Subpectoral Reconstruction Research Articles

“Prepectoral tissue expanders without mesh as a bridge to delayed autologous breast reconstruction: Experience at a single academic center”

Acellular dermal matrix (ADM) is a useful adjunct in implant-based breast reconstruction. The benefits of using ADM with an expander as a temporary bridge to delayed autologous reconstruction are unknown. Placing prepectoral tissue expanders, without ADM, as a bridge to delayed autologous reconstruction could yield cost savings, shorten operating time and decrease complications. This investigation seeks to demonstrate the safety of placing prepectoral tissue expanders without ADM at the time of mastectomy as the first stage of autologous breast reconstruction. A retrospective, chart review was performed at our major academic institution between 2015 and 2020. Included were female patients, 18 years or older at the time of reconstruction, who underwent mastectomy with prepectoral tissue expander placement followed by autologous breast reconstruction at a delayed second stage. Excluded were patients of male gender, younger than 18, patients with lumpectomy only, subpectoral reconstruction, or immediate autologous reconstruction. Data on ADM, patient demographics, comorbidities, and cancer treatment were collected. There were 189 reconstructed breasts of which 56 (29.6 %) used ADM, 131 (69.3 %) did not use ADM, and 2 patients (1.1 %) of unknown ADM use. Expanders were in place for a mean time of 8.9±6.2 months. There was no statistically significant difference in complication rates between the ADM and no-ADM groups. Therefore, not wrapping prepectoral tissue expanders in ADM, at the time of mastectomy, has an equivalent rate of complications compared to ADM wrapping among patients who go on to have second stage autologous breast reconstruction.

Use of Fascia Lata as Matrix for Subpectoral Breast Reconstruction.

Matrices are used with increased frequency to assist with tissue expander or implant-based breast reconstruction. These devices usually have a high cost, especially when they are human-derived. We present the use of fascia lata for implant and expander-based subpectoral reconstruction. According to our review of the literature, this is the first report of the use of a patient's own fascia lata instead of a matrix.

Prepectoral versus Subpectoral Breast Reconstruction after Nipple-sparing Mastectomy: A Systematic Review and Meta-Analysis.

Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) presents unique benefits and challenges. The literature has compared outcomes among total submuscular (TSM), dual-plane (DP), and prepectoral (PP) planes; however, a dedicated meta-analysis relevant to NSM is lacking. We conducted a systematic review of studies on immediate breast reconstruction after NSM using TSM, DP, or PP prosthesis placement in PubMed, Embase, and Cochrane databases. In total, 1317 unique articles were identified, of which 49 were included in the systematic review and six met inclusion criteria for meta-analysis. Pooled descriptive outcomes were analyzed for each cohort for all 49 studies. Fixed-effects meta-analytic methods were used to compare PP with subpectoral (TSM and DP) reconstructions. A total of 1432 TSM, 1546 DP, and 1668 PP reconstructions were identified for descriptive analysis. Demographics were similar between cohorts. Pooled descriptive outcomes demonstrated overall similar rates of reconstructive failure (3.3%-5.1%) as well as capsular contracture (0%-3.9%) among cohorts. Fixed-effects meta-analysis of six comparative studies demonstrated a significantly lower rate of mastectomy flap necrosis in the PP cohort compared with the subpectoral cohort (relative risk 0.24, 95% confidence interval [0.08-0.74]). All other consistently reported outcomes, including, hematoma, seroma, infection, mastectomy flap necrosis, nipple -areola complex necrosis, and explantation were comparable. A systematic review of the literature and meta-analysis demonstrated the safety of immediate prepectoral breast reconstruction after NSM, compared with submuscular techniques. Submuscular reconstruction had a higher risk of mastectomy flap necrosis, though potentially influenced by selection bias.

The Impact of Radiation on Nipple Symmetry After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: An Objective Analysis.

