Severe Capsular Contracture Research Articles

Neoadjuvant Immunotherapy and De-Escalation of Surgery in Locally Advanced Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T cell lymphoma diagnosed in patients with a history of breast implants. Most patients develop a periprosthetic effusion at early stages of disease while less common presentations include a palpable mass, severe capsular contracture, lymphadenopathy, or cutaneous erythema. Due to the complex nature of this disease, a multidisciplinary approach is necessary for optimal management, particularly in locally advanced disease or inoperable patients. We present the successful use of neoadjuvant therapeutic protocols in two cases of locally advanced BIA-ALCL. The first case, a 52-year-old patient with a left breast mass-like stage III disease who underwent combined targeted immunotherapy and chemotherapy (BV-CHP). Following a complete radiological and metabolic response, the patient underwent bilateral implant removal, right total intact capsulectomy, left en bloc capsulectomy and skin resection from the left inframammary fold in continuity with the capsule. The second case, a 65-year-old patient with a right breast swelling and mass-like stage IIA disease who received targeted immunotherapy, Brentuximab vedotin (BV). Following a complete metabolic response, she underwent bilateral implant removal and en bloc capsulectomy. A literature review and the reported cases suggest the effectiveness of targeted immunotherapy as monotherapy or in combination with chemotherapy in locally advanced BIA-ALCL in disease downstaging, surgical de-escalation, reduction of significant post-operative complications and an acceptable tolerance profile. Although surgery is an essential part of treatment, timing and type of intervention should be carefully planned, especially when primary, radical resection is uncertain.

Silicone Lymphadenopathy Following Augmentation Mammoplasty With Silicone Implants.

Silicone implants are by far the most widely used implant globally for breast augmentation. Despite technological advancements, complications persist, with silicone lymphadenopathy (siliconoma) being a noteworthy concern. This phenomenon has been inadequately addressed in the existing literature. The aim of this study was to characterize axillary siliconomas and identify potential risk factors to help reduce their occurrence. The authors conducted a retrospective observational cross-sectional study spanning between 2011 and 2021 at the Shamir Assaf Harofeh Medical Center, Israel. Preoperative ultrasound examination was conducted, categorizing patients into those with siliconomas and those without. A total of 614 women (1209 breasts) met the inclusion criteria. The incidence of siliconomas was 13.6% (165 breasts). In univariate analysis, older age (47 years vs 43 years, P < .001), older implant age (12.2 years vs 11 years, P = .026), ruptured implants (59.4% vs 17.7%, P < .001), subpectoral placement (P = .019), severe capsular contracture, and the use of Mentor implants (Irvine, CA; P = .007) and Poly Implant Prothèse implants (PIP; La Seyne-sur-Mer, France; P = .001) correlated significantly with the presence of siliconomas. In a multivariate analysis, implant rupture (odds ratio [OR] = 6.342), and implant manufacturer-Mentor (OR = 3.047) and PIP (OR = 3.475)-were identified as independent risk factors associated with a higher incidence of siliconomas. Severe capsular contracture was also associated with a higher incidence of siliconomas (OR = 1.65). Surgeons should inform candidates about the potential risk of silicone migration. Patients with ruptured implants, significant capsular contracture, and Mentor and PIP implants face an increased risk for developing siliconomas. Closer monitoring for the detection of siliconomas in the axilla for these patients is advisable, and potential prophylactic replacement or removal of implants may be warranted to mitigate siliconoma risk.

