Tissue Expander-based Breast Reconstruction Research Articles

Predictors for Implant Rupture in Two-Stage Tissue Expander-Based Breast Reconstruction: A Retrospective Cohort Study.

Two-stage tissue expander/implant-based method has been used predominantly for breast reconstruction. Implant rupture is one of the bothersome complications, inducing additional morbidity including reoperation. The present study aimed to identify the independent factors associated with development of implant rupture. Patients who underwent immediate two-stage prosthetic breast reconstruction between 2010 and 2016 were reviewed. Inserted implants were followed up using magnetic resonance imaging every 2 years and/or ultrasound/computed tomography scans every 6 or 12 months that were conducted for cancer surveillance. Associations of perioperative and intraoperative variables with the development of implant rupture were evaluated. In total, 797 cases (744 patients) were analyzed. During a median follow-up of 43months after second-stage operation, implant rupture was identified in 22 cases. The 5-year cumulative incidence was 3.1%. Multivariable analyses showed that the interval between the first- and second-stage operations was inversely associated with the risk of implant rupture. Maximal discrimination was observed at the interval of 6.5months. Cases with an interval ≤6 months were associated with higher risks for implant rupture than those with ≥7 months, after adjusting for other variables. Type of implant was associated with the development of implant rupture, showing that using two kinds of fourth-generation implant (Allergan Biocell textured round and Allergan smooth round implants) was associated with a significantly increased risk of implant rupture compared with that of Mentor MemoryShape implants (fifth-generation implant). Several operation-related variables appear to be associated with implant rupture in two-stage prosthetic reconstruction.

Preoperative β-lactam antibiotic prophylaxis is superior to bacteriostatic alternatives in immediate expander-based breast reconstruction.

Staged implant-based breast reconstruction is the most common reconstructive modality following mastectomy. Postoperative implant infections can have a significant impact on adjuvant oncologic care and reconstructive outcome. Here, we investigate the impact of β-lactam antibiotics (i.e., bactericidal) compared to alternative antibiotic agents on postoperative outcomes for implant-based breast reconstruction. A retrospective analysis of patients who underwent immediate sub-pectoral tissue expander placement with an inferior acellular dermal matrix (ADM) sling at a single institution between May 2008 and July 2018 was performed. Patient demographics, comorbidities, and complication rates were retrieved. The impact of antibiotic regimen on postoperative outcomes, including infection rate and reconstructive failure, was investigated. A total of 320 patients with a mean age and BMI of 48.2 years and 25.0 kg/m2 , respectively, who underwent 542 immediate breast reconstructions were included in the study. The use of a β-lactam antibiotic was protective against postoperative infection (odds ratio [OR] = 0.467, p = .046), infection requiring operative management (OR = 0.313, p = .022), and reconstructive failure (OR = 0.365, p = .028). Extended, that is, post-discharge, prophylaxis was not associated with any clinical benefit. The use of β-lactam antibiotics for pre-/peri-operative prophylaxis is superior to alternative antibiotics with a bacteriostatic mechanism of action regarding rates of postoperative infection and reconstructive failure following immediate tissue expander-based breast reconstruction. Extended, that is, post-discharge, prophylaxis does not appear to be indicated, regardless of the antibiotic chosen.

Evaluating the Efficacy of Povidone-Iodine Solution Infection Prophylaxis in Immediate Tissue Expander-Based Breast Reconstruction: A Controlled Retrospective Analysis.

