Tissue Expander Reconstruction Research Articles

One stage placement of permanent implant compared to two stage tissue expander reconstruction

With the advent of the skin sparing mastectomy, immediate breast reconstruction with placement of the definitive prosthesis at the time of mastectomy is possible. The question remains: does single-stage prosthetic reconstruction result in greater numbers of complications or rates of re-operation, compared to two-stage tissue expander reconstruction? A retrospective cohort study of a single centre?s experience with these techniques was carried out. From 2004 to 2012, 54 cases of immediate breast reconstruction with implant were identified, and 108 cases of immediate breast reconstruction using a tissue expander were identified. Gathered preoperative data included tumour, prior exposure to radiation, preoperative chemotherapy, smoking, and comorbidities. Complication rates, as well as the rate of secondary operations, were examined. There were no significant increased risks in the rate of post-operative complications (p = .910, odds ratio = 0.9) nor in the rate of re-operation (p = 0.421, odds ratio = 1.4) associated with the insertion of a definitive prosthesis at the time of skin sparing mastectomy. However, previously radiated breasts experienced a 100% rate of wound complications in our subset of 9 breasts that underwent one stage breast reconstruction with immediate final prosthesis placement. Our study suggests that patients with early stage disease can undergo single stage breast reconstruction without increased risk of complications nor need for secondary operations. While the mean time to completion of the reconstructive process is shortened by 5 months with the single stage technique, implant based breast reconstruction requires careful counseling and patient selection in radiated patients.

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.

Duoderm®-Bra for Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) with tissue expander reconstruction is a widely used technique that can produce aesthetically pleasing reconstruction results after mastectomy. Nipple position and healthy mastectomy flaps with good vascularity are important determinants of an adequate aesthetic final result. An initial high fill volume of the expander can produce a more natural breast mound appearance postoperatively. However, this can often lead to ischemia with loss of the nipple-areolar complex (NAC). Conversely, low intraoperative fill rates are conducive to enhanced tissue circulation and viability. But this may lead to poor skin envelope draping and nipple placement lower than desired. We have developed a new technique called "Duoderm®-bra" that brings together both mastectomy skin tissue health and aesthetic success with optimal nipple positioning. We hypothesized that with Duoderm®-bra, the NAC can be stabilized in the desired high position and ptosis can be reduced. We also hypothesized that by eliminating the need for acellular dermal matrix and intraoperative fill, "Duoderm®-bra" would decrease the rate of complications. The objective of this study was to evaluate the effects of using novel "Duoderm®-bra" technique in NSM. After an institutional review board approval, a retrospective chart review of 35 consecutive patients was done with 65 breasts undergoing NSM and tissue expander reconstruction by the same plastic surgeon. Patients in whom "Duoderm®-bra" was used were compared with patients without the "Duoderm®-bra." Patients with acellular dermal matrix were excluded. Age, ptosis grade, preoperative nipple to IMF ratio (R/L), tumor characteristics, mastectomy specimen weight (R/L), time from mastectomy to first fill, time from mastectomy to final fill, final fill volume (R/L), NAC and skin necrosis, and other complications requiring surgery were recorded. Postoperative photographs for NAC positioning (side view most projected point versus at a lower point) were assessed using a scoring system. Two groups were then compared. Complications were higher in the non-Duoderm® group compared with Duoderm®-bra (odds ratio, 4.5; 95% confidence interval [CI], 1.35-15.04; P = 0.021). Optimum nipple positioning was significantly higher with Duoderm®-bra compared with no Duoderm®-bra (odds ratio, 50.0; 95% CI, 10.9-230.1; P < 0.0001). There was no difference in timing from mastectomy to completion of expansion in the Duoderm® group compared with no Duoderm®-bra group (mean difference, -2.35; 95% CI, -10.37 to 5.68). Use of "Duoderm®-bra" without intraoperative tissue expansion in NSM is a new technique. This technique improves nipple position with less ptosis and greater elevation, decreases flap and NAC necrosis complications, and does not increase total reconstructive period in NSM patients.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

Women who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. Institutional review board-approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. Fifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). Implant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.