Abstract PO3-23-05: Capsular contracture after post-mastectomy radiotherapy in the patients undergoing implant-based breast reconstruction: impact of implant positioning and two-stage surgery

Abstract Background Capsular contracture is a significant concern in patients undergoing post-mastectomy radiotherapy (PMRT) following implant-based breast reconstruction. It negatively impacts cosmetic outcomes and can have a profound effect on the individual's quality of life. Our study aimed to explore whether the degree of capsular contracture varies based on the placement of the inserted implant and the type of operation (one- or two-staged). Patients and Methods This retrospective study was conducted at a single center, Ganganm Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea. Our study included patients who underwent PMRT following total mastectomy and implant-based breast reconstruction surgery between January 2017 and September 2022. To assess the degree of capsular contracture, we evaluated the presence of capsular contracture, particularly severe capsular contracture classified as Baker grade 3 or higher, as well as implant migration. The implants were placed either in the pre-or sub-pectoral position, and the surgical approach employed was either direct-to-implant (DTI) or two-staged operation. Results A total of 195 patients were included in the study, with 83 (42.6%) patients in the pre-pectoral group and 112 (57.4%) patients in the sub-pectoral group. In addition, 116 underwent a two-stage operation, while 79 underwent DTI surgery. There was a significant difference in the occurrence of capsular contracture based on the implant placement, with 16 patients (19.3%) in the pre-pectoral group and 46 patients (41.1%) in the sub-pectoral group experiencing this complication (OR 4.142 [1.973-8.698]). Furthermore, the severity of capsular contracture differed significantly between the two groups, with 5 patients (6.0%) in the pre-pectoral group and 16 patients (14.3%) in the sub-pectoral group affected (OR 3.434 [1.153-10.227]). The incidence of capsular contracture was lower in the two-stage operation group compared to the DTI group (28 [23.9%] vs 34 [38.6%]; OR 3.064 [1.528-6.141]), and the severity of capsular contracture was also reduced (9 [7.7%] vs 12 [14.5%]; OR 2.854 [1.092-7.455]). There were no significant differences in other complications such as seroma and infection. In addition, sub-pectoral placement was identified as a significant risk factor for implant upward migration (OR 2.531 [95% CI, 1.263-5.071]). Conclusions Our findings suggest that pre-pectoral reconstruction and the two-stage operation are beneficial for patients who may undergo PMRT based on their initial nodal stage. These approaches can help reduce the incidence of capsular contracture and abnormal implant migration following radiation, leading to improved aesthetic outcomes and greater patient satisfaction. Citation Format: Sohyun Moon, Kyunghyun Min, Jung Hwan Eom, Yoonwon Kook, Seung Ho Baek, Junghyun Kim, Min Ji Kim, Seung Eun Lee, In Sik Yun, Tai Suk Roh, Soong June Bae, Joon Jeong, Young Seok Kim, Sung Gwe Ahn. Capsular contracture after post-mastectomy radiotherapy in the patients undergoing implant-based breast reconstruction: impact of implant positioning and two-stage surgery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-23-05.

Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis

BackgroundEsthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures. MethodsWe conducted a retrospective database study (2007–2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3–4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05). ResultsWe analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement. ConclusionPost-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

A High-biocompatibility Interface for the Breast Implant: First Report of a Novel Biological Matrix-assisted Technique in Aesthetic Revision Surgery.

Development of human-compatible tissues is an active field of research that is leading to the production of optimized biological scaffolds to support regenerative medicine. Xenogenic acellular matrices are known to have strongly influenced the field of breast surgery, playing an integral role in wound healing and in preventing the foreign body reaction to silicone implants. Here, we present our experience in using a biological matrix for aesthetic revision surgery with malposition and severe capsular contracture. Revisions were performed using the new MASQUE equine acellular-pericardium-matrix (APM) as an anterior cover for the synthetic prosthesis. Acting as an internal support, the thin APM layer provides a biological and biocompatible interface between the synthetic implant and living tissues, exerting a protective function against fibrotic responses and capsular contracture. The role of an APM in matrix-assisted mammoplasty has yet to be fully established. Our early experience of APM-assisted aesthetic revision surgery shows promising results, laying the foundations for equine biological matrices as a valid tool for the management of capsular contracture-susceptible patients.