Background: There is currently no consensus among plastic surgeons regarding the optimal infection prophylaxis for immediate tissue expander placement following mastectomy. The goal of this study was to determine whether irrigation with 1 L of standard triple antibiotic solution (TAS) can achieve similar infection rates compared to a regimen of 180 mL of TAS with povidone-iodine solution (Betadine) painted on the field immediately prior to the placement of the expander. Methods: The 2 regimens were compared via retrospective propensity matching of all patients of the 2 senior authors who underwent bilateral tissue expander placement immediately following mastectomy with one of 3 mastectomy surgeons from January 2013 to December 2019 (n = 281). Groups were controlled for mastectomy surgeon, mastectomy type, mastectomy weight, age, race, body mass index, diabetes, hypertension, smoking, smoking status, prepectoral/subpectoral placement, use of acellular dermal matrix, operating room time, and duration of postoperative antibiotics. Results: Compared to the Betadine cohort (n = 65), the non-Betadine cohort (n = 65) experienced a similar rate of infections (13.8% vs 12.3%, P = 1.00), including major injections requiring intravenous antibiotic treatment (10.8% vs 9.2%, P = 1.00), after propensity matching. Infections in the non-Betadine cohort did not grow different bacteria on culture, require different antibiotic coverage, or result in prolonged duration of average antibiotic therapy (12.0 days vs 19.3 days, P = .19). Rates of subsequent expander washout and exchange (P = 1.00) and overall complications that required return to the operating room (P = .826) were similar between groups. Conclusion: The addition of Betadine solution to TAS added no benefit to infection prophylaxis or reduction of surgical complications in immediate tissue expander placement procedures.

Routine Postoperative Antibiotics After Tissue Expander Placement Postmastectomy Does Not Improve Outcome.

In an attempt to reduce the incidence of infectious complications after tissue expander-based breast reconstruction, the routine administration of postoperative antibiotics regimen is common in many practices. In recent years, there has been a plethora of reports scrutinizing the prophylactic use of postoperative antibiotics in this setting. The aim of this study was to determine the efficacy of prolonged administration of postoperative antibiotics compared with perioperative-only antibiotic administration for prophylaxis after tissue expander placement for immediate mastectomy reconstruction. A retrospective chart review of all patients who underwent immediate tissue expander placement after mastectomy at our institution from June 2005 to September 2018 was performed. All patients in the study received perioperative intravenous antibiotics 30 to 60 min preoperatively and for 24 hours postoperatively. Patients were divided into 2 groups. Patients in group A did not receive antibiotics beyond the perioperative period. Patients in group B received oral antibiotics for at least 7 days postoperatively in addition to the perioperative intravenous antibiotics. The 2 groups were compared for demographics and prevalence of risk factors such as radiation, chemotherapy, smoking, and diabetes. The incidence of complications such as infection, wound complications, hematoma, seroma, capsular contracture, loss of tissue expander, and reoperations was assessed. A total of 529 patients were included in the study, of which 241 were in group A and 288 were in group B. The total number of breasts reconstructed in group A was 398, whereas in group B, it was 466 breasts. Patients were followed up to 5 months postoperatively in each group. There were no statistically significant differences in the demographic and patient characteristics among the 2 groups. The incidence of infection in group A was 23.24% and in group B was 21.53% (P = 0.412). The incidence of other complications follows the same trend when comparing group A versus B. This retrospective study shows that the routine use of postoperative antibiotics after tissue expander placement for immediate mastectomy reconstruction does not result in reduction in the incidence of common complications or improvement of clinical outcomes.

Patient-reported opioid use for tissue expander–based breast reconstruction

There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use.Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use.A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026).These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.

Impact of overweight/obesity on the development of hematoma following tissue expander-based breast reconstruction

