Women Undergoing Breast Reconstruction Research Articles

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres.

In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Abstract P2-15-05: Prepectoral versus subpectoral implant-based breast reconstruction: A systemic review and meta-analysis

Abstract Prepectoral versus subpectoral implant-based breast reconstruction: A systemic review and meta-analysis. Edvin Ostapenko, MD1,2, Larissa Nixdorf, MD1, Yelena Devyatko, MD1, Ruth Exner, MD1, Kerstin Wimmer, MD1, Florian Fitzal, MD1 1Department of General Surgery and Breast Health Center, Medical University of Vienna, Vienna, Austria. 2Faculty of Medicine, Vilnius University, Vilnius, Lithuania Abstract Background Implant-based breast reconstruction (IBBR) is still standard and most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral IBBR has resurged in popularity, despite limited data comparing prepectoral with subpectoral IBBR. Methods A systematic search of PubMed and Cochrane Library from January 1, 2011, to December 31, 2021, was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guideline, data were extracted by independent reviewers. Random and fixed-effect models were applied to obtain pooled proportions and 95% CIs. The Risk of Bias in Nonrandomized Studies- of Interventions (ROBINS-I) tool was used for critical appraisal of cohorts and funnels plots, and the Egger bias test were used for evaluating the publication bias. Studies that compared prepectoral IBBR with subpectoral IBBR for breast cancer were included. Results Overall, 15 studies with 3101 patients were included in this meta-analysis. Our results showed that patients receiving prepectoral IBBR experienced fewer capsular contracture (odds ratio [OR], 0.54; 95% CI, 0.32-0.92; P=.02), animation deformity (OR, 0.02; 95% CI, 0.00-0.25; P=.002), and prosthesis failure (OR, 0.58; 95% CI, 0.42-0.80; P=.001). There was no significant difference between prepectoral and subpectoral IBBR in overall complications (OR, 0.83; 95% CI, 0.64-1.09; P=.19), seroma (OR, 1.21; 95% CI, 0.59-2.51; P=.60), hematoma (OR, 0.76 95% CI, 0.49-1.18; P=.22), infection (OR, 0.87; 95% CI, 0.63-1.20; P=.39), skin flap necrosis (OR, 0.70 95% CI, 0.45-1.08; P=.11), and recurrence (OR, 1.31; 95% CI, 0.52-3.39; P=.55). Similarly, no significant difference was found in Breast-Q scores between prepectoral and subpectoral IBBR groups. Conclusion The results of our systematic review and meta-analysis demonstrated that prepectoral implant-based breast reconstruction is a safe modality and have similar outcomes with significantly lower rates of capsular contracture, prosthesis failure and animation deformity compared to subpectoral implant-based breast reconstruction. Future research should include randomized clinical trials or well-designed prospective matched studies with adequate follow-up to assess long-term as well as oncologic outcomes between comparative groups. Key Words: immediate implant-based breast reconstruction, breast cancer, outcomes, prepectoral, subpectoral; Citation Format: Edvin Ostapenko, Larissa Nixdorf, Yelena Devyatko, Kerstin Wimmer, Ruth Exner, Florian Fitzal. Prepectoral versus subpectoral implant-based breast reconstruction: A systemic review and meta-analysis. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-15-05.

Contemporary Trends in Breast Reconstruction Use and Impact on Survival Among Women with Inflammatory Breast Cancer.

Breast reconstruction is generally discouraged in women with inflammatory breast cancer (IBC). Nevertheless, reconstruction rates are increasing in this population. We aimed to determine contemporary trends and predictors of breast reconstruction use and its impact on mortality among IBC patients. Demographic, clinicopathologic, and follow-up data for women with non-metastatic IBC having mastectomy between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) 18 registries database. Rates and predictors of immediate breast reconstruction, along with survival outcomes between the breast reconstruction and no reconstruction groups were calculated. To account for selection bias, a propensity score analysis matching one reconstruction patient to three no reconstruction patients was performed. A total of 4076 women with non-metastatic IBC who underwent mastectomy (388 [9.5%] with breast reconstruction and 3688 [90.5%] without) were included. The proportion of women undergoing breast reconstruction and contralateral prophylactic mastectomy increased from 6.2 to 15.3% and 12.9 to 29.6%, respectively, between 2004 and 2015. Younger age, higher annual income, metropolitan residence, and bilateral mastectomy predicted breast reconstruction use. The 10-year breast cancer-specific survival was 62.9% for women having breast reconstruction and 47.6% for women not having breast reconstruction. After propensity-matched analysis, 10-year cancer-specific survival was similar between the reconstruction (56.6%) and no reconstruction (62.2%) groups (adjusted hazard ratio 0.96, 95% confidence interval 0.79-1.16; p=0.65). Breast reconstruction rates continue to rise among IBC patients, particularly young women and women with access to reconstruction. Breast reconstruction is not associated with inferior breast cancer-specific survival and can be an option for select patients.