Trends in Breast Reconstruction by Ethnicity: An Institutional Review Centered on the Treatment of an Urban Population.

Previous studies have investigated reconstructive decisions after mastectomy and such studies document a preference among African American women for autologous tissue-based procedures and among Latin American women for implant-based reconstructions, however, there is a paucity of studies evaluating the current relationship between ethnicity and reconstructive preferences. This institutional review provides a unique, up-to-date evaluation of an understudied urban population composed of majority ethnic minority patients and explores reconstructive trends. Consecutive breast reconstruction patients were entered into a prospectively maintained database at the University of Illinois at Chicago and affiliate hospitals between July 2010 and October 2013. Demographics and oncologic characteristics including tumor stage, pathology, BRCA status, and adjuvant treatment were reviewed, and reconstructive trends were assessed by racial group with a focus on reconstructive procedure, mastectomy volume, and implant characteristics. Statistical analysis was performed using SAS (version 9.2). One-hundred and sixty breast reconstructions were performed in 105 women; of which 50 per cent were African American, 26 per cent Hispanic, 22 per cent Caucasian, and 2 per cent Asian. Age, tumor stage, prevalence of triple negative disease, chemotherapy, and radiation treatment was comparable between groups. Rates of obesity, hypertension, and diabetes mellitus were slightly higher in African American and Hispanic cohorts, with more African American patients having one or more of these comorbidities as compared with the Caucasian and Hispanic cohorts (P = 0.047). Despite comparable positive BRCA testing rates, significant differences were seen in the percentage of bilateral mastectomy; 68 per cent African American, 48 per cent Caucasian, and 30 per cent Hispanic (P = 0.004). Hispanics predominantly underwent flap-based reconstruction (56%), while African American (74%) and Caucasian (60%) patients had a preference toward tissue expander reconstruction (P = 0.04 across all groups). African American and Hispanic presented with increased mastectomy weights and thus required higher implant volumes as compared with Caucasians that approached significance (P = 0.06 and P = 0.06). Implant size utilization followed a unimodal distribution for Caucasians, peaking at 500 cc; while African American and Hispanic demonstrated a bimodal distribution, peaking once at 550 cc and again at the max implant volume of 800 cc. This study of a large proportion of minority patients in an urban geographic setting offers an evolving understanding of breast reconstruction patterns. The data demonstrated unique findings of increased rates of bilateral implant-based reconstruction in African American women and unilateral flap-based reconstructions in Hispanic patients. Reconstructive decision-making seems to be greatly influenced by cultural and geographically driven preferences.

Double-Chamber Tissue Expanders Optimize Lower Pole Expansion in Immediate Breast Reconstruction Requiring Adjuvant Radiation Therapy.

Tissue expander-based reconstruction in the irradiated breast has been associated with significant complications, including infection, skin breakdown and implant extrusion, and poor aesthetic outcome. These complications may be attributed to inadequate lower pole expansion causing increased pressure on the suture line. Achieving and maintaining adequate lower pole expansion in the reconstructed breast requiring adjuvant radiation therapy may reduce the pressure/strain on the suture line and preserve the natural appearance of the breast. We describe the effective use of a double-chamber tissue expander to control lower pole expansion in immediate breast reconstruction requiring adjuvant radiation therapy. We performed a retrospective chart review of patients who underwent postoperative radiation therapy after immediate breast reconstruction using Sientra's double-chamber tissue expander, performed by a single plastic surgeon from 2012 to 2014. A total of 22 patients met our inclusion criteria. Seventeen patients had bilateral, and 5 patients had unilateral reconstruction (n = 39 total breasts). All patients were over expanded by 20% on the side affected by cancer before the start of radiation, which started by the sixth postoperative week. There was no expansion during radiation therapy. Two patients had further expansion after radiation therapy was completed. The tissue expanders were exchanged for shaped silicone gel implants 3 to 4 months after completion of radiation. A total of 2 complications occurred in 2 patients (9.0%) and 2 breasts (5.1%). These included an infection in one patient and a tissue expander leak in another. No patient developed Baker grade 3 or 4 capsular contracture, seroma, or device malposition. Good lower pole contour and projection was maintained in all breasts at 9 to 12 months of follow-up. The double-chamber tissue expander is effective in controlling shape, contour, and position of the breast following immediate tissue expander reconstruction requiring adjuvant radiation therapy, with decreased complication rates compared to standard expanders. These results suggest that double-chamber tissue expanders may be the preferred expander option in patients requiring adjuvant radiation therapy. Prospective clinical studies are needed to better evaluate the advantages of this reconstructive approach.

