Two-stage Implant Breast Reconstruction Research Articles

1443 Comparison of Outcomes Between Immediate Direct-to-Implant Breast Reconstruction versus Two-Stage Implant Breast Reconstruction; a Systematic Review and Meta-analysis

Abstract Background Direct-to-implant (DTI) breast reconstruction is increasingly performed as the preferred method of immediate breast reconstruction following mastectomy. The proposed advantages of DTI over two-stage tissue expander (TE)/implant reconstruction relate to fewer surgical procedures. This systematic review and meta-analysis aims to evaluate the safety and efficacy of DTI versus conventional TE/implant breast reconstruction. Method A systematic review was performed (PubMed, Embase, Scopus) to identify relevant studies that compared outcomes between DTI and TE/Implant reconstructions. Publications up to October 2020 were included. The primary outcome was overall complication rate. Secondary outcomes included infection rate and implant loss. Results Nineteen studies, including 32,971 implant-based breast reconstructions, were analysed. Median age was 48 years. Mean BMI was 25.9. There was no statistically significant difference between the two groups. Duration of follow up ranged from 1-60 months. Overall complications were significantly more likely to occur in the DTI group (OR 1.81 [1.17-2.79]). Overall complications refers to all reported complications including seroma, haematoma, would dehiscence, infection, skin necrosis and capsular contracture. Implant loss was also significantly higher in the DTI cohort (OR 1.31 [1.12-1.78]). There was no significant difference in infection rates between the two groups. Subgroup analyses, focusing on high-powered multicentre studies showed that the risks of overall complications were significantly higher in the DTI group (OR 1.51 [1.06-2.14]). Conclusions This meta-analysis demonstrates significantly greater risk of complications and implant loss in the DTI breast reconstruction group. These findings serve to aid both patients and clinicians in the decision-making process regarding implant reconstruction following mastectomy

AB010. SOH21AS220. Comparison of outcomes between immediate direct-to-implant breast reconstruction versus two-stage implant breast reconstruction: a systematic review and meta-analysis

Background: Direct-to-implant (DTI) breast reconstruction is increasingly performed as the preferred method of immediate breast reconstruction following mastectomy. The proposed advantages of DTI over two-stage tissue expander (TE)/implant reconstruction relate to fewer surgical procedures. This systematic review and meta-analysis aims to evaluate the safety and efficacy of DTI versus conventional TE/implant breast reconstruction.

Efficacy of short-term antibiotic prophylaxis in immediate two-stage breast reconstruction after mastectomy: A retrospective monocentric study

Infective complications following implant-based breast reconstruction range from 2,5 to 24% and are often associated with high morbidity and poor outcome. Many authors still employ long-term antibiotic prophylaxis even though there is no conclusive evidence on the impact on infection-rate reduction. In the present study, we report we report our single-shot short-term prophylaxis protocol for surgical site infection prevention in immediate two-stage implant breast reconstruction. We retrospectively compared clinical data from two groups of women undergoing immediate two-stage breast reconstruction with tissue expander. Group 1 (n = 391) was administered with long-term prophylaxis, and Group 2 (n = 89) was administered with short-term prophylaxis associated with early drains removal (21 days maximum). We evaluated risk factors for infection, clinical preoperative data, time before drain removal, and clinical feature of the diagnosed infections (early or late onset) and compared the reconstructive outcome between the two groups (infection rate, implant loss rate). We did not find any statistically significant difference in the infection rate (11,51% overall) and implant loss rate (4,49% overall) between the two groups. We found a difference in the implant loss to infection ratio (46.67% in group 1 and 20% in group 2, p<0,05) and in the time before drain removal (19 days in group 1 and 15 days in group 2, p<0.001). We finally found an association between prolonged time before drain removal and increased infection rate (p = 0.004). Short-term single-shot perioperative antibiotic prophylaxis associated with early drain removal (within 21 days postop) represents a safe approach in terms of prevention of local infective surgical complication and allows a more effective treatment of the diagnosed SSI.