Simple UV-Grafting of PolyAcrylic and PolyMethacrylic Acid on Silicone Breast Implant Surfaces: Chemical and Mechanical Characterizations

Poly(dimethyl siloxane) (PDMS) is one of the most widely used materials in the biomedical field. Despite its numerous advantages, its hydrophobic character promotes bacterial adhesion and biofilm formation. For breast implants, biocompatibility is challenged due to the biofilm formed around the implant that can degenerate to severe capsular contracture over time. Thus, the laboratory has set up strategies to prevent bacterial contamination by grafting covalently hydrophilic bioactive polymers on the surface of implants. In this study, poly(methacrylic acid) (PMAc) and poly(acrylic acid) (PAAc) were chosen as non-toxic and biocompatible bioactive polymers known for reducing bacteria adhesion. These polymers are also good candidates to lend reactivity on the surface for further functionalization. X-ray photoelectron Spectroscopy (XPS) and Fourier-Transform Infrared spectroscopy (FTIR) analysis have highlighted the covalent grafting of these polymers. Apparent water contact angle measurements have shown the change in hydrophilicity on the surface, and a colorimetric assay allowed us to assess the grafting rate of PMAc and PAAc. Tensile strength assays were performed to ensure that the functionalization process does not significantly alter the material’s mechanical properties. Analyses of the surface aspect and roughness by Scanning Electron Microscope (SEM) and optical profilometer allow us to formulate hypotheses to approach the understanding of the behavior of the polymer once grafted.

A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review.

Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study. The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared. Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05). This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Impact of radiation on immediate breast reconstruction: a retrospective single institution cohort study.

While the trend towards immediate breast reconstruction is growing, data on the long-term outcomes of patients receiving irradiation afterwards are scarce. We retrospectively reviewed the long-term complication rates in patients who received adjuvant radiation therapy after immediate breast reconstruction in our institution. We included 134 patients with breast cancer who underwent single-stage immediate breast reconstruction between January 2008 and December 2018. Sixty-eight patients received adjuvant irradiation and 66 patients did not. Autologous tissue, implant-based, and combined (implant and flap) reconstruction were performed in 40, 55, and 39 patients, respectively. Flap and implant complications data were collected. Baker's classification was used to assess capsular contracture. The average follow-up was 47 months. Both groups had similar baseline clinical characteristics and treatments received. The irradiated-group had a higher incidence of adjuvant chemotherapy (P<0.01) and a significantly higher rate of grade III/IV capsular contracture (42.1% vs. 26.9%; P=0.004) than that of the non-irradiated group. The median time to the development of capsular contracture was 37 vs. 41 months in the irradiated vs. the non-irradiated group, respectively. There were no differences in the incidence of flap complications between both groups. The only significant risk factor associated with grade III/IV capsular contracture was adjuvant post-mastectomy irradiation. The irradiated group had a higher risk of developing grade III/IV capsular contracture [odds ratio (OR), 4.35; 95% confidence interval (CI): 1.55-12.27]. Postmastectomy radiotherapy adversely affects implant-based immediate one-stage reconstruction by increasing the rate of moderate to severe capsular contracture but is not associated with flap complications.

ADM-Assisted Direct-to-Implant Prepectoral Breast Reconstruction in Postmastectomy Radiation Therapy Setting: Long-Term Results

