Tissue Expander Breast Reconstruction Research Articles

Intraoperative Nerve Blocks Fail to Improve Quality of Recovery after Tissue Expander Breast Reconstruction: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Clinical Trial.

The authors' study represents the first level I evidence to assess whether intraoperative nerve blocks improve the quality of recovery from immediate tissue expander/implant breast reconstruction. A prospective, randomized, double-blinded, placebo-controlled clinical trial was conducted in which patients undergoing immediate tissue expander/implant breast reconstruction were randomized to either (1) intraoperative intercostal and pectoral nerve blocks with 0.25% bupivacaine with 1:200,000 epinephrine and 4 mg of dexamethasone or (2) sham nerve blocks with normal saline. The 40-item Quality of Recovery score, pain score, and opioid use in the postoperative period were compared statistically between groups. Power analysis ensured 80 percent power to detect a 10-point (clinically significant) difference in the 40-item Quality of Recovery score. Forty-seven patients were enrolled. Age, body mass index, laterality, mastectomy type, and lymph node dissection were similar between groups. There were no statistical differences in quality of recovery, pain burden as measured by visual analogue scale, opioid consumption, antiemetic use, or length of hospital stay between groups at 24 hours after surgery. Mean global 40-item Quality of Recovery scores were 169 (range, 155 to 182) for the treatment arm and 165 (range, 143 to 179) for the placebo arm (p = 0.36), indicating a high quality of recovery in both groups. Although intraoperative nerve blocks can be a safe adjunct to a comprehensive postsurgical recovery regimen, the authors' results indicate no effect on overall quality of recovery from tissue expander/implant breast reconstruction. Therapeutic, I.

The Effect of Implant Type on Nipple Position Geometry and Aesthetics Following Tissue Expander Reconstruction After Nipple Sparing Mastectomy.

While recent studies have reported modest to no difference in breast aesthetics for shaped and round implant types in breast augmentations, the anatomy and biomechanics in the setting of breast reconstruction is different. Accordingly, we endeavored to evaluate whether two implant types impacted nipple position and aesthetic features in prosthetic breast reconstruction. A retrospective chart review was carried out on patients who underwent nipple-sparing mastectomy (NSM) with immediate tissue expander breast reconstruction. Patients were divided into two cohorts: smooth round implants and textured shaped implants. Postoperative photographs were evaluated to assess nipple displacement vis-à-vis a vector of maximal projection and aesthetic outcome for features of breast shape. Of 102 breasts meeting the inclusion criteria, 41 had tissue expander-implant reconstruction with anatomical shaped implants, and 61 had reconstruction with smooth round implants. The shaped implant cohort had less nipple deviation from the point of maximal projection (3.69 ± 6.24 vs 7.52 ± 10.50; P < 0.0001). Graded semi-quantitative aesthetic scores were also higher (4.04 ± 0.67 vs 3.72 ± 0.93; P = 0.0044) in the shaped implants than in the round cohort. Unlike breast augmentation, there is a paucity of overlying breast tissue and larger dissected spaces in prosthetic breast reconstruction. Our analysis suggests that in this setting, textured anatomic implants result in less nipple deviation from the point of maximum projection and improved aesthetic outcomes compared to round implants. When considering implant choice in NSM reconstruction, the manifold risks of shaped textured implants must thus be informed by potential aesthetic benefits with respect to shape and enhanced nipple sensation.

Inferior dermal flap in breast reconstruction with tissue expanders

A surgical case, in which inferior dermal flap was used to cover a tissue expander for breast reconstruction, is reported. In spite of the skin necrosis on the seventh postoperative...

Subcutaneous implant-based breast reconstruction, a modern challenge in postmastectomy radiation planning

