Two-stage Prosthetic Breast Reconstruction Research Articles

Comparing Cortiva Silhouette to AlloDerm for Use in Prepectoral Two-stage Prosthetic Breast Reconstruction.

The use of acellular dermal matrices (ADMs) in implant-based breast reconstruction has become increasingly routine during the past 20 years. ADMs improve soft-tissue support, facilitate greater tissue expander (TE) fill volumes, and reduce rates of capsular contracture. As the ADM market continues to grow, outcomes studies are necessary to assess the risks and benefits of each product. In this study, we compare the performance of Cortiva Silhouette, the thinnest ADM widely available, to AlloDerm, commonly considered the industry standard. We performed a retrospective review of 178 consecutive two-stage prosthetic breast reconstructions performed by the senior author. In every case, either Cortiva or AlloDerm was used to provide soft-tissue support during TE placement. Subjects were divided into Cortiva and AlloDerm cohorts and compared across patient characteristics and reconstructive outcomes variables. During the study period, AlloDerm was used in 116 reconstructions; Cortiva was used in 62. After propensity score matching (62 AlloDerm, 62 Cortiva), Cortiva was associated with greater intraoperative and final TE fill volumes, as well as larger silicone implants. Cortiva was also associated with fewer complications overall, and fewer instances of mastectomy skin necrosis, delayed wound healing, and seroma. Cortiva Silhouette is noninferior to AlloDerm in terms of safety and providing soft-tissue support in prepectoral two-stage implant-based breast reconstruction. In this study, Cortiva supported greater TE fill volumes and larger silicone implants relative to AlloDerm and was associated with fewer complications.

Association of Fat Graft with Breast Cancer Recurrence in Implant-Based Reconstruction: Does the Timing Matter?

In two-stage prosthetic breast reconstruction, autologous fat graft (AFG) is often conducted simultaneously with the second-stage operation, which is usually performed shortly after mastectomy. There is a paucity of studies evaluating whether conducting AFG early, with a relatively short interval from the primary operation, is oncologically safe. This study aimed to evaluate potential associations of AFG with breast cancer prognosis, focusing on its timing. Patients with invasive breast cancer who underwent immediate two-stage prosthetic reconstruction following mastectomy between 2011 and 2016 were identified. They were categorized into two groups by whether AFG was performed during the second-stage operation. Cumulative incidence of oncologic events was compared between the two groups, after stratifying patients by the time interval between mastectomy and the second-stage operation (≤ 12 months vs. > 12 months). Of 267 cases that met the selection criteria, 203 underwent the second-stage operation within 12 months of mastectomy. AFG was performed for 112 cases and was not performed in 91 cases. The two groups showed similar baseline characteristics including tumor stage and adjuvant treatments. Compared with the control, AFG was associated with lower locoregional recurrence-free survival and disease-free survival, and this difference remained significant after adjusting for other variables including tumor stage. In the 64 cases undergoing the operation after 12 months following mastectomy, oncologic outcomes did not differ between the two groups. Our results suggest that AFG timing in relation to mastectomy may be associated with risks for breast cancer recurrence.

Postsurgical Outcomes with Meshes for Two-stage Prosthetic Breast Reconstruction in 20,817 Patients.

Patients who underwent breast reconstruction with and without ADM were identified from the National Surgical Quality Improvement Program database utilizing CPT codes. Covariates included patient demographics, preoperative comorbidities, and operative characteristics, while outcomes of interest were postoperative infection and reoperation. Univariate and multivariate analyses were performed to identify predictors of adverse outcomes. There were 8334 patients in the ADM cohort and 12,451 patients who underwent tissue expander breast reconstruction without ADM. There were significantly fewer reoperations in the non-ADM cohort (5.4%) compared to the ADM cohort (7.7%) (P < 0.0001), with infection and hematoma as the most common etiologies in both cohorts. Surgical infections were also more prevalent in the ADM cohort (4.7%) compared with the non-ADM cohort (3.6%) (P < 0.0001). Univariate and multivariate analysis of the tissue expander breast reconstruction cohort revealed race, obesity, hypertension, smoking status, albumin, and operative time as predictive for infection risk, while race, obesity, hypertension, smoking, albumin, operative time, and age were significant for reoperation. Our study of 20,817 patients revealed significantly higher risk of infection and reoperation in patients who underwent breast reconstruction utilizing ADM versus without ADM. Patients considering ADM for breast reconstruction should engage in discussion with their surgeon about complications, aesthetics, and cost.