Controlled tissue expansion in reconstruction of post burn deformities of head and neck

Reconstruction of post burn scars and contractures in the region of head and neck is a difficult task. Introduction of controlled tissue expansion has provided a versatile and reliable technique in management of these cases by providing skin of excellent quality and minimal donor site deformity. A review of forty-five (45) procedures carried out for reconstruction with controlled tissue expansion, between January 1994 and December 2003 is presented. Expanders of various shapes and sizes were used to achieve a fill volume ranging from 140 c.c to 470 c.c over a period of 9 to 12 weeks. Expander was reused in eight (8) expansions and three (3) patients with large defects underwent two or more expansions of the same area to achieve desired results. In 32 cases the procedure was completed without any complications whereas in 10 cases minor or major complications hampered or delayed eventual reconstruction. Only in 4 cases (8.8%) the reconstruction was compromised as a result of early complications. Controlled tissue expansion provides a safe and predictable technique for reconstruction in the region of Head and neck with acceptable rate of complications and provides excellent results.

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.

Abstract P2-13-02: Radiation and depression associated with complications of tissue expander reconstruction

Abstract Background: Rates of implant failure, wound healing delay, and infection are higher in patients having RT after tissue expander (TE) and permanent implant reconstruction. Some have suggested greater complications with increased body mass index (BMI) and with diabetes. Patients and Methods: 127 patients had bilateral TE reconstruction and radiation from 2003 to 2013 at two centers. In 95% (121/127) of cases RT was performed while the TE was in place with the permanent implant inserted after RT. 3D-CRT technique included 50 Gy with daily or every other day bolus and forward planned segments. The supraclavicular and/or internal mammary lymph node bearing regions were treated in 82.7% (105/127) cases. The non-irradiated breast provided an internal control. Chi-squared testing of pretreatment factors included radiation, chemotherapy, and medical history of hypertension, diabetes, cardiovascular, and pulmonary disease. BMI, tobacco and alcohol use, use of antiestrogen, statin, antidepressant, antihypertensive, anxiolytics, and antidiabetic medications were also studied. Comparison of differences in means for continuous variables used analysis of variance, then multiple pairwise comparisons with Bonferroni correction of p-value. Results: Mean age was 53 ± 10.1 years with just 14.6% African- American. Twelve (9.4%) were BRCA positive (9 BRCA1, 4 BRCA2, 1 Both). Nearly all complications were in the radiated breast. Complications were: Grade 0 (no complication; 43.9%), Grade 1 (tightness and/or drifting of implant or Baker grade II capsular contracture; 30.9 %), Grade 2 (infection, hypertrophic scarring, or incisional necrosis; 9.8%), Grade 3 (Baker grade III capsular contracture, wound dehiscence, or impending exposure of implant; 5.7%), Grade 4 (implant failure, exchange of implant, or Baker grade IV capsular contracture; 9.8%). 15.3 percent (19 cases) experienced grade 3 or 4 complication and 9.8% (12 cases) had grade 4 complication. Considering non-irradiated breasts, there were two (1.6%) Grade 3-4 complications. For BMI, there was no significant difference by category as defined by the CDC (p=0.91). Patients history of HRT tended to be more likely to have Grade 3 or 4 complications (31.8% vs 12.4% respectively; p=0.08). Patients with depression were more likely to experience a Grade 3 or 4 complication (29.4% vs 13.2%; p=0.01). Multiple logistic regression was used to predict the probability of a Grade 3 or 4 complication with HR use and depression as independent variables. Patients with depression were 4.2 times more likely to have a Grade 3 or 4 complication (OR=4.2, p=0.03) and patients with a history of HRT use were 3.4 times more likely to experience a Grade 3 or 4 complication (OR = 3.4, p=0.04). Only clinical diagnosis of depression was considered as 12/31 (38.7%) with antidepressants used only venlafaxine. Neither BRCA status (p=0.72) nor chemotherapy factors (p=0.42) were associated with complication rates. Conclusions: Higher rates of TE reconstruction complications may be expected in patients receiving radiotherapy. Patients reporting medical history of depression or HRT use showed statistically significant increase in complication rates. This effect might be attributed to a drug effect or to patient factors such as body image. Citation Format: Wagner RM, Spzunar SM, Stefani WA, Falk JS, Williams JL, Edhayan E, Dul CL, Rodriguez D, Busuito MJ, Browne CH, Aref A, Rabbani AN, Chuba PJ. Radiation and depression associated with complications of tissue expander reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-02.