PurposeA growing trend in breast reconstruction has been placement of tissue expanders in the pre pectoral space. This is a change from the practice of placement under the pectoralis major with or without an acellular dermal matrix (ADM) sling. The move toward pre pectoral placement with an ADM wrap has the intent of decreasing post-operative pain and decreasing animation deformities. The cosmesis of pre pectoral reconstructions in the setting of post mastectomy radiation has also appeared improved in our early experience, when compared to submuscular reconstructions. We sought to review the risks and benefits of this technique in the setting of post mastectomy radiation. Methods and materialsCases of ADM wrapped prepectoral tissue expander breast reconstructions in patients needing postmastectomy radiation therapy were reviewed in a single institution. ResultsThirty patients were treated with ADM wrapped prepectoral tissue expanders. On review of radiation plans, there were patients with anatomical variations, for whom standard dosimetric criteria were not met with partially wide tangent fields. Use of a medial electron field matched to steep photon tangents was not advised due to undercoverage of the tumor bed related to implant placement. Boost treatment was also omitted as a result of concerns regarding the implant location. ConclusionsWhile new advances in plastic surgery may improve on cosmetic outcomes for breast cancer patients, increased discussion with radiation oncologists is needed to appropriately select candidates for these procedures. Prospective trials are necessary to ensure that these new techniques do not compromise oncologic outcomes.

Tissue expansion for breast reconstruction: Methods and techniques.

ObjectiveIn this work, the authors review recent data on the different methods and techniques of TE/implant-based reconstruction to determine the complication profiles and the advantages and disadvantages of the different techniques. This information will be valuable for surgeons performing breast reconstructions.Materials and methodsA thorough literature review was conducted by the authors concerning the current strategy of tissue expander (TE)/implant-based breast reconstruction following breast cancer surgery.ResultsLoss of the breast can strongly affect a woman's personal and social life while breast reconstruction reduces the sense of mutilation felt by women after a mastectomy, and provides psychosocial as well as aesthetic benefits. TE/implant-based reconstruction is the most common breast reconstructive strategy, constituting almost 65% of all breast reconstructions in the US. Although numerous studies have been published on various aspects of alloplastic breast reconstructions, most studies are single-center observations. No evidence-based guidelines are available as yet. Conventional TE/implant-based reconstruction can be performed as a two-stage procedure either in the immediate or delayed setting. Moreover, the adjunctive use of acellular dermal matrix further broadened the alloplastic breast reconstruction indication and also enhanced aesthetic outcomes.ConclusionsTE/implant-based reconstruction has proved to be a safe, cost-effective, and reliable technique that can be performed in women with various comorbidities. Short operative time, fast recovery, and absence of donor site morbidity are other advantages over autologous breast reconstruction.

Dermal Autograft Using Donor Breast as Alternative to Acellular Dermal Matrices in Tissue Expander Breast Reconstruction

Shifting preference for implant-based breast reconstruction has resulted in an increased use of acellular dermal matrix (ADM) in tissue-expander breast reconstruction. The benefits afforded by ADM must be weighed against a potential increased risk for postoperative complications. Dermal autograft-assisted breast reconstruction using autograft harvest from the lower abdomen has been shown to result in equivalent aesthetics and patient satisfaction compared with ADM at a lower cost, with fewer complications. The purpose of this study was to review a series of patients who underwent bilateral mastectomy and immediate dermal autograft-assisted tissue expander (TE) breast reconstruction using the non-cancerous breast as a donor site, comparing the outcomes with a concurrent cohort of patients undergoing ADM-assisted reconstruction to determine the relative safety, cost, and effectiveness of the 2 procedures. The study population included all patients who underwent dermal autograft-assisted TE breast reconstruction, using the contralateral cancer-free breast as the source of dermal autograft, between 2010 and 2015. The ADM cohort consisted of patients who underwent bilateral mastectomy and immediate ADM-assisted TE breast reconstruction during the same period. Univariate analysis was performed for demographic data, complications, operative cost, and operative time. Data were compared using the Wilcoxon rank sum test for nonparametric data and χ analyses for continuous and categorical variables. Significance was defined as P value less than 0.05. Seventeen patients received dermal autograft using the non-cancerous breast donor site. Twenty-seven patients who underwent ADM-assisted reconstruction during the same period were identified. Significantly higher cost was demonstrated between groups (ADM, US $9999.87; autograft, US $3924.19; P < 0.0001). No significance difference existed operative time (autograft, 97 min; ADM, 120 min). No difference was found in wound healing complications (ADM, 14.8%; autograft, 23.53%; P = 0.47). No significant difference was found in major complications (ADM, 26%; autograft, 17.65%; P = 0.52) or infectious complications (ADM, 26%; autograft, 17.65%; P = 0.52). Dermal autograft-assisted breast reconstruction using the contralateral non-cancerous breast as the source of dermal autograft harvest represents a lower cost alternative to ADM without increased risk of postoperative complications.