BackgroundPostmastectomy radiotherapy (PMRT) on immediate breast reconstruction historically involved a marked increase in complication rate (up to 50%). Prepectoral breast reconstruction (PPBR) has shown promising early postoperative results. This study aims to evaluate PPBR long-term results in PMRT setting. Materials and MethodsThis is a retrospective monocentric analysis of 485 PPBR (439 patients) undergoing Acellular-Dermal-Matrix assisted direct-to-implant reconstruction (46 bilateral procedures) between January 2015 and December 2020 (mean FU:35.6 months). Group 1 comprised 401 PPBR not submitted to PMRT, and 84 reconstructions receiving PMRT in Group 2. Patients’ characteristics, postoperative complication and revisional surgery rate were examined. PMRT characteristics and subcutaneous tissue thickness, measured in Group 2 by CT scan, were also evaluated. ResultsLong-term complication rate was 11.2% in Group 1 vs. 21.4% in Group 2 (P-value = .019). Capsular contracture represented the only complication associated to a statistically significant difference between the 2 groups (P-value < .001). In Group 2, only 4.8% implant loss and 8.3% severe capsular contracture rate was found. In patients who underwent PMRT, 38.9% of complications settled with no consequences, and only 4.8% of patients needed revisional surgery in the long-term FU. According to multivariate analysis, drug intake and PMRT were significantly associated with postoperative complications. In Group 2, a thinner subcutaneous tissue was linked to a higher complication risk. ConclusionIn our series, patients treated with PPBR who underwent PMRT, presented a low complication rate and minimal need for revisional surgery in the long-term follow-up, suggesting that this technique is feasible and safe also in PMRT context.

Immediate Single Stage Implant-based Breast Reconstruction with or Without TIGR Mesh in Iranian Patients Undergoing Mastectomy: A Quasi-experimental Study

Background: Breast cancer is still a major contributing factor to the burden of the disease worldwide. A single-stage implant-based reconstruction (IBR) lowers tissue morbidity, thus increasing overall aesthetic outcome and patient satisfaction. Objectives: Because of the high price of ADM and the lack of insurance coverage in Iran, we aimed at examining the results of using TIGR® mesh in patients with breast cancer. Methods: This quasi-experimental study was conducted in Iran (Tehran) from 2016 to 2018. About 140 eligible patients with breast cancer were included and their information was collected and analyzed prospectively during the 3 years that they were referred to the surgery center in Tehran. The reconstruction was performed, as either direct-single staged, implant + TIGR MESH, or delayed-multistage. Patient satisfaction was calculated after 1 year of follow-up, using Body Checking Questionnaire (BCQ) by applying the VAS scale. All statistical analyses were performed at a 95% significance level, using SPSS statistical software version. (Evidence-based medicine level: Level III, a prospective cohort). Results: The results of our study showed slightly more short-term complications than other studies due to the surgical team’s first experience in the surgery. Complications were infection (7.1%), epidermal necrosis (15.9%), and severe capsular contracture (14.2%). Seven patients (6.2%) had full-thickness skin necrosis, and the prosthesis was finally removed. The use of the TIGR Mesh did not increase the rate of complications, and only 5 implant losses in this group and 2 in the tissue expander group were reported. The levels of patients’ satisfaction in IBR and delayed-multistage groups were 44.4% and 12.7%, respectively. Conclusions: Our results showed that placement of TIGR MESH for lower pole support during IBR does not increase the complication rate. Additionally, patients’ satisfaction levels increased compared to traditional methods of reconstruction.

From Sub-Pectoral to Pre-Pectoral Implant Reconstruction: A Decisional Algorithm to Optimise Outcomes of Breast Replacement Surgery