Abstract P6-18-02: Patterns of breast reconstruction in patients diagnosed with inflammatory breast cancer

Abstract Background Inflammatory Breast Cancer (IBC) is a rare and aggressive type of breast cancer treated by multimodality therapy. Due to the presence of dermal lymphatic involvement by disease it is unknown whether a skin sparing mastectomy (SSM) would be safe, even after completion of preoperative chemotherapy, therefore immediate breast reconstruction (BR) following modified radical (MRM) is discouraged. We sought to explore the patterns of BR outcomes in IBC patients (pts) and to evaluate their surgical outcomes. Methods A retrospective analysis was performed using an IRB-approved database of IBC pts evaluated at Dana Farber Cancer Institute (DFCI) from 1997 until 2014. Pts with stage III IBC who received preoperative systemic therapy followed by MRM and post-mastectomy radiation (PMRT) were analyzed. Receipt and timing of BR, post-operative morbidity and subsequent esthetic issues were collected. We also analyzed oncologic events which may have hindered receipt of BR. Results 318 pts were enrolled in the IBC registry at DFCI between 1997 and 2014. 181 pts with stage III IBC were identified, with a median follow-up of 57 months (mo) from MRM. 33/181 pts (18%) underwent BR; 2 pts were not evaluable due to lack of details concerning BR. 12 pts had immediate BR, 10 of which were performed elsewhere, prior to initial evaluation at DFCI. These included 3 tissue expander (TE) reconstructions, 3 single stage implants, 1 deep inferior epigastric perforator (DIEP) flap, 4 transverse rectus abdominis myocutaneous (TRAM) flaps, 1 latissimus dorsi (LD) flap. 19 had delayed BR. These included 1 TE, 5 DIEP flaps, 2 LD flap, 1 TE+LD flap, 10 TRAM flaps. Delayed BR occurred at a median of 13 mo (range 3-64 mo) following completion of PMRT. Complications post-BR were rare. Among the immediate BR pts, 1 pt with a TRAM flap BR required a reoperation 15 days (d) following BR for a partial TRAM flap necrosis. Among the delayed BR pts, one had a reoperation for abdominal TRAM flap donor site wound dehiscence 29 d after BR. Another delayed BR pt, who had a TE+LD flap BR, had her reconstruction implant removed due to chronic hematoma 79 mo after her initial BR; this occurred following 3 operative attempts to salvage her reconstruction by evacuating the hematoma. Overall, 12 reoperations were performed including 6 immediate BR (6/19 (31.6%) and 6 delayed BR pts (6/12 (50.0%); 6 of these reoperations (50%) were done for minor esthetic issues, such as reconstruction revisions for fat necrosis and capsular contracture, in addition to the more significant surgeries described above. Among 148 pts who did not undergo BR, 69 (47%) had disease recurrence following MRM (66 distant +/- local-regional recurrence (LRR); 3 LRR only); within 12 mo of MRM disease recurrence developed in 22% of pts (33/148). Conclusion Only 11% of pts presenting with stage III IBC recieved delayed BR in this retrospective analysis of 181 pts. The majority of these pts achieved successful BR, except for 1 pt. It is possible that BR was not sought more frequently due to a fairly high rate of distant disease relapse (47% in this cohort). Further studies addressing the outcomes of BR in IBC pts are needed in order to assist in counseling pts regarding their reconstructive expectations. Citation Format: Nakhlis F, Regan M, Chun YS, Dominici LS, Jacene HA, Yeh ED, Bellon JR, Warren LE, Hirko K, Hirshfield-Bartek J, Hazra A, Overmoyer BA. Patterns of breast reconstruction in patients diagnosed with inflammatory breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-18-02.