SPY Elite's Ability to Predict Nipple Necrosis in Nipple-Sparing Mastectomy and Immediate Tissue Expander Reconstruction.

Background:Nipple-sparing techniques have improved the aesthetics of reconstruction following mastectomy, but nipple necrosis complicates up to 37% of procedures, distressing patients, delaying adjuvant therapy, and compromising outcomes. No method reliably detects nipple necrosis better than clinical assessment of tissue perfusion. We prospectively assessed the accuracy of intraoperative indocyanine green laser angiography to predict nipple necrosis.Methods:Twenty consecutive women undergoing immediate tissue expander breast reconstruction following 32 nipple-sparing mastectomies underwent indocyanine green fluorescence imaging to assess nipple perfusion immediately before and after intraoperative tissue expansion. Imaging findings were correlated with postoperative nipple viability.Results:Among the 32 nipple-sparing mastectomies (8 unilateral, 12 bilateral) in 20 women (mean age, 48 years), partial or full-thickness necrotic changes developed in 3 breasts of 2 patients (10%). Imaging identified impaired perfusion and predicted necrosis in these cases.Conclusions:In this initial series, intraoperative indocyanine green laser angiography correctly identified patients who developed nipple necrosis during mastectomy and tissue expander breast reconstruction.

Management of Mastectomy Skin Necrosis in Implant Based Breast Reconstruction.

Mastectomy skin necrosis is a significant problem after breast reconstruction. This complication may lead to poor wound healing and need for implant removal, which may delay subsequent oncologic treatment. We sought to characterize factors associated with mastectomy skin necrosis and propose a management algorithm. A retrospective review was performed on consecutive patients undergoing implant-based breast reconstruction by the senior author from 2006 through 2015. Patient-level factors including age, race, body mass index, history of hypertension, history of diabetes, history of smoking, and history of radiation were collected. Surgical factors including type of mastectomy, location of implant placement, and immediate versus delayed reconstruction were collected. The incidence and treatment of mastectomy skin necrosis were analyzed. A total of 293 patients underwent either unilateral or bilateral implant-based breast reconstructions after mastectomy with a total of 471 reconstructed breasts. Mastectomy skin necrosis was observed in 8.1% of reconstructed breasts. Skin necrosis was not associated with age, hypertension, diabetes, prior radiation, or type of mastectomy. The incidence of skin necrosis was higher among smokers (17.9% vs 5.0%, P < 0.001), among patients with higher body mass index (11.4% vs 6.1%, P = 0.05), patients who underwent immediate reconstruction compared to delayed (9.6% vs 0%, P = 0.004), placement of expander under acellular dermal matrix compared with submuscular placement (12.0% vs 5.2%, P = 0.02), and use of higher initial expander fill volume compared with lower fill volume (11.4% vs 5.4%, P = 0.02).The median necrosis size was 8 cm. The median time to treatment was 15 days postoperatively. In 55% of patients minor necrosis was treated with clinic debridement, whereas 43% had larger areas of necrosis requiring operative debridement. The median size treated with clinic debridement was 5.5 cm, compared to 15 cm for operative debridement. All necrosis was treated in a timely fashion and did not delay adjuvant therapy. Mastectomy skin necrosis occurred in 8.1% of breasts after implant-based reconstruction. Necrosis less than 10 cm can be treated successfully with local debridement in the clinic setting. Timely and appropriate treatment of skin necrosis with debridement and primary closure expedites wound healing and facilitates tissue expander breast reconstruction.

Clinical Outcomes in Breast Reconstruction Patients Using a Sterile Acellular Dermal Matrix Allograft.

Human acellular dermal matrices (ADMs) have enabled successful breast reconstructions while decreasing muscle donor morbidity and pain for the patient. However, some literature reports indicate an increase in complications, especially infection. The decellularization and terminal sterilization properties of DermACELL (D-ADM), a human ADM, may reduce the rate of complications in augmented breast reconstruction while still maintaining successful outcomes. In the study presented here, we evaluate the quality and safety of outcomes with the use of D-ADM during tissue expander breast reconstruction. A retrospective chart review was conducted of patients who underwent breast reconstruction with the use of D-ADM, at a single-military hospital-based practice, resulting in a population of 38 subjects and 58 breasts who had breast reconstruction augmented with D-ADM. Fifty-six breasts (96.6%) in thirty-six patients demonstrated successful outcomes with a median 27weeks' time to complete healing. Post-reconstruction radiation and chemotherapy were applied to 24.1 and 25.9% of reconstructions, respectively. Complications rates were minimal with rates of 1.7% for surgical site infection and 1.7% for red breast syndrome. The low complication rates combined with the high success and patient satisfaction rates observed for D-ADM support the use of this ADM in breast 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 .