Overweight and obesity are well-known risk factors for postoperative complications; however, their impacts on hematoma formation have not been clarified. Several studies have suggested that overweight/obesity could have procoagulative effects, potentially reducing a risk for developing postoperative bleeding complications. This study aimed to investigate the effects of overweight/obesity on hematoma formation following tissue expander-based breast reconstruction. Patients who underwent immediate tissue expander-based unilateral breast reconstruction between January 2010 and November 2018 were reviewed. They were categorized into four groups according to body mass index (BMI): underweight (<18.5 kg/m2), normal weight (18.5-25.0 kg/m2), overweight (25.0-30.0 kg/m2), and obesity (>30.0 kg/m2). The outcome was major postoperative hematoma, defined as one requiring emergent surgical intervention. Independent impacts of variables on hematoma development were evaluated via uni- and multivariable analyses. A total of 1,431 patients were analyzed, including 133 cases (9.3%) with underweight, 952 (66.5%) with normal weight, 302 (21.1%) with overweight, and 44 (3.1%) with obesity. Postoperative major hematoma developed in 29 cases (2.0%). The rate of hematoma formation was 2.3%, 2.6%, 0.3%, and 0% in the underweight, normal weight, overweight, and obesity groups, respectively, showing a significantly decreasing trend (p = 0.009), while those of other complications including seroma and mastectomy flap necrosis revealed the opposite trends, being significantly elevated as patient BMI increased. Multivariate analyses found overweight to be an independent protector against major hematoma compared with normal weight (p = 0.014; odds ratio=0.071). Overweight/obesity might have a protective effect on development of major bleeding complications following tissue expander-based breast reconstruction.

Blossom smart expander technology for tissue expander-based breast reconstruction facilitates shorter duration to full expansion: A pilot study.

BackgroundThis study evaluated the Blossom system, an innovative self-filling, rate-controlled, pressure-responsive saline tissue expander (TE) system. We investigated the feasibility of utilizing this technology to facilitate implant-based and combined flap with implant-based breast reconstruction in comparison to conventional tissue expansion.MethodsIn this prospective, single-center, single-surgeon pilot study, participants underwent either implant-based breast reconstruction or a combination of autologous flap and implantbased breast reconstruction. Outcome measures included time to full expansion, complications, total expansion volume, and pain scores.ResultsFourteen patients (TEs; n=22), were included in this study. The mean time to full expansion was 13.4 days (standard error of the mean [SEM], 1.3 days) in the combination group and 11.7 days (SEM, 1.4 days) in the implant group (P=0.78). The overall major complication rate was 4.5% (n=1). No statistically significant differences were found in the complication rate between the combination group and the implant group. The maximum patient-reported pain scores during the expansion process were low, but were significantly higher in the combination group (mean, 2.00±0.09) than in the implant group (mean, 0.29±0.25; P=0.005).ConclusionsThe reported average duration for conventional subcutaneous TE expansion is 79.4 days, but this pilot study using the Blossom system achieved an average expansion duration of less than 14 days in both groups. The Blossom system may accommodate single-stage breast reconstruction. The overall complication rate of this study was 4.5%, which is promising compared to the reported complication rates of two-stage breast reconstruction with TEs (20%–45%).

Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes.

Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

Poly-4-Hydroxybutyric Acid Mesh Compares Favorably With Acellular Dermal Matrix in Tissue Expander-Based Breast Reconstruction.

Acellular dermal matrix (ADM) is commonly used during immediate expander-based breast reconstruction, with potential advantages of greater intraoperative expansion, decreased time to complete expansion, and decreased rates of capsular contracture. However, ADM is associated with increased infection rate, seroma, and subsequent reconstructive failure. Poly-4-hydroxybutyric acid (P4HB) mesh is a large pore, biosynthetic scaffold shown to fully resorb and incorporate host tissues within 18 months. We sought to compare outcomes between the use of P4HB and ADM in immediate retropectoral expander-based reconstruction. One hundred ninety-two consecutive cases (107 patients) of breast reconstruction using ADM were compared with a subsequent cohort of 112 cases (62 patients) using P4HB mesh. In all patients, reconstruction was performed immediately after mastectomy by a single surgeon, and outcomes were compared between groups. Baseline characteristics were similar between the P4HB and ADM groups. Overall infection rates were lower, but not significantly with P4HB (11% vs 17%, P = 0.18). Time to drain removal was significantly lower with P4HB (15 vs 18 days, P = 0.008), although there was no difference in rates of seroma (0.9% vs 3%, P = 0.43). Similar numbers of patients underwent external beam radiation (22% vs 24%) and received chemotherapy in each group (48% vs 45%). By univariate analysis, all odds ratios were decreased with use of P4HB, including risk of major complications (0.55), seroma (0.17), infection (0.59), need for reoperation (0.78), and skin necrosis (0.77). Initial findings suggest P4HB mesh to be a safe alternative to ADM in expander-based breast reconstruction, with trends toward decreased rates of infection, seroma, and need for device removal using P4HB mesh. Although our results are limited to a small series of initial patients, P4HB mesh may be a promising novel technique to decrease complications inherent to use of ADM at a reduced material cost.