The Thoracodorsal Artery Perforator Flap: A Powerful Tool in Breast Reconstruction.

Perforator flap use in breast cancer reconstruction has evolved significantly in the last decade. The authors reviewed their experience and evaluated thoracodorsal artery perforator (TDAP) flap outcomes in breast reconstruction. A retrospective chart review was conducted of all women undergoing breast reconstruction between 2012 and 2018. Included were patients who underwent a mastectomy (unilateral or bilateral) with immediate reconstruction or requiring a revision reconstruction with a TDAP flap. Reconstruction for nonmalignant causes were excluded. Patient demographics, risk factors, indications, operative details, and complications were reviewed. Major (partial or total flap necrosis, hematoma, and wound breakdown requiring operative management) and minor (cellulitis, seroma, and minor wound breakdown managed with local wound care) complications were recorded. A total of 138 charts were reviewed for the years 2012 and 2018, and 126 patients met inclusion criteria. Mean patient age was 52.1 years. Mean patient body mass index was 29.1 kg/m 2 . A total of 174 TDAP flaps were performed. The success rate was 98.3 percent. There were three flap losses (all partial). Operable fat necrosis rate was 3 percent. Donor-site morbidity was low at a rate of 1.2 percent. There was no difference in complications between patients who had a history of radiation therapy and those who did not (16.7 and 18.6 percent, respectively; p = 0.829). This study is the largest series in the literature that highlights the utility of the TDAP flap in breast reconstruction. This flap is a powerful tool that should be considered in patients for whom other reconstructive options have been exhausted or unavailable. Therapeutic, IV.

Which Factors Are Important to Women When Choosing a Breast Reconstruction Surgeon?

Women undergoing breast reconstruction often research their health care provider options. The authors studied which factors may influence how a woman selects a plastic surgeon for breast reconstruction surgery. An online survey was distributed by means of Amazon Mechanical Turk (MTurk; Amazon Web Services, Inc., Seattle, Wash.) to 1025 adult women. Participants were asked to imagine a scenario in which they had breast cancer, needed to undergo mastectomy, and were choosing a reconstructive surgeon. They were then asked to rank factors influencing this decision on a 1 to 7 Likert scale. Two-sample t tests were used to compare Likert scores between dichotomized categories based on participant characteristics. Women assigned the highest scores [mean (standard deviation)] to online reviews on Vitals or WebMD [6.1 (1.2)], years of experience [5.7 (1.4)], recommendations from another surgeon [5.7 (1.3)] or family/friend [4.9 (1.7)], and attending a top medical school [4.7 (1.7)]. Lowest ranked factors were online advertising and surgeon demographics, including having a sex concordant (female) surgeon. After amalgamation into attribute subsections, mean (standard deviation) rated relative importance of surgeon reputation [0.72 (0.13)] was higher than that of appearance [0.46 (0.19)] and demographics [0.31 (0.13)]. Patient demographics influenced relative importance of certain attributes; older, educated, and higher-income patients placed higher value on surgeon appearance (all p < 0.05). When selecting a breast reconstruction surgeon, women place the highest value on surgeons' online, educational, and personal reputations. Though most show no strong preferences for surgeon demographics or physical attributes, specific features may be important for some patients. Cognizance of these preferences may enable providers to more effectively understand patient expectations.

Acellular Dermal Matrices in Breast Reconstruction: CARE Trial 5-Year Outcomes Data for More Than 9500 Patients.

Background:Few studies have assessed long-term complications in women undergoing implant-based breast reconstruction with use of an acellular dermal matrix (ADM). This study compared outcomes over 5 years in women undergoing breast reconstruction procedures with and without ADM.Methods:Complications data in patients enrolled in the prospective Continued Access Reconstruction/Revision Expansion trial were segregated by use of ADM versus no ADM in patients undergoing primary breast reconstruction or revision-reconstruction. Continued Access Reconstruction/Revision Expansion trial evaluated long-term safety and effectiveness of shaped, textured, silicone implants.Results:Of the 9502 women, 257 had primary (n = 160) or revision-reconstruction (n = 97) with ADMs; 9245 had primary (n = 6977) or revision-reconstruction (n = 2268) without ADMs. Capsular contracture rates in primary reconstruction were lower with ADM than without at year 5 (3.2% versus 7.4%); rates were similar at year 1 (≤2.4%). Capsular contracture rates in revision-reconstruction were lower with ADM than without at year 5 (1.4% versus 8.9%); rates were similar at year 1 (≤2.5%). Seroma rates were low and sustained for all cohorts throughout the 5 years (≤2.9%). Reoperation rates increased over time in all cohorts, with similar rates between groups (2.4%–47.3% from week 4 to year 5 across cohorts). Other trends over time included lower rates for asymmetry and implant malposition with ADM than without.Conclusion:These long-term data suggest that the use of ADM in breast reconstruction procedures may provide a benefit in reducing complications, such as capsular contracture, and may sustain low rates of seroma.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