Radiation therapy can adversely affect outcomes of implant-based breast reconstruction, potentially complicating procedures like nipple-sparing mastectomy (NSM), which is increasingly popular in breast cancer management. This study aims to evaluate the impact of radiation on nipple symmetry in patients undergoing bilateral NSM with implant-based reconstruction. We conducted a retrospective analysis using data from an Emory University review board-approved database. This encompassed bilateral NSMs coupled with immediate implant-based reconstructions. The BCCT.core software was employed to objectively measure nipple asymmetry preoperatively and postoperatively. Metrics, such as Breast Retraction Assessment values, upper nipple retraction, lower breast contour, and nipple to midline (NML) discrepancies were quantified. The study included 80 patients with a minimum of 1 year of follow-up; among them, 15 received radiation therapy (RT) while 65 did not. The reconstructions were divided into tissue expander, used in 39 cases (48.8%), and direct-to-implant (DTI), employed in 41 cases (51.2%). The DTIs were further categorized based on the location of the implant: 22 subpectoral and 19 prepectoral. Radiation was applied to 15 breasts, distributed among prepectoral DTI (4), subpectoral DTI (6), and tissue expander (5). Breast Retraction Assessment scores significantly differed between the nonirradiated and irradiated groups (1.49 vs 2.64, P < 0.0004). Nipple to midline differences and Upper Nipple Retraction also significantly varied postradiation, especially when comparing subpectoral and prepectoral implant placements. Radiation therapy has a detrimental effect on nipple symmetry after bilateral NSM and implant-based reconstruction, with variations seen regardless of the implant's placement or the reconstructive technique utilized. Specifically, subpectoral reconstructions irradiated were prone to lateral nipple displacement, likely related to radiation-induced pectoralis muscle changes, while prepectoral irradiated reconstructions tended to have increased vertical displacement. These insights are crucial for patient education and surgical planning in the context of radiation and breast reconstruction.

Improvement of Shoulder Motion in Two-Stage Dual-Plane Implant-Based Breast Reconstruction followed by Radiation Therapy through Delayed Prepectoral Conversion.

Background Although prepectoral implant-based breast reconstruction has recently gained popularity, dual-plane reconstruction is still a better option for patients with poor-quality mastectomy skin flaps. However, shoulder morbidity is aggravated by subpectoral reconstruction, especially in irradiated patients. This study aimed to demonstrate shoulder exercise improvement in subpectoral reconstruction by delayed prepectoral conversion with an acellular dermal matrix (ADM) inlay graft technique at the time of expander-to-implant exchange after irradiation. Methods Patients with breast cancer treated for expander-to-implant exchange after subpectoral expander insertion and subsequent radiotherapy between January 2021 and June 2022 were enrolled. An ADM inlay graft was inserted between the pectoralis major muscle and the previously inserted ADM. The ADM was sutured partially overlapping the pectoralis muscle from the medial side with the transition part, to the muscle border at the lateral side. Perioperative shoulder joint active range-of-motion (ROM) for forward flexion, abduction, and external rotation was also evaluated. Results A total of 35 patients were enrolled in the study. Active shoulder ROM significantly improved from 163 degrees preoperatively to 176 degrees postoperatively in forward flexion, 153 to 175 degrees in abduction, and 69 to 84 degrees in external rotation. There was no difference in patient satisfaction regarding the final outcome between the conventional prepectoral reconstruction group and the study group. Conclusion Shoulder exercises in irradiated patients who underwent subpectoral reconstruction were improved by delayed prepectoral conversion using an ADM inlay graft. It is recommended that subpectoral reconstruction not be ruled out due to concerns regarding muscle contracture and shoulder morbidity in radiation-planned patients with poor mastectomy skin flaps.

Meshed Dermal Sling for Prepectoral Breast Reconstruction.

The best breast reconstruction solution after mastectomy remains a topic of wide debate. Recently, the focus in the field of implant-based reconstruction has been on the increasing indications for prepectoral reconstruction. This offers undoubted advantages over subpectoral reconstruction, ranging from better aesthetic results and patient comfort to a less invasive procedure that spares the pectoralis major muscle, reducing pain and postoperative recovery time. The dermal sling is a reconstructive variant introduced by Bostwick in the 1990s and is commonly used to complete the subpectoral pocket in one- or two-stage reconstruction, creating a dual-plane reconstruction. This method may be indicated after mastectomy for both therapeutic and prophylactic purposes. It can also be used for unilateral and bilateral reconstructions. We propose a new meshed dermal sling technique that allows complete prepectoral reconstruction without the use of acellular dermal matrix, thus reducing the cost of reconstruction. It also allows the indication for complete prepectoral reconstruction to be extended to patients with medium breast volume and grade 1 or 2 ptosis, without the need to use acellular dermal matrix or the pectoralis major muscle to complete the breast pocket.