Discussion: Decreased Length of Postoperative Drain Use, Parenteral Opioids, Length of Stay, and Complication Rates in Patients Receiving Meshed versus Unmeshed Acellular Dermal Matrix in 194 Submuscular Tissue Expander-Based Breast Reconstructions: A Single-Surgeon Cohort Study.

Discussion: Decreased Length of Postoperative Drain Use, Parenteral Opioids, Length of Stay, and Complication Rates in Patients Receiving Meshed versus Unmeshed Acellular Dermal Matrix in 194 Submuscular Tissue Expander-Based Breast Reconstructions: A Single-Surgeon Cohort Study.

Therapeutic Interventions to Reduce Radiation Induced Dermal Injury in a Murine Model of Tissue Expander Based Breast Reconstruction.

Radiation therapy (XRT) induced dermal injury disrupts type I collagen architecture. This impairs cutaneous viscoelasticity, which may contribute to the high rate of complications in expander-based breast reconstruction with adjuvant XRT. The objective of this study was to further elucidate the mechanism of radiation-induced dermal injury and to determine if amifostine (AMF) or deferoxamine (DFO) mitigates type I collagen injury in an irradiated murine model of expander-based breast reconstruction. Female Lewis rats (n = 20) were grouped: expander (control), expander-XRT (XRT), expander-XRT-AMF (AMF), and expander-XRT-DFO (DFO). Expanders were surgically placed. All XRT groups received 28 Gy of XRT. The AMF group received AMF 30 minutes before XRT, and the DFO group used a patch for delivery 5 days post-XRT. After a 20-day recovery period, skin was harvested. Atomic force microscopy and Raman spectroscopy were performed to evaluate type I collagen sheet organization and tissue compositional properties, respectively. Type I collagen fibril disorganization was significantly increased in the XRT group compared with the control (83.8% vs 22.4%; P = 0.001). Collagen/matrix ratios were greatly reduced in the XRT group compared with the control group (0.49 ± 0.09 vs 0.66 ± 0.09; P = 0.017). Prophylactic AMF demonstrated a marked reduction in type I collagen fibril disorganization on atomic force microscopy (15.9% vs 83.8%; P = 0.001). In fact, AMF normalized type I collagen organization in irradiated tissues to the level of the nonirradiated control (P = 0.122). Based on Raman spectroscopy, both AMF and DFO demonstrated significant differential protective effects on expanded-irradiated tissues. Collagen/matrix ratios were significantly preserved in the AMF group compared with the XRT group (0.49 ± 0.09 vs 0.69 ± 0.10; P = 0.010). β-Sheet/α-helix ratios were significantly increased in the DFO group compared with the XRT group (1.76 ± 0.03 vs 1.86 ± 0.06; P = 0.038). Amifostine resulted in a significant improvement in type I collagen fibril organization and collagen synthesis, whereas DFO mitigated abnormal changes in collagen secondary structure in an irradiated murine model of expander-based breast reconstruction. These therapeutics offer the ability to retain the native microarchitecture of type I collagen after radiation. Amifostine and DFO may offer clinical utility to reduce radiation induced dermal injury, potentially decreasing the high complication rate of expander-based breast reconstruction with adjuvant XRT and improving surgical outcomes.