Abstract P2-12-16: Current trend and indications of endoscopy-assisted breast surgery for breast cancer: Experience from Taiwan endoscopic breast surgery cooperative group

Abstract Background: Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or periareolar incisions is a possible alternative to conventional surgery for certain patients with breast cancer. In this study, we report the early results of an EABS program in Taiwan. Methods: The medical records of patients who underwent EABS for breast cancer during the period May 2009 to December 2014 were collected from the Taiwan Endoscopic Breast Surgery Cooperative Group database. The Taiwan Endoscopic Breast Surgery Cooperative Group (T-EBSCG) was established to monitor the effectiveness of and clinical outcome associated with EABS in Taiwan. The T-EBSCG comprises members from three major endoscopic breast surgery centers, namely Changhua Christian Hospital, National Cheng-Kung University Hospital,and Taipei Medical University Hospital in Taiwan. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications and recurrence were analyzed to determine the effectiveness and oncologic safety of EABS in Taiwan. Results: A total of 315 EABS procedures were performed in 292 patients with breast cancer, including 23 (7.8%) patients with bilateral disease. The mean tumor size of these 315 EABS was 2.2 ± 1.8 cm, and 44(13.9%) of them were multifocal/multicentric breast cancer. Lymph node metastasis was found during 23.3% of the procedures. The stage distribution of them were stage II cancer (n=103, 34.4%), followed by stage I cancer (n=92, 30.7%), ductal carcinoma in situ (stage 0) (n=86, 28.7%), and stage III breast cancer (n=19, 6.3%). The number of breast cancer patients who underwent EABS increased initially from 2009 to 2012 and then stabilized during the period 2012-2014. The most commonly performed EABS was endoscopy-assisted total mastectomy (EATM) (85.4%) followed by endoscopy-assisted partial mastectomy (EAPM) (14.6%). Of the 269 patients who underwent EATM, 198 (73.6%) received immediate breast reconstruction. The majority (72.2%) of them received implant-based (cohesive Gel implant or tissue expander) reconstruction and the remaining 27.8% received autologous pedicled TRAM flap for breast reconstruction. Endoscopic assisted nipple sparing mastectomy with Gel implant reconstruction was the most frequently performed EABS now. During the six-year study period, there was an increasing trend toward more frequently use of EABS in the management of breast cancer when total mastectomy was indicated (EATM) than breast conserving surgery (EPM). Overall, the rate of complications associated with EABS was 15.2% and all were minor and wound-related. There were no major or life threatening complications. The positive surgical margin rate was 1.9%. During a median follow-up of 26.8 months (range, 3.3-68.6 months), there were 3 (1%) cases of local recurrence (1 ipsilateral breast recurrence, 1 axillary local recurrence, and 1 core needle biopsy tract recurrences), 1 (0.3%) case of distant metastasis, and 1 death. Conclusion: The EABS program in Taiwan showed that EABS is a safe procedure and results in acceptable cosmetic outcome, these findings could help to promote this under-used surgical technique in the field of breast cancer. Citation Format: Lai H-W, Kuo Y-L, Hung C-S, Chen S-T, Chen D-R. Current trend and indications of endoscopy-assisted breast surgery for breast cancer: Experience from Taiwan endoscopic breast surgery cooperative group. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-16.