Postsurgical Outcomes with Acellular Dermal Matrices for Two-stage Prosthetic Breast Reconstruction in 20,817 Patients

PURPOSE: The use of acellular dermal matrices (ADM) for tissue expander breast reconstruction remains controversial with uncertain safety and efficacy profile. This study analyzes the rates and factors for reoperation and postoperative infection in patients who underwent tissue expander breast reconstruction with and without ADM. Methods Patients who underwent breast reconstruction with and without ADM were identified from the NSQIP database utilizing CPT codes. Covariates included patient demographics, preoperative comorbidities, and operative characteristics, while outcomes of interest were postoperative infection and reoperation. A univariate and multivariate analysis were performed to identify predictors of adverse outcomes. RESULTS: There were 8,334 patients in the ADM cohort and 12,451 patients who underwent tissue expander breast reconstruction without ADM. There were significantly fewer reoperations in the non-ADM cohort (5.4%) compared to the ADM cohort (7.7%) (p<0.0001), with infection and hematoma as the most common etiologies in both cohorts. Surgical infections were also more prevalent in the ADM cohort (4.7%) compared to the non-ADM cohort (3.6%) (p<0.0001). Univariate and multivariate analysis of the tissue expander breast reconstruction cohort revealed race, obesity, hypertension, smoking status, albumin, and operative time as predictive for infection risk, while race, obesity, hypertension, smoking, albumin, operative time, and age were significant for reoperation. CONCLUSION: Our study of 20,817 patients revealed significantly higher risk of infection and reoperation in patients who underwent breast reconstruction utilizing ADM compared to those without ADM. Patients considering ADM for breast reconstruction should engage in discussion with their provider about complications, aesthetics, and cost.

The Effect of Intraoperative Submaximal Tissue Expander Inflation on Outcomes in Two-stage Prosthetic Breast Reconstruction: Less is More?

The Effect of Intraoperative Submaximal Tissue Expander Inflation on Outcomes in Two-stage Prosthetic Breast Reconstruction: Less is More?

Symmetry following unilateral two-stage prosthetic breast reconstruction: Is there an optimal time for managing the contralateral breast?

Achieving breast symmetry following unilateral mastectomy remains a challenge. Contralateral procedures are usually necessary to achieve breast symmetry. Controversy exists regarding whether these symmetry procedures should be performed at the time of the initial reconstruction or on a delayed basis. The study included 105 patients who had unilateral mastectomy, of which 55 had a simultaneous (immediate) contralateral symmetry procedure and 50 had a delayed contralateral symmetry procedure. Outcomes were compared and assessed for each cohort based on demographics, complications, and patient satisfaction. The delayed cohort required more procedures (3.4vs. 1.8, p < 0.0001) but shorter overall hospitalization length (2.8vs. 4.1 days, p < 0.0001). The two cohorts experienced a similar rate of revision (38.3% vs. 49.3%, p=0.17) The delayed cohort required a contralateral balancing procedure after completion of reconstruction more often than the immediate cohort (p=0.021). Overall reconstruction-specific complication rates were similar in both cohorts. The 36-Item Short-Form Health Survey (SF-36), a validated questionnaire for quality-of-life assessment, was administered 3 months after surgery and demonstrated that both cohorts reported similar outcomes when comparing their satisfaction with treatment. The results of this study demonstrate that immediate contralateral symmetry operations can be performed safely without increased morbidity. A new algorithm is presented.

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

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

Single-Unit technique for the use of acellular dermal matrix in immediate expander-based breast reconstruction

The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry. We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed. Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition. This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

Single-unit Technique for the Use of Acellular Dermal Matrix in Immediate Expander-based Breast Reconstruction

Summary Background The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry. Methods We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed. Results Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition. Conclusions This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

Stability of Long-Term Outcomes in Implant-Based Breast Reconstruction: An Evaluation of 12-Year Surgeon- and Patient-Reported Outcomes in 3489 Nonirradiated and Irradiated Implants.