Impact of Prepectoral vs. Subpectoral Tissue Expander Placement on Post-mastectomy Radiation Therapy Delivery: A Retrospective Cohort Study.

Implant-based reconstruction is the most common method of postmastectomy reconstruction. Many patients require postmastectomy radiation (PMRT). Tissue expanders (TEs), typically inserted as a first stage, have historically been placed subpectorally. More recently, prepectoral reconstruction has gained popularity, but its impact on PMRT is unknown. Prior studies focus on complication rates and aesthetic outcomes. This study examines whether there is a difference in radiation dosimetry among patients undergoing prepectoral versus subpectoral TE reconstruction. Electronic medical records and radiation plans of 50 patients (25 prepectoral, 25 subpectoral) who underwent mastectomy with immediate TE reconstruction at our institution or affiliate site were reviewed. Pectoralis major muscle and chest wall structures were contoured and mean percentage volumes of these structures receiving less than 95%, 100%, and more than 105% target radiation dose were calculated, as were heart and ipsilateral lung doses. Welch two sample t test, Fisher exact test, and Pearson chi-squared tests were performed. The groups had comparable patient and tumor characteristics and underwent similar ablative and reconstructive procedures and radiation dosimetry. Subpectoral patients had larger mean areas receiving less than 95% target dose ("cold spots"); prepectoral patients had larger mean areas receiving greater than 105% ("hot spots") and 100% target doses. There were no differences in chest wall, heart, and lung doses. Our results demonstrate an increased mean percentage area of pectoralis cold spots with subpectoral reconstruction and increased area of hot spots and 100% dose delivery to the pectoralis in prepectoral patients. Larger studies should analyze long-term effects of prepectoral reconstruction on radiation dosing and recurrence rates.

Online Breast Reconstruction Risk Assessment (BRA) Score Tool in Prosthetic Breast Reconstruction in a Case Series with Cutoff Determination

AbstractThe Breast Reconstruction Risk Assessment (BRA) score is a tool for the prediction of the risk of complications in breast surgery, elaborated in 2014. This score assesses the risk of surgical complications related to each type of breast reconstruction technique. The purpose of this study was to evaluate the effectiveness of using the calculator on patients who underwent prosthetic breast reconstruction with submuscular tissue expander or prepectoral prosthesis. Our retrospective study analyzed 92 patients whose data was entered into the calculator. The predicted and observed 1-year rates of overall surgical complications were compared, separately for both cohorts. Subsequently, the accuracy, the applicability, and the discrimination ability of the BRA score were assessed using statistical analysis. In the two-stage subpectoral reconstruction group, Mann–Whitney U test showed a statistically significant difference in BRA-score values between the patients who developed complications compared to the patients who had no complications (p-value &lt; 0.02). Moreover, the score has an excellent discrimination ability (AUC = 0.9), and a cutoff of overall surgical complication rate was found to be between 17 and 18%. For the one-stage prepectoral prosthetic reconstruction group, the BRA score tool was unable to discriminate between patients with complications and patients without complication. Our results suggest that the BRA score can accurately identify patients with risk of complications following two-stage subpectoral breast reconstruction. Moreover, we believe it is possible to identify a risk rate cutoff of overall surgical complications that may potentially help physicians select the safest surgical strategy.