Concurrent Skin Reduction in Nipple Sparing Mastectomy and Immediate Tissue Expander Reconstruction for Grade Three Ptosis Breasts

However, not all women are candidates for the operation. From an oncologic perspective, NSM is limited to women with small, early stage peripheral cancers [1, 2]. From a plastic surgery perspective, the NSM is typically offered to women with small breasts and minimal ptosis. The large breasted woman with significant ptosis faces risks with this operation, including NAC and skin necrosis due to poor perfusion to the long mastectomy skin flaps, NAC malposition, and poor contour and profile of the breast due to redundant skin.

Breast Implant-Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome.

The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection. A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed. Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime. Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors' unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive. Therapeutic, IV.

Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction

PTV was modified accordingly. Cosmesis was scored according to the Harvard scale at the 3 month follow up visit. Results: Since February 2014, ten patients were enrolled on this prospective registry. Median age was 57.4 (range: 42 e 77). Mean PTV volume was 76.4 cc (range: 131 e 54.6 cc), representing a 64% reduction in volume when compared to a conventional PTV margin. Mean time in treatment room was 36 min, of which 15 min was spent on patient set up and MR imaging. 100 online volumetric MR images were available for evaluation. The mean 90% and 95% prescription dose covered 99.7% (range: 99.1-100%) and 97.6% (range: 90.5 e 99.9%) of PTV respectively. Mean inter-fraction standard deviation in 90% and 95% prescription coverage was less than 1% of PTV (90% prescription coverage: 0.26% PTV, and 95% prescription coverage: 0.63% PTV). Evaluation of cine MR during treatment did not demonstrate significant intra-fractional motion. Maximum skin dose was less than prescription in all cases. Nine of the ten patients had 3 month cosmetic data collected per the Harvard scale for breast cosmesis. All nine patients had excellent (7/9) or good (2/9) cosmetic results. Conclusion: Delivery of MR-guided APBI with reduced margins achieved appropriate target coverage based on assessment of actual delivered dose with favorable short term cosmesis. To our knowledge, this is the first series of APBI patients to be treated using MR-IGRT with minimal margins, thereby sparing a greater proportion of normal breast. Efforts to collect local control and long term cosmetic data are currently underway. Author Disclosure: S. Acharya: None. B.W. Fischer-Valuck: None.M.C. Roach: None. R. Kashani: None. L.L. Ochoa: None. M. Yang: None. S. Mutic: Honoraria; Philips Healthcare. Consultant; ViewRay. Travel Expenses; American Association of Medical Dosimetrists, American Association of Physicists in Medicine, American Society for Therapeutic Radiation Oncology. Stock; TreatSafely, Radialogica. I. Zoberi: None. M.A. Thomas: None.

Does “two is better than one” apply to surgeons? Comparing single-surgeon and cosurgeon bilateral mastectomy outcomes.

35 Background: Bilateral mastectomies (BM) are generally performed by a single surgeon (SS). A two-attending ‘co-surgeon’ (CS) technique, in which each surgeon concurrently performs a unilateral mastectomy, offers an alternative operative approach. We sought to examine differences in general surgery time (GST), overall surgery time (OST), and patient outcomes for BM performed by CS and SS at our institution. Methods: Patients undergoing BM with tissue expander reconstruction (BMTR) between January 2010 and May 2014 at our institution were identified and divided into SS and CS cases. Operative records were used to calculate GST (incision to end of BM procedure), reconstruction time (plastic surgery start time to end of reconstruction) and OST (OST = GST + reconstructive time). Patient age, presence and stage of cancer, breast weight, axillary procedure [sentinel node biopsy (SNB) or axillary dissection (ALND)], and 30-day postoperative complications were extracted from medical charts. Differences in GST and OST between CS and SS performed cases were assessed using a t-test. A linear regression was performed to identify factors contributing to GST. Results: We identified 116 BMTR cases performed by 8 breast surgeons, [CS, n = 67 (57.8%); SS, n = 49 (42.2%)]. Demographic characteristics did not significantly differ between groups. In the bivariate analyses, GST and OST for CS cases were significantly shorter than for SS, 75.8 vs 116.8 minutes, p &lt; 0.0001, and 255.2 vs 278.3 minutes, p = 0.005, respectively. The linear regression demonstrated a significant decrease in GST when BMTR was performed by CS (β = -38.82, p &lt; 0.0001); total breast weight (β = 0.0093, p = 0.03) and axillary dissection (β = 28.69, p = 0.0003) were found to significantly impact GST. Conclusions: The GST of BMTR is significantly decreased using a CS-approach without impacting complication rates. However, the degree of GST and OST-reduction suggests the addition of a CS does not proportionally impact surgical time as would be expected. A CS-approach may be more beneficial for patients with large total breast weight or those requiring ALND. A larger study is warranted to better characterize time, cost, and outcomes of the CS-approach for BM.