Background:For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer.Methods:We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.Results:We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4–8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1–10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5–4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions.Conclusions:Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

The collagenase of the bacterium Clostridium histolyticum does not favor metastasis of breast cancer.

Breast cancer is the most common malignancy among women worldwide. As survival rates increase, breast reconstruction and quality of life gain importance. Of all women undergoing breast reconstruction, approximately, 70% opt for silicone implants and 50% of those develop capsular contracture, the most prevalent long-term complication. The collagenase of the bacterium Clostridium histolyticum (CCH) showed promising results in the therapy of capsule contracture; however, its influence on residual cancer cells is unknown. The aim of this study was to investigate whether CCH-treatment negatively impacts breast cancer cells in vitro and in vivo. MDA-MB-231 and MCF-7 cells were used in this study. In vitro, we tested the influence of CCH on proliferation, wound healing, migration and cell cycle by MTT-assay, scratch-assay, transwell-migration-assay, and flow cytometry. In vivo, solid tumors were induced in immune-deficient mice. CCH was injected into the tumors and tumor growth and metastasis formation was monitored by caliper measurement, in vivo bioluminescence imaging and histology. Gene expression analysis was performed by microarray including 27,190 genes. CCH-incubation led to a dose-dependent reduction in proliferation for both cell lines, while wound healing was reduced only in MDA-MB-231 cells. No morphological alterations were monitored in cell cycle or apoptosis. In vivo, bioluminescence imaging and histology did not show any evidence of metastasis. Although CCH led to changes in gene expression of breast cancer cells, no relevant alterations in metastasis-related genes were monitored. CCH has no impact on tumor growth or metastasis formation in vitro and in vivo. This paves the way for first clinical trials.

Normative data for the BREAST-Q Reconstruction module in an Australian population and comparison with US norms and breast reconstruction patient outcomes

Normative data for interpreting the BREAST-Q reconstruction module are currently limited to the US population. This study aimed to generate normative BREAST-Q data from women in the Australian general population and compare it to US norms. Secondary aims were to compare normative scores to those of women undergoing breast reconstruction post-mastectomy. Women aged 18 years and older without a history of breast cancer or breast surgery were recruited according to the Australian Census-derived population distribution. Participants completed the pre-operative BREAST-Q Reconstruction module and provided socio-demographic information. A comparison was made to a breast reconstruction patient cohort and published US norms. BREAST-Q data were obtained from 500 women. Mean BREAST-Q scores were as follows: Satisfaction with Breasts (Aus. 50.4±15.2, US 57.8±18.4), Psychosocial Well-being (Aus. 55.4±15.8, US 70.7±17.6), Physical Well-being Chest (Aus. 78.5±14.8, US 92.6±10.7), Physical Well-being Abdomen (Aus. 76.1±19.6, US 78.1±20.3) and Sexual Well-being (Aus. 41.5±20.6, US 56.5±8.2). Australian women with a higher BMI or chronic health condition reported lower scores for four of the five BREAST-Q scales. Lower scores were reported by younger women for Psychosocial Well-being and Sexual Well-being. Mean BREAST-Q scores for the Australian population were significantly lower than US norms in four of the five scales. When compared to normative data, breast reconstruction patients had significantly higher BREAST-Q scores post-operatively in all scales except for Physical Well-being Chest. This study derived only the second set of normative scores for the BREAST-Q reconstruction module reported globally and found that significant differences exist between populations.

The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis.

