methods of reconstruction. Although this approach is generally reliable, exchange of breast tissue expander for implant through the standard anterior incision presents a challenge in cases with attenuated soft tissue envelope due to radiation, thin anatomy, prior surgery, or combination of the above. We propose that a trans-axillary approach is a safe and alternate approach for implant exchange in the high-risk patients. A case series of 16 patients with multiple risk factors for compromised soft tissue that underwent a trans-axillary approach for implant exchange is reported. The trans-axillary implant exchange technique involves use of a standard 4 cm axillary incision, removal of the expander, judicious capsulotomy, placement of permanent implant, and closure in three separate tissue layers. All trans-axillary cases were successful and all incisions were well healed without dehiscence, infection, or seroma. The average patient age was 49.4 years, and 50% of patients had received or were scheduled to receive radiation therapy. Nine patients underwent unilateral trans-axillary expander exchange while 7 patients were bilateral. Median implant size was 360 cc (mean 369 cc, range 150-600 cc), and mean follow-up for all patients was over 24 months. There were no cases of implant extrusion, capsular contracture requiring re-operation, or lymphedema. Six patients underwent concurrent or subsequent nipple reconstruction. This approach illustrates application of a technique commonly used in breast aesthetic augmentation to address a common reconstructive dilemma, which we believe to be a useful tool in prosthesis-based breast reconstruction, especially in patients with compromised soft tissue envelopes.

Whom Should We SPY? A Cost Analysis of Laser-Assisted Indocyanine Green Angiography in Prevention of Mastectomy Skin Flap Necrosis during Prosthesis-Based Breast Reconstruction

Skin flap necrosis is the most common complication following prosthesis-based breast reconstruction. Many studies have reported on the efficacy of laser-assisted indocyanine green angiography (SPY Elite System) in detecting flap necrosis. A cost-effectiveness analysis of laser-assisted indocyanine green angiography is lacking. The authors performed a retrospective review of all consecutive immediate postmastectomy prosthesis-based reconstructions at the Brigham and Women's Hospital over a 7-year 10-month period. The rate of mastectomy skin flap necrosis and related implant loss was determined for the entire cohort and for the subgroups of patients at increased risk for developing this complication: smokers, obese patients, and patients with large breasts. Cost of treating implant loss and skin flap necrosis was calculated based on the average treatment courses and costs at the authors' institution. The cost of the SPY was obtained from LifeCell Corp. From January of 2004 through October of 2011, 79 of 710 prosthesis-based breast reconstructions (11.1 percent) developed mastectomy skin flap necrosis requiring excision and reclosure. Performing laser-assisted indocyanine green angiography on the entire cohort would result in an additional cost of $1537.30 per case of flap necrosis prevented. If laser-assisted indocyanine green angiography was performed on only these high-risk subgroups, the cost savings per case of flap necrosis prevented is $2098.80 for smokers, $5162.30 for patients with a body mass index greater than 30, and $1892.70 for patients with mastectomy weight greater than 800 g. Laser-assisted indocyanine green angiography is not cost-effective as a preventative measure for flap necrosis if used indiscriminately on all patients undergoing prosthesis-based breast reconstructions, but it is cost-effective for high-risk patients, such as smokers, obese patients, and patients with large breasts.