Local Infiltration of Liposomal Bupivacaine for Pain Control in Patients Undergoing Mastectomy with Immediate Tissue Expander Reconstruction.

Mastectomy with immediate tissue expander reconstruction is associated with postoperative pain, nausea, and vomiting. Various techniques of perioperative and postoperative pain control have been described. Our standard of care for postsurgical pain management in patients undergoing mastectomy with immediate tissue expander reconstruction has been preoperative ultrasound-guided paravertebral block. Recent literature demonstrating the opioid-sparing benefits of liposomal bupivacaine has directed two of our plastic surgeons to pilot its use in immediate tissue expander reconstruction. In the accompanying video, we present our technique of intraoperative local infiltration of liposomal bupivacaine into the base of mastectomy skin flaps, serratus fascia, and periaxillary tissue aftercompletion of the mastectomy and before tissue expander placement into the reconstruction pocket.

Improving postoperative pain management in subpectoral tissue expander implant reconstruction of the breast using an elastomeric pump.

Postoperative pain after breast surgery is one of the major factors contributing to delay in mobilisation and prolonged hospital stay. A retrospective analysis was performed of patients undergoing skin sparing mastectomy and insertion of a subpectoral implant. The aim was to determine whether the use of an elastomeric local anaesthetic pump improved pain control and length of stay. Twenty-five consecutive patients undergoing the above procedure were sited with an elastomeric local anaesthetic infusion pump intraoperatively, in addition to standard regular and pro re nata analgesia. The control group comprised 25 patients undergoing the same procedure in the same year who received standard analgesia alone. Visual analogue scale scores were recorded for the duration of inpatient stay, as was any further analgesic requirement. The median age was 51 years (range: 26-75 years) in the intervention group and 50 years (range: 28-70 years) in the control group. The mean visual analogue scale score was 0.28 (standard deviation [SD]: 0.61) at 24 hours for the intervention group and 1.84 (SD: 0.37) for the control group (p<0.0001). The mean length of stay was 1.8 days (SD: 0.71 days) for the intervention group and 2.28 days (SD: 0.94 days) for the control group (p=0.15). There were no complications involving catheter placement, leakage or toxicity relating to use of the local anaesthetic. There was significantly reduced pain with the use of the local anaesthetic infusion pump. The elastomeric pump is a step towards enhanced patient recovery after breast surgery in the case of skin sparing mastectomy and subpectoral tissue expander reconstruction.

Plesiotherapy: The Treatment of Choice for Mastectomy Scar Boost After Tissue Expander Reconstructions

Plesiotherapy: The Treatment of Choice for Mastectomy Scar Boost After Tissue Expander Reconstructions

Abstract P2-13-11: Multimodality perioperative analgesia with paravertebral nerve block and gabapentin reduces narcotic use and hospital length of stay in mastectomy patients