Innovations and advancements with implant-based breast reconstruction, such as the use of ADMs, fat grafting, NSMs, and better implants, have enabled surgeons to now place breast implants in the pre-pectoral space rather than under the pectoralis major muscle. Breast implant replacement surgery in post-mastectomy patients, with pocket conversion from retro-pectoral to pre-pectoral, is becoming increasingly common, in order to solve the drawbacks of retro-pectoral implant positioning (animation deformity, chronic pain, and poor implant positioning). A multicentric retrospective study was conducted, considering all patients previously submitted to implant-based post-mastectomy breast reconstruction who underwent a breast implant replacement with pocket conversion procedure at the University Hospital of Udine-Plastic and Reconstructive Surgery Department-and "Centro di Riferimento Oncologico" (C.R.O.) of Aviano, from January 2020 to September 2021. Patients were candidates for a breast implant replacement with pocket conversion procedure if they met the following inclusion criteria: they underwent a previous implant-based post-mastectomy breast reconstruction and developed animation deformity, chronic pain, severe capsular contracture, or implant malposition. Patient data included age, body mass index (BMI), comorbidities, smoking status, pre- or post-mastectomy radiotherapy (RT), tumour classification, type of mastectomy, previous or ancillary procedures (lipofilling), type and volume of implant used, type of ADM, and post-operative complications (breast infection, implant exposure and malposition, haematoma, or seroma). A total of 31 breasts (30 patients) were included in this analysis. Just three months after surgery, we recorded 100% resolution of the problems for which pocket conversion was indicated, which was confirmed at 6, 9, and 12 months post-operative. We also developed an algorithm describing the correct steps for successful breast-implant pocket conversion. Our results, although only early experience, are very encouraging. We realized that, besides gentle surgical handling, one of the most important factors in proper pocket conversion selection is an accurate pre-operative and intra-operative clinical evaluation of the tissue thickness in all breast quadrants.

Immediate Breast Reconstruction in Skin-Reducing Mastectomy with Prepectoral Polyuretane (Pu) Implant Covered with an Autologous Dermo-Adipose Flap.

The aim of this study was to present our new technique of immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, in skin-reducing mastectomy both for risk-reducing (prophylactic mastectomy) and therapeutic cases. We performed a single-center, retrospective review of 21 patients (mean age 47 years), undergone skin-reducing mastectomy and immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, un the period January 2018-June 2021. All procedures were performed by the same surgeon. A total of 36 skin-reducing mastectomies (6 curative, 15 prophylactic) with one-stage prepectoral PU foam-coated implant and autologous dermo-adipose flap reconstruction were performed. All postoperative complications were collected. Quality of life (QoL) and satisfaction with reconstruction were evaluated through the BREAST-Q questionnaire, administered preoperatively and at 12 months after surgery. Independent Student's t tests were used to compare means of continuous variables and Chi-square test was used for ordinal variables. A p-value ≤0.05 was considered statistically significant. Uni- and multiple linear regression analyses were used to confirm all results. Out of 21 patients, we observed one small wound dehiscence and one partial Nipple-Areola Complex (NAC) necrosis. All cases of minor complications were managed conservatively and did not affect the quality of the final outcome. No implant loss was observed. No significant severe capsular contracture (grade III or IV) was detected at follow-up. Overall satisfaction with breasts, psychosocial, physical and sexual well-being all significantly increased, analyzing BRAST-Q data. Statistical analysis showed a significant influence of diabetes on the risk of complications. Our experience suggests that the procedure described is effective, feasible and cost-effective. It is easier to perform compared to similar and more demanding procedure, reduces operative time, and minimizes complications related to manipulation of the pectoralis major muscle, while also contributing to the containment of costs. Moreover, it appears to be oncologically safe, provides good esthetic results with low postoperative complication rate and leads to high level of patients' satisfaction. 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 .

Postmastectomy Radiation Therapy in the Setting of Two-Stage Retropectoral Implant-Based Breast Reconstruction: Should It be Delivered Before or After Implant Exchange? A Retrospective Analysis on 183 Patients.