Pre-pectoral Breast Reconstruction: Surgical and Patient-Reported Outcomes of Two-Stages vs Single-Stage Implant-Based Breast Reconstruction

BackgroundTwo-stages pre-pectoral breast reconstruction may confer advantages over direct to implant (DTI) and subpectoral reconstruction in selected patients who have no indication for autologous reconstruction. The primary endpoint of the study was to evaluate and compare the incidence of capsular contracture in the pre-pectoral two-stages technique versus the direct to implant technique. Complications related to the two surgical techniques and patient satisfaction were also evaluated.MethodsA retrospective review of 45 two stages and 45 Direct-to-implant, DTI patients was completed. Acellular dermal matrix was used in all patients. An evaluation of anthropometric and clinical parameters, surgical procedures and complications was conducted. Minimum follow-up was 12 months after placement of the definitive implant.ResultsThere was no statistically significant difference in the rate of capsular contracture in the two groups. Rippling occurred more in DTI reconstruction. In the two-stages reconstruction, lipofilling was applied more often and there was a higher incidence of seroma. Patient satisfaction extrapolated from the Breast Q questionnaire was better for patients submitted to two-stage implant-based breast reconstruction.ConclusionDual-stage pre-pectoral reconstruction with acellular dermal matrix appears to be a good reconstructive solution in patients with relative contraindications for one-stage heterologous reconstruction with definitive prosthesis and no desire for autologous reconstruction.

Quantifying the Impact of Prepectoral Implant Conversion on Patient Satisfaction and Quality of Life.

Conversion of subpectoral reconstruction to the prepectoral plane has been increasing in popularity. However, there is a paucity of research assessing patient-reported outcomes after this operation. The primary aim of this study was to examine patient-reported outcomes after conversion of implants from the subpectoral to prepectoral plane using the BREAST-Q. The authors retrospectively examined patients who underwent subpectoral-to-prepectoral implant conversion by three surgeons at two separate centers from 2017 through 2021. Patient demographics, primary indication for the conversion, surgical characteristics, postoperative outcomes, and BREAST-Q scores were obtained. Sixty-eight breasts in 39 patients underwent implant conversion. The most common primary indications for implant conversion were chronic pain (41%), animation deformity (31%), and cosmetic concerns (28%). Average BREAST-Q scores improved significantly preoperatively to postoperatively in all the domains measured (satisfaction with breasts, satisfaction with implants, physical well-being, psychosocial well-being, and sexual well-being) ( P < 0.01). When examined by primary indication, all cohorts had significant preoperative to postoperative score improvement in satisfaction with breasts ( P < 0.001) and physical well-being ( P < 0.01) domains. Fifteen breasts (22%) developed postoperative complications, with implant loss in 9% of breasts. Conversion of subpectoral implants to the prepectoral plane significantly improves BREAST-Q outcomes in all aspects, including patient satisfaction with breasts and implants, as well as psychosocial, physical, and sexual well-being. Implant conversion to the prepectoral plane is becoming the authors' primary solution for most patients with chronic pain, animation deformity, or cosmetic concerns after subpectoral reconstruction. Therapeutic, IV.

Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction.

The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established. The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane. We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation. The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction. Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes.

54. Assessing Long Term Outcomes in Prepectoral Versus Subpectoral Alloplastic Breast Reconstruction

PURPOSE: Tissue expanders (TEs) and implants can be placed using a subpectoral or prepectoral approach. At this time, long term data is needed to more effectively interpret the differences in clinical and patient reported outcomes (PROs) between prepectoral and subpectoral reconstruction. METHODS: We retrospectively reviewed female patients who underwent TE exchange to implants from 2017 to 2020. Patients had subpectoral or prepectoral reconstruction, along with preoperative and/or 1-2-year postoperative BREAST-Q data. We assessed PROs and complication rates with null hypothesis testing (significant: p<0.05). RESULTS: 2116 patients were included: 1797 subpectoral and 319 prepectoral. Regarding BREAST-Q scores, prepectoral patients had significantly higher scores than subpectoral patients for physical well-being of the chest preoperatively (p<0.001) and at 1-2-years postoperatively (p=0.003) and for satisfaction with breasts scores at 1-2-years postoperatively. Complications were low overall, but patients with prepectoral devices were more likely to get an infection, seroma, or wound dehiscence (p<0.001, p<0.001, p=0.009, respectively). In a subgroup analysis of radiated patients (neoadjuvant or adjuvant) (n =508; 464 subpectoral, 44 prepectoral), there was no difference between BREAST-Q scores of subpectoral and prepectoral patients. Patients with prepectoral devices were more likely to be affected by seromas (p=0.004) or wound dehiscence (p=0.020). CONCLUSION: Our preliminary analysis shows that, among patients undergoing alloplastic breast reconstruction, PROs are superior following prepectoral placement. However, the complication profile slightly favors subpectoral reconstruction. Additional long-term analyses should be conducted to better assess the differences between the prepectoral and subpectoral technique.