Abstract Postoperative pain control is the major determinant in hospital length of stay (LOS) in patients undergoing mastectomy. Using a multimodality approach for peri-operative analgesia (PA) with paravertebral nerve block (PVB)(regional anesthesia) as well as including pre- and postoperative oral gabapentin, we significantly reduced both LOS and narcotic usage (NU) when compared to PVB alone or conventional postoperative management (CPM) with on demand postoperative pain medications. A single institution, retrospective chart review of patients undergoing mastectomy from 2009 to 2014 was performed (n = 129; 84 bilateral, 45 unilateral) with a subset analysis performed on patients undergoing tissue expander (TE) reconstruction (n=86) or bilateral mastectomies (n=84). Patients were grouped by PA type (CPM, PVB by catheter infusion, and PVB with gabapentin (PVB+G)). Data were analyzed via using Student t-test and significance was defined as p&amp;lt;0.05. As seen in the table below, LOS and NU decreased with increasing multimodal PA approach. LOS was significantly decreased by PVB+G compared to CPM and PVB for all mastectomies, bilateral mastectomies, and mastectomies with tissue expander (TE) reconstruction. NU was significantly decreased by PVB+G compared to CPM and PVB for all mastectomies and bilateral mastectomies, and trended toward decreasing NU in TE reconstruction. All (n = 129)(1) CPM (n=51)(2) PVB (n=35)(3) PVB+G (n=53)p 1 vs 3; p 2 vs 3LOS (days)2.3 (0.84)2.1 (0.71)1.61 (0.54)&amp;lt;0.0001; &amp;lt;0.0005NU (mg)73 (42.9)52 (32.3)39 (25.3)&amp;lt;0.001; 0.04TE reconstruction (n=86)(1) CPM (n=25)(2) PVB (n=21)(3) PVB+G (n=40) LOS (days)2.2 (0.50)2.3 (0.63)1.61 (0.44)&amp;lt;0.001;&amp;lt;0.001NU (mg)86 (32.6)55 (34.4)43 (36.3)&amp;lt;0.001; 0.10Bilateral (n=84)(1) CPM (n=20)(2) PVB (n=24)(3) PVB+G (n=40) LOS (days)2.4 (0.7)2.2 (0.72)1.65 (0.52)&amp;lt;0.009;&amp;lt;0.001NU (mg)84 (37.4)58 (32.4)38 (24.5)&amp;lt;0.001;0.0066NU = narcotic use normalized to morphine sulfate We have found employing a multimodality approach to PA with the addition of the GABA analogue, gabapentin, to regional anesthesia via PVB catheter infusion significantly improves the postoperative course of patients undergoing mastectomy procedures by decreasing LOS and NU. Citation Format: Zandra H Cheng, Vlad Frenk, Jennifer D Bishop, Theresa Bowling, Helen A Pass. Multimodality perioperative analgesia with paravertebral nerve block and gabapentin reduces narcotic use and hospital length of stay in mastectomy patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-11.

A Blinded Randomized Controlled Trial to Evaluate the Use of Botulinum Toxin for Pain Control in Breast Reconstruction With Tissue Expanders

Tissue expander placement is a common means of reconstruction after mastectomy. Many patients report significant pain and discomfort with the tissue expansion process. Because placement is subpectoral, it was hypothesized that injection of the pectoralis muscle with botulinum toxin could decrease pain associated with tissue expanders. A prospective, randomized, double-blinded controlled trial was used to evaluate the effects of intraoperative injection of 100 U of botulinum toxin into the pectoralis muscle on one side versus placebo on the contralateral side during immediate tissue expander reconstruction after bilateral mastectomy. Patients were enrolled in the study between October 2009 and February 2012. Preoperative and postoperative pain scores, number and volume of tissue expansion, and complications were recorded. The paired t test was used to compare preoperative to postoperative changes in pain between the botulinum toxin and placebo injections. Twenty-three patients were enrolled in the trial. There was no statistically significant difference between preoperative to postoperative changes in the pain scores on the botulinum toxin side compared to the control side at any time point postoperatively. All pain scores trended to zero over time. Intraoperative injection of the pectoralis muscle with botulinum toxin is not an effective method to improve pain control in tissue expander reconstruction.