Long-term impact of lipofilling in hybrid breast reconstruction: retrospective analysis of two cohorts

Lipofilling has recently gained popularity as a tool in primary treatment of breast cancer, and its association with two-stage implant breast reconstruction is considered as standard treatment in many centers. However, no data are available about the long-term results of the association of lipofilling in combination with expander-implant reconstruction. A retrospective analysis was conducted on patients treated between January 2010 and December 2014. Two groups were compared. Group 1 had a standard expander-implant two-stage reconstruction. Group 2 underwent hybrid breast reconstruction (HBR). Patient characteristics, hospitalization, outcomes, reoperation details, outpatient visits, and evaluation questionnaires were taken into consideration. Intergroup comparison was performed using Wilcoxon Mann-Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Two hundred fourteen patients were evaluated: 130 patients in group 1 and 84 patients in group 2. Group 2 showed significant benefits over group 1 in terms of capsular contracture rate, breast pain, and displacement/rotation of the implant (p = 0.005). The HBR protocol is associated with lower rate of capsular contracture, less breast pain at long follow-up times, and lower overall rates of revision surgery compared to standard expander-implant reconstruction. A specific cost analysis will help further clarify the advantages of this protocol over a standard procedure.Level of Evidence: Level III, risk/prognostic, therapeutic study.

Complication Profiles by Mastectomy Indication in Tissue Expander Breast Reconstruction.

Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exist regarding reconstruction complication rates examined by mastectomy indication. Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011 to 2017 were included in the study. Perioperative complications were compared. Chi-square analysis, t tests, and Fisher's exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis. Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p = 0.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p = 0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups. Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than those undergoing prophylactic mastectomies. Although the underlying cause still needs to be determined, differences in technique may be related to mastectomy flap necrosis. Risk, II.

The impact of postmastectomy radiotherapy on two-stage implant breast reconstruction: an analysis of long-term surgical outcomes, aesthetic results, and satisfaction over 13 years.

Postmastectomy radiation therapy is increasingly indicated in patients with node-positive breast cancer. The authors prospectively evaluated long-term outcomes in patients with two-stage implant-based reconstruction and postmastectomy radiation therapy to the permanent implant. A cohort of 1415 patients operated on by a single surgeon from 1998 to 2010 was evaluated annually. Outcomes were recorded prospectively. Complication rates were compared between irradiated and nonirradiated implants, including reconstructive failure (implant loss), complications (e.g., capsular contracture), aesthetic results, and satisfaction. Predicted implant loss and replacement rates were examined by irradiation status with Kaplan-Meier analysis and the log-rank test. A total of 2133 breast implant reconstructions with a mean follow-up of 56.8 months (range, 12 to 164 months) were included. Three hundred nineteen implants received radiation. Implant loss occurred in 9.1 percent of irradiated implants and 0.5 percent of nonirradiated implants (p < 0.01). Capsular contracture grade IV was present in 6.9 percent of irradiated and 0.5 percent of nonirradiated implants (p < 0.01). There was no difference between groups regarding implant replacement. Ninety-two percent of irradiated patients had good to excellent aesthetic result, and 94.2 percent would choose implants again. Predicted implant loss rates were 17.5 percent and 2.0 percent for irradiated and nonirradiated implants, respectively, at 12 years (p < 0.01), and predicted implant replacement rates were 12.7 percent and 8.8 percent, respectively, at 8 years (p = not significant). This is the largest prospective long-term outcomes evaluation in women with immediate tissue expander/implant reconstruction and postmastectomy radiation therapy. Most patients had a good to excellent aesthetic result and preserve their reconstruction at 12 years. Therapeutic, III.

Post-Mastectomy Radiotherapy after Two-Stage Implant Breast Reconstruction

Post-Mastectomy Radiotherapy after Two-Stage Implant Breast Reconstruction

Comparison of Immediate Implant-Based versus Staged Tissue Expander Breast Reconstruction Technique