Outcomes following prosthetic breast reconstruction have been well studied. However, the majority of studies are limited by short-term follow-up and a lack of aesthetic and patient-reported outcomes. This study objectively examines long-term surgeon- and patient-reported outcomes following two-stage prosthetic breast reconstruction. Consecutive patients undergoing two-stage prosthetic breast reconstruction from 1994 to 2016 performed by the senior author (P.G.C.), with at least 1-year follow-up after implant exchange, were reviewed retrospectively. Long-term surgeon-reported outcomes, including aesthetic and capsular contracture scores, and patient-reported outcomes using the BREAST-Q, were recorded at each outpatient visit and analyzed over the 12-year follow-up period. Retrospective review revealed 2284 patients, or 3489 breasts, that fit the inclusion criteria. Aesthetic scores and capsular contracture rates remained stable over the entire follow-up period. Subset analysis demonstrated that bilateral and nonirradiated reconstructions consistently had the highest aesthetic scores, whereas unilateral irradiated breasts had the lowest. Irradiated breasts consistently had high rates of capsular contracture, although the extent of contracture improved over time in all patients. Patient-reported BREAST-Q scores showed either stability or improvement over time in all patients. Irradiated and nonirradiated patients demonstrated comparable long-term satisfaction with outcomes despite significant differences in satisfaction with their breasts. The authors' study, the largest of its kind, demonstrates that prosthetic breast reconstruction outcomes do not deteriorate over time. This stability is apparent in both long-term surgeon- and patient-reported outcomes data measured in the same patients. These results contradict the surgical dogma surrounding prosthetic breast reconstruction and therefore should be given significant consideration when counseling patients. Therapeutic, IV.

Two-stage prosthetic breast reconstruction with latissimus flap: Prepectoral versus subpectoral approach

Use of latissimus flap in prosthetic breast reconstruction after mastectomy is an established approach, particularly in patients who have failed breast-conserving therapy. This study presents a comparison of the prepectoral and the subpectoral approach for two-stage prosthetic breast reconstruction with a latissimus flap. A retrospective review of outcomes and complications was completed between the prepectoral group (n = 33 patients, 50 reconstructed breasts) and the subpectoral group (n = 22 patients, 36 reconstructed breasts). The demographics were similar between the prepectoral and subpectoral groups in terms of mean age (52.4 vs. 52.5 years, p = 0.97), smoking history (15.1% vs. 13.6%; p = 1.00), radiation history (75.8% vs. 91.0%; p = 0.28), and mean length of follow-up (479 vs. 680 days; p = 0.07). The body mass index was significantly higher in the prepectoral group (27.6 vs. 25.2 kg/m2; p = 0.03). Complications were similar between the groups in terms of hematoma (9.1% vs. 0.0%, p = 0.26), infection resulting in implant failure (9.1% vs. 4.5%, p = 0.64), thromboembolic events (3.0% vs. 4.5%, p = 1.0), donor site seroma (66.7% vs. 40.9%, p = 0.09), breast seroma (18.2% vs. 27.3%, p = 0.51), capsular contracture (9.1% vs. 4.5%, p = 0.64), animation deformity (39.4% vs. 50.0%, p = 0.58), and reoperation (24.2% vs. 22.8%, p = 1.00). Patient satisfaction scores were also similar between the groups (4.33 ± 1.08 vs. 4.14 ± 1.13, p = 0.52). The prepectoral approach for two-stage immediate prosthetic reconstruction with a latissimus flap has similar outcomes and complications to those of the subpectoral approach, yet obviating the need for any pectoralis major muscle dissection.

Influence of Radiation Dose to Reconstructed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction.

Purpose: This study investigated the association between radiation dose and complication rate in patients who underwent breast reconstruction to understand the role of radiation hypofractionated regimen, boost radiation therapy (RT), and RT techniques.Methods: We retrospectively evaluated 75 patients treated with post-mastectomy adjuvant RT for breast cancer in the setting of two-stage prosthetic breast reconstruction. Near maximum radiation dose (Dmax) in the 2 or 0.03 cc of reconstructed breast or overlying breast skin was obtained from dose-volume histograms.Results: Post-RT complications occurred in 22.7% of patients. Receiver operating characteristic analysis showed that all near Dmax parameters were able to predict complication risk, which retained statistical significance after adjusting other variables (odds ratio 1.12 per Gy, 95% confidence interval 1.02–1.23) with positive dose-response relationship. In multiple linear regression model (R2 = 0.92), conventional fractionation (β = 11.7) and 16 fractions in 2.66 Gy regimen (β = 3.9) were the major determinants of near Dmax compared with 15 fractions in 2.66 Gy regimen, followed by utilization of boost RT (β = 3.2). The effect of bolus and dose inhomogeneity seemed minor (P > 0.05). The location of hot spot was not close to the high density metal area of the expander, but close to the surrounding areas of partially deflated expander bag.Conclusions: This study is the first to demonstrate a dose-response relationship between risk of complications and near Dmax, where hypofractionated regimen or boost RT can play an important role. Rigorous RT-quality assurance program and modification of dose constraints could be considered as a critically important component for ongoing trials of hypofractionation. Based on our findings, we initiated a multi-center retrospective study (KROG 18-04) and a prospective study (NCT03523078) to validate our findings.