PC35. PATIENT REPORTED OUTCOMES AND NIPPLE POSITION FOLLOWING NIPPLE-SPARING MASTECTOMY (NSM): A PROSPECTIVE EXAMINATION OF PREPECTORAL AND SUBPECTORAL PATIENTS

PURPOSE: Nipple-sparing mastectomy (NSM) is becoming more popular. The role of pocket dissection (prepectoral vs subpectoral) in implant-based reconstruction on patient reported outcomes (PRO’s) and nipple position following NSM has not yet been explored. We hypothesize that prepectoral reconstruction results in superior PRO’s and more anatomical nipple position compared to subpectoral reconstructions following NSM. METHODS: Surgical details and short-term complication in NSM patients from 2018 to 2021 were prospectively collected. PROs were obtained preoperatively, 6 and 12 months postoperatively. Nipple displacement from baseline was analyzed using three-dimensional(3D) surface imaging by three independent researchers. RESULTS: 216 patients who underwent 391 NSM were divided into two cohorts, subpectoral and prepectoral. There were no differences in demographics or comorbidities between cohorts. Prepectoral patients (N=83 (86%) vs. 54 (44%); p<0.001) reported better physical well-being of the chest preoperatively (median 76, IQR 67,92 vs 72, IQR 64,80; p=0.022). No other differences in PRO’s or complications were observed. Linear regression suggested that radiation is the most important factor impacting satisfaction following NSM. 3D photographs for 97 patients were analyzed and 175 nipple positions were measured in 3 dimensions. Controlling for implant size, there was greater elevation and less projection of the nipple compared to baseline in subpectoral cohort (elevation: median -16 mm, IQR -24,-7 vs -3 mm, IQR -12,5; p<0.001; projection: median -1 mm, IQR -9,6 vs -6 mm, IQR -14,4; p=0.002). CONCLUSION: Implant pocket did not impact PRO’s or short-term complications in patients who underwent NSM. Patients with prepectoral reconstruction had less nipple displacement and more nipple projection following NSM.

28. Enhanced Recovery After Surgery (ERAS) Protocol Allows Safe Same-day Discharge in Expander Based and Oncoplastic Breast Reconstruction

PURPOSE: Data following Enhanced Recovery After Surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes following same-day discharge in tissue expander-immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction (OBR). METHODS: A single-institution retrospective review of TE-IBR patients from 2017-2022 and OBR patients from 2014-2022. Patients were divided by procedure and recovery pathway: Group 1 (TE-IBR, overnight admission), Group 2 (TE-IBR, ERAS), Group 3 (oncoplastic, overnight admission), and Group 4 (oncoplastic, ERAS). Group 1 and 2 were subdivided by implant location: Group 1a (pre-pectoral) and 1b (sub-pectoral); Group 2a (pre-pectoral) and 2b (sub-pectoral). Demographics, comorbidities, complications, and reoperations were analyzed. RESULTS: 160 TE-IBR patients (Group 1: 91; Group 2: 69) and 60 OBR patients (Group 3: 8; Group 4: 52) were included. Of the 160 TE-IBR patients, 73 underwent pre-pectoral reconstruction (Group 1a: 25; Group 2a: 48) and 87 underwent sub-pectoral reconstruction (Group 1b: 66; Group 2b: 21). There were no differences in demographics and comorbidities between Groups 1 and 2. Group 3 had a higher average BMI than Group 4 (37.6 vs 32.2, p <0.022). There was no significant difference between Groups 1a and 2a or between Groups 1b and 2b in rates of infection, hematoma, TE loss, or reoperations. Notably, no ERAS patients required hospital admission. Group 3 and Group 4 showed no significant difference in any complications or in reoperations. CONCLUSION: Our research shows that same-day discharge in both TE-IBR and OBR does not increase risk for major complications or reoperations.