Sir:FigureWe had the great pleasure of reading the interesting article by Roostaeian et al. published recently in this Journal,1 and we congratulate the authors on their study. The two-stage tissue expander/implant technique is currently the most commonly performed procedure in breast reconstruction. A wide variety of procedures have been used for breast reconstruction, and the choice of technique depends on the needs, body habitus, general conditions, and preference of the patient. The advent of oncologically safe skin-sparing mastectomies and the improved cosmetic results achieved by these techniques have influenced and improved the aesthetic quality of breast reconstruction, especially from implants.2,3 The authors showed in their study that one-stage breast reconstruction is not burdened with more complications and a higher revision rate. In any event, the majority of their patients had grade 1 ptosis or less in approximately 80 percent and only 20 percent of large-breasted patients. Furthermore, they did not mention whether they had used total or partial muscular coverage of expander/implant, or acellular dermal matrices to achieve total muscular coverage, especially in the immediate implant-based breast reconstruction group. This information is extremely important for analyzing the possible complications and properly judging the aesthetic outcome. Finally, these factors might influence the results and explain why there is no difference in one-stage versus two-stage implant breast reconstruction groups. In our Unit, we always perform total muscular coverage of the device, and we think that with expanders there is a decreased risk of mastectomy skin flap necrosis because of less tension. Furthermore, immediate placement of large implants underneath the pectoralis major muscle without adequate expansion can be associated with increased postoperative pain and an inferior aesthetic result. Often, for immediate and adequate implant coverage, acellular dermal matrix is needed, and this yields an increased cost and greater risk of complications. Breast reconstruction using expanders/implants provides an excellent option for properly selected patients. We believe that patients with small, minimally ptotic breasts are the best candidates for implant reconstruction alone (Fig. 1), whereas patients with larger, more ptotic breasts should require a two-stage approach and a matching procedure to attain symmetry. The matching procedure can be a simple augmentation or mastopexy, or can involve a breast reduction (Fig. 2).Fig. 1: One-stage implant breast reconstruction after nipple-sparing mastectomy and contralateral augmentation mammaplasty in a 39-year-old patient.Fig. 2: A 44-year-old patient underwent skin-sparing mastectomy and two-stage breast reconstruction with an extraprojected implant, restoration of the inframammary fold, and contralateral reduction mammaplasty.For us, immediate one-stage reconstruction is limited to prophylactic and risk-reducing mastectomy, especially in small and nonptotic breasts, whereas with this two-stage technique, we are able to achieve good quality breast reconstruction using anatomically shaped expanders and implants in all types of patients, especially in those with large/ptotic breasts and in those requiring adjuvant chemotherapy, which can cause weight gain, which could be a cause of late breast asymmetry. Contralateral breast surgery can improve patient satisfaction and aesthetic outcome, especially in young patients. Our only concern is that the patients have to undergo two operations with the additional costs of two prostheses. The combined cost of the anatomically shaped expander and implant is over one and a half times the cost of a single mammary prosthesis. Despite these limitations, we consider the quality and aesthetic outcome of reconstruction justified in the use of two-stage technique. Stefano Bonomi, M.D. Fernanda Settembrini, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Milan, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

Patient Selection and Aesthetic Outcomes in One-Stage versus Two-Stage Implant Breast Reconstruction

Patient Selection and Aesthetic Outcomes in One-Stage versus Two-Stage Implant Breast Reconstruction

A Single Surgeon???s 12-Year Experience with Tissue Expander/Implant Breast Reconstruction: Part I. A Prospective Analysis of Early Complications

Multiple prior reports are conflicted regarding the true incidence of complications following implant-based breast reconstruction. A review of a single surgeon's extensive experience with tissue expander/implant reconstruction provides the opportunity to critically evaluate outcomes in a uniformly treated patient population. The objective of this study was to analyze the development of early complications in patients following two-stage implant breast reconstruction. A review of all tissue expander/implant reconstructions performed by a single surgeon over the 12-year period from July of 1992 to June of 2004 was performed. A prospectively maintained database was analyzed with respect to reconstructive and early complication data on 1522 reconstructions in 1221 patients. Early complications were defined as those occurring 12 months or less from initiation of reconstruction. The overall rate of early complications was 5.8 percent; the rate of premature expander removal was 2.7 percent. The most common complication was infection (2.5 percent). The incidence of complications after tissue expander insertion (8.5 percent) was significantly higher than that after the exchange procedure (2.7 percent). The rate of complications was significantly higher in patients with a history of preoperative chest wall irradiation. There was no difference in the incidence of complications in patients who were expanded during chemotherapy and those who were not. Tissue expander/implant reconstruction is a safe, reliable method of reconstruction with minimal early complications. Early complications are more common after expander insertion. Chemotherapy administered during tissue expansion does not increase the rate of complications. The rate of complications, although higher in previously irradiated patients, remains low.