A Simple Technique to Accomplish Total Muscular Coverage in Complicated Cases of Tissue Expander-Based Breast Reconstruction.

A Simple Technique to Accomplish Total Muscular Coverage in Complicated Cases of Tissue Expander-Based Breast Reconstruction.

Predictors for Prolonged Drainage following Tissue Expander-Based Breast Reconstruction.

A closed-suction drain is usually inserted during tissue expander-based breast reconstruction. Prolonged duration of drain retention can disturb patients' daily lives and affect overall sociomedical costs. This study aimed to investigate factors that may influence the drainage and to identify predictors of unusually prolonged drain duration. Patients who underwent delayed-immediate, two-stage breast reconstruction using a tissue expander between January of 2013 and July of 2017 were reviewed. Prolonged drain duration was defined as drain duration for longer than the 75th percentile of that for the entire cohort. Effects of patient- and operation-related variables on drainage and prolonged drain duration were evaluated. A total of 1056 cases (1002 patients) were analyzed. The median drain duration was 10 days. Drain placement for more than 12 postoperative days was observed in 256 cases (24.2 percent), classified as prolonged drain duration. Multivariate analyses demonstrated that old age, high body mass index, neoadjuvant chemotherapy, insertion of large Siltex textured tissue expanders, and greater volume of initial inflation were independent risk factors of prolonged drain duration. The size and texture of the tissue expanders and initial inflation volume retained their influence, regardless of mastectomy specimen weight. Use of acellular dermal matrix had contradictory effects according to breast size, being protective against prolonged drain duration in cases with mastectomy specimen weight greater than 400 g, and being a significant predictor for it in cases with mastectomy specimen weight less than or equal to 400 g. Several factors, including reconstructive operation-related factors, might influence drain duration following tissue expander-based breast reconstruction. Risk, III.

Treatment With Topical Deferoxamine Improves Cutaneous Vascularity and Tissue Pliability in an Irradiated Animal Model of Tissue Expander-Based Breast Reconstruction.

Postmastectomy radiation therapy is an important component of the multimodality approach to later-stage breast cancers. Unfortunately, despite its proven survival benefits, postmastectomy radiation therapy is deleterious to the skin and soft tissue, causing increased complications and worse aesthetic outcomes after breast reconstruction.There is currently no effective pharmaceutical agent to mitigate the soft tissue fibrosis and hypovascularity associated with soft tissue radiation. We hypothesized that a novel topical formulation of deferoxamine (DFX) will result in improved cutaneous vascularity and soft tissue pliability in an animal model of irradiated tissue expander-based breast reconstruction. This study consisted of 16 hairless rats divided into 4 equal groups: a control group (expander only), a tissue expanded and irradiated group, a tissue expanded + DFX group, and a tissue expanded/irradiated/DFX group. A novel topical formulation of DFX consisted of reconstituted drug dissolved in agents designed to enhance dermal penetrance. Vessels per high-power field (vHPF) were quantified histologically; micro-computed tomography angiography was used to assess vessel volume fraction (VVF) and vessel length density. Irradiated skin had less vascularity compared with control (3.81 vHPF vs 8.25 vHPF, P = 0.03; 0.79% VVF vs 1.53% VVF, P = 0.06). Treatment of irradiated skin with topical DFX reversed these effects, resulting in vascular findings similar to the control group histologically (7.94 vHPF vs 8.25 HPF, P = 0.985) and via micro-computed tomography angiography (1.05% VVF vs 1.53% VVF, P = 0.272). Similarly, radiation resulted in less volume expansion compared with controls (0.72 vs 0.8 mL, P = 0.04), whereas treatment with topical DFX reversed this effect, allowing for an expansion volume similar to the control group (0.81 vs 0.80 mL, P = 0.999). In an animal model of irradiated tissue expander-based breast reconstruction, treatment with topical DFX improved the cutaneous vascularity and tissue pliability, resulting in vascular density and final tissue expansion volumes similar to those found in the nonirradiated control group. Topical DFX may be an effective agent for the treatment of soft tissue radiation injury; future studies are indicated to further characterize this novel drug formulation.