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.

Peer review report 1 on “Tissue expansion for breast reconstruction: Methods and techniques”

Peer review report 1 on “Tissue expansion for breast reconstruction: Methods and techniques”

Peer review report 2 on “Tissue expansion for breast reconstruction: Methods and techniques”

Peer review report 2 on “Tissue expansion for breast reconstruction: Methods and techniques”

The BREASTrial Stage II: ADM Breast Reconstruction Outcomes from Definitive Reconstruction to 3 Months Postoperative.

Background:The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a prospective randomized trial comparing outcomes of tissue expander breast reconstruction using either AlloDerm or DermaMatrix. The trial was divided into 3 outcome stages; this study reports stage II outcomes, which are those from the time of definitive reconstruction to 3 months postoperative.Methods:A randomized trial was conducted to compare complication rates between AlloDerm and DermaMatrix groups. The impact of matrix type, age, obesity, radiation therapy, chemotherapy, and reconstruction type on complications was analyzed with regression models.Results:Of the 128 patients (199 breasts) who were randomly assigned into the trial, 111 patients (173 breasts) were available for analysis in stage II. There was no difference in overall rates of complications (15.4% vs 18.3%, P = 0.8) or implant loss (2.2% vs 3.7%, P = 0.5) between the AlloDerm and DermaMatrix groups, respectively. Obesity was the only significant predictor of complications on regression analysis (odds ratio, 4.31, P = 0.007). Matrix type, age, radiation therapy, chemotherapy, or reconstruction type had no impact on the incidence/severity of complications.Conclusions:Acellular dermal matrix (ADM) will likely continue to have a role in breast reconstructive surgery; however, caution should be taken when using ADM because of relatively high complication rates, especially in obese patients. The particular ADM product should be selected based on individual surgeon preference, experience, and success rates. These data and forthcoming long-term outcomes from the Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial will enable surgeons to carefully weigh the risks and benefits of ADM use in breast reconstruction.

Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique.

Objective Breast cancer, the most common malignancy in women, comprises 18% of all female cancers. Mastectomy is an essential intervention to save lives, but it can destroy one's body image, causing both physical and psychological trauma. Reconstruction is an important step in restoring patient quality of life after the mutilating treatment. Material and Methods Tissue expanders and implants are now commonly used in breast reconstruction. Autologous reconstruction allows a better aesthetic result; however, many patients prefer implant reconstruction due to the shorter operation time and lack of donor site morbidity. Moreover, this reconstruction strategy is safe and can be performed in patients with multiple health problems. Tissue-expander reconstruction is conventionally performed as a two-stage procedure starting immediately after mammary gland removal. Results Mastectomy is a destructive but essential intervention for women with breast cancer. Tissue expansion breast reconstruction is a safe, reliable, and efficacious procedure with considerable psychological benefits since it provides a healthy body image. Conclusion This article focuses on this surgical technique and how to achieve the best reconstruction possible.

Antibiotic Prophylaxis and Resistance in Surgical Site Infection After Immediate Tissue Expander Reconstruction of the Breast.

A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI. An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed. In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin). Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.

Abstract: Adipofascial Flap Versus ADM: An Intraoperative Selection Algorithm for Implant Coverage in Immediate Breast Reconstruction