Subpectoral Implant Placement Is Not Protective against Postmastectomy Radiotherapy-Related Complications Compared to Prepectoral Placement.

Postmastectomy radiotherapy (PMRT) is associated with altered cosmetic outcomes and higher complication rates in implant-based breast reconstruction (IBR). Conventional wisdom suggests that muscle coverage is somewhat protective against PMRT-related complications. In this study, the authors compared surgical outcomes in patients who underwent two-stage prepectoral versus subpectoral IBR in the setting of PMRT. The authors performed a retrospective cohort study of patients who underwent mastectomy and PMRT with two-stage IBR from 2016 to 2019. The primary outcome was breast-related complications, including device infection; the secondary outcome was device explantation. The authors identified 179 reconstructions (101 prepectoral and 78 subpectoral) in 172 patients with a mean follow-up time of 39.7 ± 14.4 months. There were no differences between the prepectoral and subpectoral reconstructions in rates of breast-related complications (26.7% and 21.8%, respectively; P = 0.274), device infection (18.8% and 15.4%, respectively; P = 0.307), skin flap necrosis (5.0% and 1.3%, respectively; P = 0.232), or device explantation (20.8% and 14.1%, respectively; P = 0.117). In adjusted models, compared with prepectoral device placement, subpectoral device placement was not associated with a lower risk of breast-related complications [hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.41 to 1.36], device infection (HR, 0.73; 95% CI, 0.35 to 1.49), or device explantation (HR, 0.58; 95% CI, 0.28 to 1.19). Device placement plane was not predictive of complication rates in IBR in the setting of PMRT. Two-stage prepectoral IBR provides safe long-term outcomes with acceptable postoperative complication rates comparable to those with subpectoral IBR, even in the setting of PMRT. Therapeutic, III.

Enhanced Recovery After Surgery Protocol Allows Safe Same-Day Discharge in Expander Based and Oncoplastic Breast Reconstruction.

Data after enhanced recovery after surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes after same-day discharge in tissue-expander immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction. A single-institution retrospective review of TE-IBR patients from 2017 to 2022 and oncoplastic breast reconstruction patients from 2014 to 2022 was performed. Patients were divided by procedure and recovery pathway: group 1 (TE-IBR, overnight admission), group 2 (TE-IBR, ERAS), group 3 (oncoplastic, overnight admission), and group 4 (oncoplastic, ERAS). Groups 1 and 2 were subdivided by implant location: groups 1a (prepectoral) and 1b (subpectoral), and groups 2a (prepectoral) and 2b (subpectoral). Demographics, comorbidities, complications, and reoperations were analyzed. A total of 160 TE-IBR patients (group 1, 91; group 2, 69) and 60 oncoplastic breast reconstruction patients (group 3, 8; group 4, 52) were included. Of the 160 TE-IBR patients, 73 underwent prepectoral reconstruction (group 1a, 25; group 2a, 48), and 87 underwent subpectoral reconstruction (group 1b, 66; group 2b, 21). There were no differences in demographics and comorbidities between groups 1 and 2. Group 3 had a higher average body mass index than group 4 (37.6 vs 32.2, P = 0.022). There was no significant difference between groups 1a and 2a or between groups 1b and 2b in rates of for rates of infection, hematoma, skin necrosis, wound dehiscence, fat necrosis, implant loss, or reoperations. Group 3 and group 4 showed no significant difference in any complications or in reoperations. Notably, no patients in same-day discharge groups required unplanned hospital admission. Many surgical subspecialities have successfully adopted ERAS protocols into their patient care and have shown both its safety and feasibility. Our research shows that same-day discharge in both TE-IBR and oncoplastic breast reconstruction does not increase risk for major complications or reoperations.