Abstract: Impact of Combined Gynecologic Procedures on Two Staged Implant-Based Breast Reconstruction in Patients with Genetic Cancer Risks

BACKGROUND: Patients sometimes undergo combined mastectomy, risk-reducing gynecologic procedures, and breast reconstruction during one OR visit. We explored this method’s impact on reconstruction outcomes in patients with and without genetic cancer risks (GCR). METHODS: We retrospectively reviewed 443 tissue expander-based breast reconstructions, performed by two surgeons at one tertiary-care academic hospital from January 2012 to February 2016. Patients were split into groups by GCR status and combined gynecologic procedures (GYN) status: GCR+, GYN+ (Group 1,n=39); GCR+, GYN- (Group 2,n=73); GCR-, GYN+ (Group 3,n=9); GCR-, GYN- (Group 4,n=327). GCR included mutations in BRCA, CHEK2, PALB2, and others. Rates of reconstruction loss and percentages of patients choosing flaps were calculated using ANOVA and Tukey-HSD. For patients completing implant-based reconstruction (n=269) ANOVA and Tukey-HSD was used for statistical analysis. RESULTS: Among all patients, co-morbidities and age were equivalent, except between Group 2 (43.3 yrs) and Group 4 (50 yrs), p<.01. Rates of reconstruction loss and percentage of patients choosing flaps-based reconstruction were equivalent. Among implant patients, co-morbidities and age were equivalent except for Group 2 (42 yrs) and Group 4 (48.5 yrs), p=.02. Complication rates were equivalent between groups. There were no significant differences in the mean number of complication-related surgeries before (p=.79) or after (p=.76) implant, revision surgeries (p=.34), or total surgeries (p=.52). Percentages of patients undergoing at least one complication-related surgery before implant (p=.81), at least one complication-related surgery after implant (p=.60), or at least one revision surgery (p=.48) were equivalent. CONCLUSION: When comparing patients that completed implant-based reconstruction, combining risk-reducing gynecologic procedures with mastectomy and reconstruction into one OR visit does not appear to negatively impact reconstructive outcomes.

Abstract P3-14-09: Quality of life assessed by BREAST-Q in patients with delayed immediate tissue expander based breast reconstruction with and without radiotherapy

Abstract Introduction Radiotherapy of the breast is known for having a negative impact on implant based breast reconstruction. Technical improvements, such as expander-implant based delayed immediate reconstruction (EIBR), seem to produce better results. The purpose of this study was to analyze the effects of prior radiotherapy (RT) and postmastectomy radiotherapy (PMRT) on patient-reported quality of life (QoL) in patients with EIBR compared to patients that underwent EIBR without any RT. Material and methods After a retrospective chart review, all patients with a history of EIBR at the Red Cross Hospital Munich were invited for a structured physical examination and interview. All operations were performed between 2008 and 2012 by two surgeons (H.U. and B.M.). To assess QoL, the BREAST-Q - post reconstruction module was used and results were compared between the following three cohorts: 1. patients without RT (n=65), 2. patients with PMRT (n= 27) and 3. patients with a history of breast irradiation before mastectomy (n=16). Patients with prior RT and a PMRT after local relapse were excluded. Results Of 161 patients eligible, 94 patients followed the invitation, 14 of them with bilateral EIBR. Baseline characteristics between participating and non-participating patients were comparable. The median follow-up time was 18.1 months. Most of the baseline characteristics (e.g. tobacco use, diabetes) were comparable between the cohorts. Application of (neo-) adjuvant chemotherapy was significantly more frequent in cohort 2. The category Satisfaction with the breast was numerically but not significantly better in cohort 1 than in cohort 2 (p 0,078) whereas the psychosocial well-being showed a trend in favor of cohort 2 (p 0,058). Satisfaction with breast was significantly better in cohort 1 than 3 (p 0,014) as well as Satisfaction with breast (implant only) (p=0,007). There was no difference for Satisfaction with outcome (p=0,666). Cohort 2 reached more points in all categories than cohort 3 although this difference was not significant. Of all patients, 92,7 %, 84,6 % and 78,6% (cohorts 1, 2 and 3) would undergo the operation again. Conclusion After short follow-up time, EIBR seems to be a feasible method for breast reconstruction resulting in a high QoL, even if PMRT is required. In patients with a prior RT, QoL is worse compared to the other groups. However, patients´ acceptance of EIBR is still high. Prospective studies and long-term follow-up are required for definitive conclusions. Citation Format: Hamann M, Brunnbauer M, Scheithauer H, Hamann U, Pölcher M, Braun M. Quality of life assessed by BREAST-Q in patients with delayed immediate tissue expander based breast reconstruction with and without radiotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-09.