Two-stage prepectoral breast reconstruction.

The options for prosthetic breast reconstruction have expanded and include prepectoral versus subpectoral location of devices as well as performing these operations in one- or two-stage. Current practice patterns are evolving toward the placement of devices in the prepectoral plane in a single stage. The authors' patient selection criteria and surgical technique were reviewed and organized in a step-by-step format. On and off label techniques for acellular dermal matrix (ADM) assembly were reviewed. A review of surgical outcomes was completed. Two-stage reconstruction confers several advantages such as reducing pressure on the mastectomy skin flaps, optimal implant selection for the second stage and the opportunity to revise the reconstruction, all of which can increase the likelihood of a successful outcome. This manuscript will review the indications, techniques, and outcomes following prepectoral, two-stage prosthetic breast reconstruction.

Influence of Hypofractionated Radiation Therapy Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction

Influence of Hypofractionated Radiation Therapy Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction

Immediate Two-Stage Prosthetic Breast Reconstruction Failure: Radiation Is Not the Only Culprit.

Immediate prosthetic breast reconstruction produces a satisfactory aesthetic result with high levels of patient satisfaction. However, with the broader indication for postmastectomy adjuvant radiation therapy, many patients are advised against immediate breast reconstruction because of concerns of implant loss and infection, particularly as most patients also require chemotherapy. This retrospective cohort study examines outcomes for patients who underwent immediate two-stage prosthetic breast reconstruction after mastectomy with or without adjuvant chemotherapy or radiotherapy. Between 1998 and 2010, 452 patients undergoing immediate two-stage prosthetic breast reconstruction involving a total of 562 breasts were included in this study. Stage 1 was defined as insertion of the temporary expander, and stage 2 was defined as insertion of the final silicone implant. Postoperative adjuvant radiotherapy was recommended with a tissue expander in situ for 114 patients. Complications, including loss of prosthesis, seroma, and infection, were recorded and analyzed. Cosmetic result was assessed using a four-point scale. Postoperative prosthesis loss was 2.7 percent, 5.3 percent for patients undergoing adjuvant chemotherapy and increasing to 11.3 percent for patients receiving chemotherapy plus radiotherapy. Chemotherapy and radiotherapy independently were the main, statistically significant risk factors for expander or implant loss [incidence rate ratio, 13.85 (p = 0.012) and 2.23 (p = 0.027), respectively]. Prosthesis loss for patients undergoing combination chemotherapy plus radiotherapy was also significant [incidence rate ratio, 4.791 (p < 0.001)]. These findings serve to better inform patients on risk in weighing treatment options. Postmastectomy radiation therapy doubles the risk of prosthesis loss over and above adjuvant chemotherapy but is an acceptable option following immediate two-stage prosthetic breast reconstruction in a multidisciplinary setting. Therapeutic, III.

The use of acellular dermal matrix in immediate two-stage prosthetic breast reconstruction provides protection from postmastectomy radiation therapy: a clinicopathologic perspective.

Although there is ample evidence showing that radiation therapy increases the risk of complications of breast reconstruction, the efficacy of human acellular dermal matrix (CGCryoDerm®) in immediate tissue expander breast reconstruction in the setting of postmastectomy radiation therapy has not been fully elucidated. In this study, we report our institutional experience with pertinent refined surgical technique, and determine whether acellular dermal matrices have a protective effect in this increasingly prevalent clinical setting. Twenty-six patients who underwent immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy with at least 2 years of follow-up were retrieved. Fifteen patents were reconstructed with ADM, whereas 11 patients were reconstructed without ADM. The occurrence of complications was assessed according to the reconstruction type (with ADM vs without ADM). Furthermore, in patients reconstructed with ADM (n = 15), immunohistochemistry was performed to analyze the breast capsule with ADM compared with that without ADM in the same patient, according to the expression of alpha-smooth muscle actin (α-SMA). The occurrence of complications was significantly associated with the reconstruction type (with ADM vs. without ADM, p = 0.015). On the basis of the results of α-SMA staining, α-SMA+ myofibroblasts were relatively highly expressed throughout the breast capsule without ADM. On the contrary, α-SMA+ myofibroblasts present at the breast capsule adjacent to the ADM were scarce and irregularly scattered. Use of an acellular dermal matrix may be recommended to patients who are concerned about complications after immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy.