PURPOSE: Acellular dermal matrix (ADM) has gained popularity1 to enhance lower pole coverage in immediate implant or expander reconstruction. Advantages of ADM include improved rapid reconstruction, postoperative expander filling and lower capsular contracture. Potential trade-offs include higher seroma, infection2,3 and cost. Alternatives for implant coverage include local fascial flaps and inferior dermal flaps as autologous options in select patients.4,5 Given the controversy about the use of ADM, this study provides an intraoperative algorithm for its selective use and review of clinical outcomes in two-stage immediate breast reconstruction. METHODS: A 2 year retrospective chart review of women who underwent the first-stage of two-stage immediate tissue expander reconstruction following skin-sparing mastectomy by two senior surgeons. Patients who had an inferior dermal flap were excluded. Patients were divided into two groups: Group 1 was reconstructed with ADM as an adjunct, and group 2 had a local adipofascial flap. Primary outcomes measures included intraoperative and first visit expander-fill volume, time to reach final fill volume, expansion ratios and clinic visits. Secondary outcome measures included the size of expander, pain during inpatient stay, and complications. RESULTS: 84 patients (148 expanders) were included: group 1 (ADM) had 41 patients (72 breasts) and group 2 (No ADM) had 43 patients (76 breasts). There were no statistical differences in patient demographics, mastectomy weight (P=0.10), and expander placement plane. There were no significant differences between the two groups of tissue expanders for intraoperative expansion volume (P=0.15), total expansion volume (P=0.28), and number of inflations required (P=0.18). Multivariate models adjusted for expander placement and postoperative radiation demonstrated that ADM patients had 0.13 higher expansion ratio intra-operatively (P=0.02) and at the first postoperative fill (P=0.001), but this did not differ significantly for final expansion volumes (P=0.58). There were 10 complications, 6 in the ADM and 4 in the no ADM groups. Complications were treated conservatively except two patients who had previous radiotherapy and requiring explantation for infection (ADM, N=1) and mastectomy skin flap necrosis (No ADM, N=1). CONCLUSION: We provide an anatomical and simple surgical approach to successfully assess and perform adipofascial flaps for implant coverage. Autologous adipofascial tissue, if present, can provide reliable comparable coverage to the inferior pole of the implant with no increased morbidity, complications, and comparable outcomes and can have a beneficial cost reduction. REFERENCES: 1. Gurunluoglu R, Gurunluoglu A, Williams SA, Tebockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70(1):103–10. 2. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606–14. 3. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol. 2010;17 Suppl 3:202–10. 4. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010;125(4):1057–64. 5. Kijima Y, Yoshinaka H, Owaki T, Funasako Y, Aikou T. Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy. Am J Surg. 2007;193(6):789–91.

Improving Antimicrobial Regimens for the Treatment of Breast Tissue Expander-Related Infections.

Background:Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient’s demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections.Methods:We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a “definite” device-related infection leading to TE explantation and had a positive intraoperative culture.Results:A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions.Conclusions:Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking. A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal. Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035). Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Risk factors for complications following immediate tissue expander based breast reconstruction in Taiwanese population.

Breast cancer patients in Asia show considerable disparities from Caucasian patients, such as younger age of onset and lower rates of smoking, obesity, and diabetes. Findings of prior studies regarding risk factors associated with complications in tissue expander may not hold for Asian populations, since most of these studies involved Caucasian patients. In this study, we surveyed risk factors in the Taiwanese population, providing additional evidence about the important differences and discuss the implications for clinical practice. Patients who underwent immediate, two-stage, tissue expander breast reconstruction from December 2008 to August 2014 in the National Taiwan University Hospital, Taipei, Taiwan were included. Follow-up observations of all patients were conducted until December 2014. Complications occurring during the tissue expander stage were evaluated. Multivariate regression modeling was used to identify risk factors for complications. A total of 246 consecutive, immediate, smooth round tissue expander placements were performed for breast reconstruction. The most common complication was skin necrosis (4.9%), followed by wound dehiscence (4.1%). In the multivariate model, body mass index (BMI)≥24kg/m2 was the only risk factor that reached statistical significance (odds ratio: 2.41, 95% confidence interval: 1.17-4.96). We provided evidence that racial disparities have an impact on the risk factors for complications associated with tissue expander breast reconstruction. BMI≥24kg/m2 was the only risk factor significantly associated with complications. Clinically, BMI≥24kg/m2, rather than the standard definition of obesity (BMI>30kg/m2), may be a more suitable cutoff point for risk in patients of Asian ethnicity.

Rib cage deformity during two-stage tissue expander breast reconstruction in patient with previous radiotherapy: a case report

Patients undergoing two-stage breast reconstruction with tissue expander and a history of previous irradiation are predisposed to a various chest-wall deformations more than non-irradiated patients. If chest-wall depression with/without rib fracture is found intra-operatively, bigger implant should be used, with a subsequent radiologic evaluation. In the future, the development of a new, modified expander with a harder base could minimise such complications.