Infectious Loss of Tissue Expanders in Breast Reconstruction: Are We Treating the Right Organisms?

Postoperative infections following tissue expander-based breast reconstruction represent a significant threat to the reconstructive process. Studies have found the incidence to be as high as 29%. There has been abundant research into the risk factors associated with these infections, although very few studies have focused on the causative organisms. The purpose of this study was to investigate the bacterial flora associated with tissue expander infections after breast reconstruction. A retrospective analysis of all patients who underwent tissue expander-based breast reconstruction at our institution between February 2010 and April 2013 was conducted. The medical records were reviewed for demographic information, medical history, operative technique, postoperative course, and culture results. Descriptive data analysis was then performed. A total of 56 tissue expander infections were identified in 49 patients during the study period. 41.1% of the cultures grew gram-positive organisms, whereas 28.6% grew gram-negative species. The 2 most common organisms were Staphylococcus aureus (17.9%) and Staphylococcus epidermidis (14.3%). Pseudomonas aeruginosa was the most frequent gram-negative species and was also the third most frequent organism cultured (10.9%). Due to the high rate of infection in breast reconstruction patients, adequate perioperative prophylaxis is necessary. The surgeon must also be prepared to treat patients who may return with infection postoperatively. Although the majority of our infections were secondary to normal skin flora, a significant proportion were caused by gram-negative species. Given these results, the empiric antibiotic of choice for postoperative infections should be reconsidered to cover for these various organisms.

Abstract: Opioid Consumption Following Outpatient Plastic Surgery

BACKGROUND: A rise in opioid abuse has led to increases in dependency, overdose, and healthcare resource utilization. Currently, there are no data detailing the need for opioids in post-operative pain management following outpatient Plastic Surgery procedures. The goal of this study was to evaluate patient satisfaction, opioid consumption, and physician prescribing practices following these procedures to provide evidence-based strategies for post-operative pain control. METHODS: Patients who underwent outpatient Plastic Surgery procedures were identified at their first post-operative visit. Included were all English-speaking patients aged 18 to 90 who underwent elective, outpatient procedures. Those with pre-existing pain disorders were excluded. Patients were asked to complete an electronic survey in which they were queried on overall satisfaction with pain control, highest post-operative pain level, current pain level, number of days requiring opioid pain medication, reason for discontinuing medication, use of non-opioid medication for pain control, adverse effects, number of tablets consumed, and number of tablets remaining. Responses were also stratified by type of procedure performed. RESULTS: Sixty patients completed the survey. The majority (92%) reported overall satisfaction with pain control. On a scale of 1–10, the average worst post-operative pain score was 6.4. The average pain score at the first post-operative visit was 2.3, with only 25% still taking opioids at that time. Opioids were discontinued in 58.6% of patients because they no longer had pain, in 20.7% because they had mild pain controlled with other analgesics, in 13.8% because they ran out of medication, and in 6.9% because they experienced intolerable side effects. Patients who underwent first-stage tissue expander-based breast reconstruction were prescribed the most opioids, but patients who underwent facial fracture repair consumed the most opioids. Patients who underwent soft tissue excisional procedures were prescribed the least and consumed the least number of tablets. The average number of tablets prescribed was 30, while the average number of tablets consumed was 17. CONCLUSION: A balance between pain control and responsible prescribing of narcotic pain medications must be achieved. In most cases, pain was well-controlled with high rates of patient satisfaction. On average, patients received nearly twice the amount of pain medications that were used. This study can be used to guide prescribing practices of narcotic analgesics amongst Plastic Surgeons. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest to disclose.