Two-Stage Prosthetic Breast Reconstruction after Mastectomy with or without Prior Postmastectomy Radiotherapy.

Background:Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period.Methods:Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded.Results:Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections.Conclusions:Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.

The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: a systematic review.

The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: a systematic review.

Treatment of Irradiated Expanders: Protective Lipofilling Allows Immediate Prosthetic Breast Reconstruction in the Setting of Postoperative Radiotherapy

Immediate two-stage prosthetic breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) currently is hardly achieved with the fast-track expander exchange proposed by Cordeiro and colleagues or the delayed-immediate breast reconstruction proposed by Kronowitz and Robb. Each of these techniques has important drawbacks and complications. To overcome these problems, the authors in 2011 described lipofilling on irradiated expanders in patients undergoing unplanned PMRT (Cagliari University Hospital [CUH] protocol) for early breast cancers with specific risk factors. The authors report their experience after expanding the use of such a protocol for any immediate expander/implant reconstruction in a patient undergoing PMRT. The timing for advanced breast cancer involves immediate reconstruction with a tissue expander, complete tissue expansion, radiotherapy (RT) after neoadjuvant chemotherapy starting 2-3 months after mastectomy, one or two fresh fat-grafting sessions at least 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. The timing for early breast cancers with specific risk factors involves immediate reconstruction with a tissue expander, complete tissue expansion during postoperative chemotherapy, RT 6 months after mastectomy, one or two fat-grafting sessions 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. From 2008 to 2012, 16 patients undergoing total mastectomy and immediate expander-implant breast reconstruction with subsequent PMRT were treated according to the CUH protocol. The results have been extremely encouraging, with rates of ulceration and implant exposure in the radiotreated area dropping to 0 %. These results were retrospectively compared with those for a control group of 16 patients who underwent immediate implantation of an expander. In this latter group, the extrusion rate of the implant in the end was 31.25 %, and this was statistically significant (p < 0.03). The shape and symmetry also were significantly better in the lipofilled patients. Protective lipofilling on irradiated expanders appears to be a valid technique for avoiding ulceration and implant exposure after PMRT while allowing a complete expansion. 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 .

The Effects of Postmastectomy Adjuvant Radiotherapy on Immediate Two-Stage Prosthetic Breast Reconstruction

The authors performed a systematic review of the literature on the outcome of therapy for patients with breast cancer who underwent adjuvant radiotherapy after an immediate two-stage prosthetic breast reconstruction, either following tissue expansion (stage 1) or after removal of the tissue expander and insertion of a final breast implant (stage 2). Their outcomes were compared to those of patients who had reconstruction without postmastectomy irradiation. Electronic database searches were supplemented by a full-text review of possible relevant articles on two-stage prosthetic immediate breast reconstruction and radiotherapy. Delayed or one-stage prosthetic or nonprosthetic breast reconstruction studies were excluded. The primary outcome measured was the reconstruction failure rate with prosthesis loss. Secondary endpoints were capsular contracture and aesthetic outcome. No randomized controlled trials were identified, and only one prospective, nonrandomized, multicenter trial was found. Reports with more than 15 patients were included; 12 studies had a total of 1853 patients (715 irradiated and 1138 nonirradiated). Adjuvant radiotherapy resulted in a significantly higher reconstruction failure rate in immediate two-stage prosthetic breast reconstruction compared with controls (18.6 percent versus 3.1 percent, p < 0.00001). Radiotherapy particularly increased the failure rate when given after stage 1 (expander) (29.7 percent versus 5 percent, p < 0.00001) but also stage 2 (permanent implant) (7.7 percent versus 1.5 percent, p = 0.0003). There was also an increase in severe capsular contractures and an inferior cosmetic result in the irradiated patients. Nonrandomized studies suggest that adjuvant radiotherapy results in a higher risk of reconstruction failure.