Postmastectomy radiation therapy (PMRT) has a primary role in the treatment of locally advanced breast cancer; however, the most appropriate timing of irradiation in immediate tissue expander breast reconstruction (ITEBR) still remains unknown. A retrospective review was performed on all women undergoing mastectomy and retropectoral ITEBR at Campus Bio-Medico University Hospital in Rome, Italy, between 2010 and 2019. The patients were categorized into three cohorts: patients undergoing PMRT with the tissue expander (TE) in situ, patients with PMRT delivered to the permanent implant (PI), patients who were not administered RT. Complications and failure rates were analysed and compared. Potential predictors of adverse outcomes were analysed. Over 10 years, 183 patients underwent retropectoral ITEBR (55 PMRT-TE, 50 PMRT-PI, 78 no-PMRT). The three groups were well matched with respect to patient- and treatment-related factors (p > 0.05), with the exception of neoadjuvant chemotherapy and irradiation. The mean follow-up was, respectively, 4.58, 7 and 5.75 years. Radiotherapy either to the TE or to the PI was independently associated with failure and conversion to autologous procedures (p < 0.0001). Failure rate was significantly higher when TE was irradiated (p = 0.03). PMRT was associated with severe capsular contracture development (p < 0.00001), the odds being higher when irradiation was delivered after implant exchange (p = 0.04). Increased BMI was significantly associated with failure. When PMRT is delivered to the TE, the risk of failure is higher (OR 2.77); when the PI is irradiated, reconstruction will more likely be affected by severe capsular contracture (OR 2.7). However, considering that the overall risk of severe capsular contracture correlated to PMRT is higher than failure, we believe that irradiation should be delivered to the TE. Performing a proper capsuloplasty at the time of implant exchange, indeed, allows to correct the deformities related to radiation-induced capsular contracture. Patients with unfavourable outcomes after TE placement and RT, instead, can be directly switched to autologous reconstruction. 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 .

Association of Radiation Timing with Long-Term Satisfaction and Health-Related Quality of Life in Prosthetic Breast Reconstruction.

Radiation therapy is increasingly used after breast cancer surgery, which may impact patients' postoperative quality of life. This study assessed differences in long-term patient satisfaction and health-related quality of life after radiation therapy administered at different stages of implant-based breast reconstruction or with no radiation after surgery. In this observational study, long-term outcomes were evaluated for four cohorts of women who completed breast reconstruction and received (1) no radiation, (2) radiation before tissue expander placement, (3) radiation after tissue expander placement, or (4) radiation after permanent implant between 2010 and 2017 at Memorial Sloan Kettering. Satisfaction and health-related quality of life were assessed using the prospectively collected Satisfaction with Breasts and Physical Well-Being of Chest BREAST-Q subscales. Score distributions were examined by radiation exposure status for 3 years after surgery using nonparametric analyses and regression models. Of 2932 patients who met the inclusion criteria, 25.8 percent received radiation during breast cancer treatment, including before tissue expander placement ( n = 239; 8.2 percent), after tissue expander placement ( n = 290; 9.9 percent), and after implant placement ( n = 228; 7.8 percent). Radiotherapy patients had average scores 7 to 9 points lower at all postoperative time points for Satisfaction with Breasts and Physical Well-Being of Chest subscales ( p < 0.001). Although patient-reported outcomes did not differ by radiation timing, there were higher rates of severe capsular contracture with postimplant radiotherapy ( p < 0.001). Radiation therapy significantly affected patient satisfaction and health-related quality of life following implant breast reconstruction through 3 years postoperatively. Patient perception of outcome was unaffected by radiotherapy timing; however, capsular contracture was higher after postimplant radiotherapy, suggesting there may be an advantage to performing radiotherapy before placement of the final reconstruction. Therapeutic, III.

Latissimus dorsi muscle flap transfer through endoscopic approach combined with the implant after tissue expansion for breast reconstruction of mastectomy patients