Predicting Final Implant Volume in Two-Stage Prepectoral Breast Reconstruction

Introduction: Two-stage implant based breast reconstruction remains the most commonly performed post-mastectomy reconstruction. While prior studies have explored the relationship between tissue expander (TE) features and permanent implant (PI) size in subpectoral reconstruction, recent trends have demonstrated a shift towards prepectoral implant placement with acellular dermal matrix (ADM). This study aims to identify pertinent TE characteristics and evaluate their correlations with PI size for prepectoral implant-based reconstructions. Materials and Methods: This study analyzed patients who underwent two-stage prepectoral tissue expansion for breast reconstruction followed by implant placement at single institution. Exclusion criteria were delayed, autologous, and direct-to-implant breast reconstruction patients. Clinical and demographic patient data were collected for the cohort. TE and PI features were recorded, along with mean TE size, PI size, and mean mastectomy weights. Significant predictors for PI volume were identified with regression analysis. Results: We identified 177 patients and 296 breast reconstructions that met the inclusion criteria. Multivariate analysis identified significant variables for PI size prediction, including mastectomy weight (R2=0.42; p<0.0001), TE size (R2=0.60; p<0.0001), and TE final fill (R2=0.57; p<0.0001). The prediction expression was calculated to model the correlation: PI size = 26.6 + 0.38*(TE final fill) + 0.61*(TE size). Conclusion: Tissue expander size, final expansion volume, and mastectomy weight were significant variables for implant size prediction. The formula yielded significant regression coefficient values for TE size and final fill. With prepectoral implant placement gaining popularity, this algorithm may help optimize preoperative planning for prepectoral reconstructions.

The Utility of a Lateral Adipodermal Flap in Prepectoral Direct-to-implant Breast Reconstruction.

Prepectoral implant-based breast reconstruction has become more common given the reduced dissection, decreased postoperative pain, elimination of animation deformity, and improved aesthetics compared with subpectoral reconstructions. Despite these benefits, surgeons must contend with increased rates of implant rippling and more tenuous implant positioning and coverage, especially in direct-to-implant reconstructions. Although the use of an acellular dermal matrix can assist with both implant rippling and support/positioning, it does not protect against implant exposure, and rippling can still occur, despite its use, with significant additional cost. This article looks into the use of a lateral adipodermal flap that assists with reducing the mismatch between the excess skin and implant surface area, implant positioning (by helping secure the lateral mammary fold), and providing implant coverage. Twenty-two patients underwent 38 nipple-sparing mastectomies and prepectoral direct-to-implant reconstructions using a lateral adipodermal flap without acellular dermal matrix. No patients had evidence of implant malposition or exposure with at least 6 months follow-up. The author concludes that the lateral adipodermal flap may be helpful in securing the lateral mammary fold, reducing excess skin and providing viable tissue coverage in patients undergoing prepectoral direct-to-implant reconstruction.

Abstract P4-07-13: Satisfaction of patients after implant-based subpectoral reconstruction with a titanized polypropylene mesh (TiLOOP® Bra) compared to prepectoral reconstruction with a titanzied polypropylene pocket (TiLOOP® Bra Pocket)