Reducing Infectious Complications in Implant Based Breast Reconstruction: Impact of Early Expansion and Prolonged Drain Use.

The most common modality of breast reconstruction continues to be implant based, with infection being the most significant complication. Risk factors including radiation, obesity, and smoking have been associated with infection and other surgical complications. We hypothesized that prolonged drain use may likewise be associated with postoperative complications, particularly infection, and that early postoperative expansion may allow for earlier drain removal and improved outcomes. A retrospective chart review was performed to identify all immediate, tissue expander-based breast reconstruction patients using acellular dermal matrix. Time to first expansion, postoperative day (POD) of drain removal, and complication data including infection, seroma, wound separation, and skin necrosis were collected. Early expansion was defined as occurring before POD14, and prolonged drain duration as removal after POD21. Logistic regression was used to identify risk factors for complications. Fisher's exact test was used to compare complications between early and late drain removal and early and late expansion. Spearman correlation was used to define the relationship of early expansion and drain duration. Three hundred twenty-three breast reconstructions met inclusion criteria. Our overall infection rate was 11.8%, seroma was 2.2%, skin necrosis 1.9%, and wound separation 4.3%. Logistic regression revealed prolonged drain use as an independent risk factor for infection (odds ratio, 3.3; P = 0.002). Earlier expansion was correlated with earlier post operative drain removal (r = 0.3, P = 0.001) with fewer early expansion patients (7.4%) requiring prolonged drain use than those undergoing late expansion (24.7%). Smoking was also associated with skin flap necrosis (odds ratio, 8.0; P = 0.002). Prolonged drain use was associated with postoperative infection and may represent an independent source of infection or may be an indicator of delayed healing. Early tissue expansion was associated with earlier drain removal and so may help avoid infectious complications and improve outcomes. Early expansion was not associated with an increase in complications. Results from this study have informed our current drain management practice. Whether this has led to a reduction in our infection rate is a future topic of study.

Does Acellular Dermal Matrix Thickness Affect Complication Rate in Tissue Expander Based Breast Reconstruction?

Background. While the benefits of using acellular dermal matrices (ADMs) in breast reconstruction are well described, their use has been associated with additional complications. The purpose of this study was to determine if ADM thickness affects complications in breast reconstruction. Methods. A retrospective chart review was performed including all tissue expander based breast reconstructions with AlloDerm (LifeCell, Branchburg, NJ) over 4 years. We evaluated preoperative characteristics and assessed postoperative complications including seroma, hematoma, infection, skin necrosis, and need for reintervention. We reviewed ADM thickness and time to Jackson-Pratt (JP) drain removal. Results. Fifty-five patients underwent 77 ADM-associated tissue expander based breast reconstructions, with average age of 48.1 years and average BMI of 25.9. Average ADM thickness was 1.21 mm. We found higher complication rates in the thick ADM group. Significant associations were found between smokers and skin necrosis (p < 0.0001) and seroma and prolonged JP drainage (p = 0.0004); radiated reconstructed breasts were more likely to suffer infections (p = 0.0085), and elevated BMI is a significant predictor for increased infection rate (p = 0.0037). Conclusion. We found a trend toward increased complication rates with thicker ADMs. In the future, larger prospective studies evaluating thickness may provide more information.