BackgroundImplant-based breast reconstruction is easy to be performed but has flaws that an unnatural appearance might be presented when no sufficient coverage existing. While autologous tissue reconstruction also has disadvantages like donor site scar and skin patch effect. There is a demand for a new method to obtain natural and aesthetic appearance while surmounting drawbacks of conventional breast reconstruction surgery.Methods A retrospective review of thirty-one patients undergoing tissue expander (TE)/implant two-stage breast reconstruction with latissimus dorsi muscle flap (LDMF) transfer through endoscopic approach in Peking University Third Hospital from April 2016 to August 2020 was performed. The LDMF harvest time, drain time, and complications were reviewed. The 3D volume was obtained to assess the volume symmetry of bilateral breasts. The BREAST-Q reconstruction module was used to evaluate the satisfaction.Results The mean endoscopic LDMF harvest time was 90.4 min. In the mean follow-up of 11.2 months, there were no severe capsular contracture happened. The reconstructed side achieved good volume symmetry to the contralateral side (P = 0.256). Based on the evaluation of the BREAST-Q scores, the outcome of Satisfaction with Breasts was excellent or good in 87.1% of the cases.Conclusions The novel type of two-stage breast reconstruction protocol, which includes tissue expansion followed by implant insertion with endoscopy-assisted LDMF transfer, could effectively reduce visible scars, avoid the patch effect, while require short time for LDMF harvest and present low incidence of complications. It is a promising method for breast reconstruction because it achieves good outcomes in the mastectomy patients.

Outpatient Cosmetic Breast Augmentation with DIEP Flaps

BACKGROUND: Breast augmentation ranks as one of the most commonly performed cosmetic procedures. It is a relatively inexpensive and straightforward procedure that yields good results with low risk. However, potential problems with implants exist such as deflation, leaks, malposition, pain, and capsular contraction. Breast Implant Illness (BII) or Breast Implant Associated Lymphoma (BIA-ALCL) remains a high concern for many patients. As a reliable alternative or treatment for these issues and concerns, the authors describe the use the deep inferior epigastric perforator (DIEP) flap in outpatient cosmetic breast augmentation and mastopexy. METHODS: We reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. Charts were reviewed for all patients who elected to proceed with cosmetic DIEP flaps. All patients underwent our early recovery protocol, including microfascial incisions to harvest the DIEP flaps, and rib preservation in addition to ERAS protocols with intraoperative anesthetic blocks. RESULTS: Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients referred dissatisfaction with their abdomen and breasts. Three patients presented with ptotic breasts following recent pregnancies. Four patients were displeased with their breasts following augmentation with prosthetic implants. Three patients were experiencing pain and discomfort due to bilateral capsular contractures, with two of them being consistent with Breast Implant Illness. Lastly, one patient decided to undergo breast augmentation following bariatric surgery. Microfascial incisions for single perforator abdominal flaps (n = 17) averaged 1.7 cm (range 1.3–2.4), while flaps with multiple perforators (n = 5) averaged 2.4 cm (range 2-–2.5). Dissection of recipient IMA vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses were reported, without major complications or take-backs. Average follow-up was 15 weeks. One patient required in-office debridement and closure due to suture granuloma at the abdominal incision. One patient developed minimal T-zone necrosis of the mastopexy site, which healed secondarily. Another patient, who had undergone prior mini-abdominoplasty, had limited flap edge necrosis that also healed secondarily. DISCUSSION: Combined breast augmentation or augmentation mastopexy with abdominoplasty is a commonly performed surgical procedure. Patients who desire abdominoplasty and augmentations are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. Likewise, women with implant complications like severe capsular contractures, or patients who have concerns for BIA-ALCL or have Breast Implant Illness, yet would like to maintain breast volumes, are excellent candidates. These conditions and the fear of these problems required other reliable options for breast augmentation or removal of implants secondary to refractory illness. Our early recovery protocol allows us to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with outstanding results and no total or partial flap losses, thus offsetting the high costs associated with the DIEP flap.

Complications after breast reconstruction with alloplastic material in breast cancer patients submitted or not to post mastectomy radiotherapy.

Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material. Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications. 251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications. The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.

Retraction: Failure of an Ancient Breast Implant Can Lead to Significant Morbidity.

[This retracts the article DOI: 10.7759/cureus.13700.].