Abstract Introduction Patients’ satisfaction after breast reconstruction can be evaluated with validated questionnaires as the Breast-Q questionnaire. The Breast-Q questionnaire includes different domains; one of them is “satisfaction with the result”. Material and methods: In the multicentre, prospective studies PRO (patient related outcome)-BRA (clinicaltrials.gov: NCT01885572) and PRO-Pocket (clinicaltrials.gov: NCT03868514), patient satisfaction was assessed using the Breast-Q questionnaire. In the PRO-Bra study, 269 patients underwent subpectoral surgery using the TiLOOP® Bra polypropylene mesh (pfm medical ag, Germany). In the "PRO-Pocket" study, 311 patients underwent prepectoral surgery using the TiLOOP® Bra Pocket polypropylene mesh. For the evaluation, those patients from the PRO-Bra and PRO-Pocket studies who completed a Breast-Q questionnaire 6 and/or 12 months after surgery were included. The BreastQ score is measured from 0 to 100, with a score of 100 corresponding to "very satisfied". Satisfaction with the result of the breast reconstruction was evaluated. Results: In the PRO-Bra study, a total of 221 and 203 patients completed a Breast-Q at 6 months and/or 12 months FU, respectively. The mean age and BMI of the patients with completed Breast-Q were comparable between the two studies (PRO-Bra: 49.3 [±11.6] years, 22.9 kg/m2 [±3.5]; PRO-Pocket: 47.7 [±11.7] years, 24.5 kg/m2 [±4.3]). In the PRO-Pocket study, a total of 258 and 266 patients completed a Breast-Q at 6 months and/or 12 months FU, respectively. In the PRO-Bra study the mean score of satisfaction with the result at 6 months follow-up (FU) was 74.5 (±19.9), in the PRO-Pocket 79.1 (±19.1), at 12 months FU the mean scores were 76.3 (±18.9) for PRO-Bra and 78.2 (±20.4) for PRO-Pocket. Furthermore, stratification according to age (cutoff 50 years) or BMI (cutoff 25 kg/m2) did not reveal any differences between the subgroups or the two studies (see Table). PRO-Bra PRO-Pocket mean score (±SD) 6 months 12 months 6 months 12 months BMI ≤ 25 75.1 (±19.7) 76.4 (±17.8) 77.7 (±19.9) 78.9 (±19.8) BMI &amp;gt; 25 72.1 (±20.7) 76.1 (±22.9) 82.1 (±16.9) 76.8 (±21.8) age ≤ 50 76.4 (±18.7) 77.0 (±18.9) 80.1 (±18.7) 78.1 (±19.6) age &amp;gt; 50 71.5 (±21.5) 75.3 (±19.0) 77.5 (±19.5) 78.4 (±21.8) Conclusion: Our data so far show high patient satisfaction with overall outcome of the surgery. In addition, patients’ satisfaction with the result was comparable after subpectoral as well as prepectoral implant placement. This is particularly important in the PRO-Pocket study, as approximately 60% of the operations and the follow-up period took place during the COVID-19 pandemic. Citation Format: Stefan Paepke, Anne Andrulat, Christine Ankel, Lelia Bauer, Kristin Baumann, Jens-Uwe Blohmer, Andree Faridi, Visnja Fink, Claudia Gerber-Schaefer, Daphne Gschwantler-Kaulich, Jörg Heil, Sherko Kuemmel, Anette Kossmann-Meiré, Ralf Ohlinger, Marc Thill. Satisfaction of patients after implant-based subpectoral reconstruction with a titanized polypropylene mesh (TiLOOP® Bra) compared to prepectoral reconstruction with a titanzied polypropylene pocket (TiLOOP® Bra Pocket) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-13.

A systematic review and meta-analysis of postmastectomy radiation therapy on prepectoral versus subpectoral breast reconstruction.

Prepectoral breast reconstruction has once again appealed, which attributes to the introduction of acellular dermal matrices (ADMs) and mesh. Postmastectomy radiation therapy (PMRT), meanwhile, is crucial in the whole course of treatment for breast cancer patients with lymph node-positive. The impact of PMRT on outcomes after prepectoral breast reconstruction has not been clearly defined to date. This study aimed to compare the impact of PMRT on outcomes after prepectoral vs. subpectoral breast reconstruction. A comprehensive research on databases including PubMed, Embase, and Cochrane libraries was performed to retrieve literature pertaining to prepectoral breast reconstruction from database inception to October 2021. All included studies evaluated the impact of PMRT on outcomes after breast reconstruction. Only studies comparing patients who underwent prepectoral breast reconstruction with a control group who underwent subpectoral breast reconstruction were included. Data were analyzed using RevMan version 5.2. A total of 4 studies were included in the meta-analysis, with a total of 394 breasts. In the setting of postmastectomy radiation therapy, 164 breasts were reconstructed with a prepectoral approach, whereas the remaining 230 breasts underwent subpectoral reconstruction. Overall, outcomes between PBR and SBR was no statistical significance in the overall complications (OR: 1.30, 95% CI: 0.35-4.85), infection (OR: 1.62, 95% CI: 0.90-2.91), seroma (OR: 1.60, 95% CI: 0.48-5.27), skin flap necrosis (OR: 0.77, 95% CI: 0.17-3.45), hematoma (OR: 0.38, 95% CI: 0.10-1.41), wound dehiscence (OR: 0.82, 95% CI: 0.36-1.85). But, included studies lacked data about the patient quality of life and satisfaction with the outcome of the reconstructed breast. In the setting of postmastectomy radiation therapy, prepectoral breast reconstruction is a safe and effective option.