TERTIARY BREAST RECONSTRUCTION: A PROSPECTIVE STUDY ON COSEMETIC OUTCOME AND PERIOPERATIVE COMPLICATIONS

Implant breast reconstruction has seen an upturn over the last decade leading to a rise in referrals of failed prosthetic cases that require salvage by conversion to autologous reconstruction, the most popular being free tissue transfer. This salvage breast reconstruction is complex because of the older patient population with increased comorbidities, effects of previous treatments and inevitable intraoperative challenges. Notable issues include irradiated and scarred skin, severe capsular contracture (CC) and silicone lymphadenopathy. There is also difficulty and potential vascular injury during internal mammary recipient vessel exposure due to scarring, and increased bleeding risk during and after the required capsulectomies. Breast Cancer Conservation therapy cosmetic results BCCT.core computer software program was initially used to assess objectively cosmetic outcomes for lumpectomies but it’s now used for total post mastectomy breast reconstructions. Whilst it is well established that free flap conversion addresses the pain, firmness and cold feel of prosthetic reconstructions (from severe CC) and subjectively improves the cosmetic results, there has hitherto been no objective documentation of the improvement in aesthetic outcomes.

Complications and Pattern of Failure Following Immediate Breast Reconstruction after Breast Cancer Surgery: A Retrospective Analysis over Nine Years

Post-operative radiotherapy (RT) has been reported to increase the complications following immediate breast reconstruction (IBR) for breast cancer (BC) patients. ESTRO guideline in 2019 has published the recommendation for CTV-chest wall definition in retro-pectoral IBR-implant reconstruction (IBR-i), which excludes the implant on the dorsal border in patients with no risk factors. The guideline aims to decrease the RT-related complications without compromising the oncological outcomes. The present study aims to explore risk factors related with complications after IBR and the pattern of local-regional recurrence (LRR) to view the potential benefit of delineation recommendation and oncological safety of CTV border. Consecutive BC patients treated with IBR in single center from Jan.2009 to Dec.2018 were retrospectively analyzed. Reconstruction failure (RF) is defined as any unplanned implantation/replacement/adjustment of implants, or complete loss/necrosis of autologous flaps. Severe capsular contracture (CC) is defined as requiring capsulotomy or capsulectomy. Univariate and multivariate analysis were performed using logistic regression analysis. In total, 265 patients undergoing 274 IBR were reviewed, including 262 breasts receiving retro-pectoral IBR-i with or without latissimus dorsi flaps and 12 autologous flaps only. The median age was 40 years. A total of 55 breasts received RT and CTV was defined to include entire implants or flaps. In total, RF events occurred in 15 (5.5%) breasts and the most common cause (60%) of RF was implant exposure and/or infection. Univariate analysis showed that adjuvant chemotherapy (CT) and BMI were both significant risk factors for RF while RT was not (OR 0.995, 95% CI 0.271-3.656, p = 0.994). Multivariate analysis showed that only adjuvant CT was the significant risk factor for RF (OR 6.283, 95% CI 1.332-29.643, p = 0.02). CC was evaluated in 262 breasts with IBR-i. Severe CC occurred in 11 patients, with 7 in the RT group. Multivariate analysis showed that RT was the only significant risk factor for developing severe CC (OR 4.000, 95% CI 1.017-15.738, p = 0.047). After a median follow-up of 44 months, 6 LRR events were observed, including 2 in chest-wall, 1 in nipple-areolar and 3 in axilla. No recurrence in pectoral muscles, ribs or intercostal muscles was observed. None of recurrence occurred outside the border of ESTRO CTV-chest wall recommendation. The 5-year recurrence from survival (RFS), local-regional RFS and overall survival were 93.0%, 98.2% and 98.7%, respectively. IBR after BC surgery yields a low rate of RF and severe CC. Adjuvant CT was associated with increased risk of RF. Post-operative RT remains a risk factor for severe CC. Pattern of LRR in our study supports the oncological safety of ESTRO delineation guideline. Further study is needed to confirm if the new delineation will help to decrease the RT-related complications in patients with IBR.