BackgroundA personal history of depression prior to breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores.MethodologyWe conducted a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to November 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, six weeks following tissue expander (TE) insertion for patients undergoing staged reconstruction, and six and 12 months following the final reconstruction. Medical records were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between groups and within groups. Groups compared were the depression (n = 50) and no depression (n = 250) patients, along with anti-depressant (n = 36) and no anti-depressant (n = 14) use in the depression group.ResultsWithin-group Sexual Well-being scores at the six-week post-TE follow-up for patients in the depression group (median = 37, interquartile range [IQR] = 25-47) were significantly lower (p < 0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60). There were no statistically significant differences in BREAST-Q scores in other domains. When compared to patients diagnosed with depression who were not taking anti-depressants, anti-depressant medication use did not result in statistically significant higher BREAST-Q scores, although Satisfaction With Breasts six months post-operatively, Psychosocial Well-being at six weeks post-TE, Sexual Well-being at six weeks post-TE and six months post-operatively were clinically higher in patients taking anti-depressants for depression.ConclusionsPatients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the six-week TE group with or without anti-depressant medication. Patients with a pre-cancer diagnosis of depression considering TEs may benefit from additional counseling prior to breast reconstruction or electing a different method of breast reconstruction. Anti-depressant medications may provide clinically higher BREAST-Q scores in patients with a pre-cancer diagnosis of depression. Adding an anti-depressant medication to a patient’s treatment plan may provide additional benefits. Larger samples are required to properly determine the impact of anti-depressant medications on BREAST-Q scores in patients with a pre-cancer diagnosis of depression.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction.

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Goldilocks Principle: Preference for Change in Breast Size in Breast Cancer Reconstruction Patients.

Patients’ preferences regarding changing or maintaining their breast size after mastectomy and reconstruction are important but understudied determinants of post-surgical satisfaction and quality of life. The goal of this study was to identify factors associated with preferences for changing or maintaining breast size for women undergoing breast reconstruction at The University of Texas MD Anderson Cancer Center in the United States from 2011 to 2014. The average age of participants was 45.7 ± 9.1 years. At baseline, mean average breast volumes were 755.7 ± 328.4 mL for all women (n = 48), 492.3 mL ± 209.3 for 13 women who preferred to be “bigger than now,” 799.2 mL ± 320.9 for 25 women who preferred to remain “about the same,” and 989.3 mL ± 253.1 for 10 women who preferred “smaller than now.” Among the 23 women who preferred to change their breast size, 19 desired to shift toward the mean. Women with the smallest and largest 20% of baseline breast size were more likely to desire a change toward the mean (p = 0.006). Multinomial logistic regression models found average breast volume and satisfaction with breast size to be the most important factors associated with preferences for changing or maintaining breast size for women undergoing breast reconstruction. This study provides preliminary evidence for a “Goldilocks principle” in women’s preferences for breast size change in the context of breast reconstruction, and identifies hypotheses for future studies of the associations among preference for change in breast size, preference achievement, and post-reconstruction body image.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

INSTRUCTIONS: Satisfaction with Expectations-Based Education in Women Undergoing Breast Reconstruction.

INSTRUCTIONS: Satisfaction with Expectations-Based Education in Women Undergoing Breast Reconstruction.

Optimizing Postoperative Pain Control in Autologous Breast Reconstruction: A Systematic Review.

Pain management approaches in autologous breast reconstruction have become a topic of great interest in the era of enhanced recovery after surgery protocols, as well as the opioid epidemic. The management of postoperative pain is of critical importance for women undergoing breast reconstruction; however, these protocols have yet to be synthesized and compared in the primary literature. Herein, we present a systematic review of approaches to provide optimal pain control while minimizing narcotic use and its associated potential negative sequelae in autologous breast reconstruction. A comprehensive systematic review of the published literature was conducted using Ovid Medline/PubMed database without timeframe limitations, in compliance with the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria were selected for studies reporting objective outcomes of pain modulation in autologous breast reconstruction. Articles for inclusion were stratified based on intervention. A total of 101 articles were identified on initial search query. After full-text review and final screening of all articles and review of included studies' references, 28 studies met the inclusion criteria and were analyzed. There continues to be a substantial need for evidence-based guidelines in the plastic surgery literature. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Given the increasing popularity of and access to autologous approaches to breast reconstruction, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized postoperative care.

Decreasing Opioid Prescriptions in Women Undergoing Mastectomy and Breast Reconstruction

BackgroundFlorida enacted legislation limiting opioid prescriptions and affecting the management of acute pain in the postoperative patient. Patients in a reconstructive surgery practice were receiving prescriptions for opioids as their primary method of pain management. Clinic providers identified a need to limit opioid prescriptions. AimThe aim of this quality improvement initiative was to decrease the number of opioids prescribed while effectively managing pain in women undergoing mastectomy and breast tissue expander placement. DesignThis is a quality improvement project. MethodsThe Model for Improvement was used as a framework for this project. An evidence-based pain management plan was developed after a review of the breast reconstruction surgery literature. The plan incorporated preoperative patient and family education and the standard use of preemptive analgesia, intraoperative nerve blocks, and postoperative multimodal analgesia in all patients undergoing mastectomy with breast tissue expander placement. Patient and family education and perioperative pain management were provided to patients, and the number of opioid tablets prescribed was tracked. ResultsBetween January 2018 and August 2019, the average number of opioid tablets prescribed per patient decreased from 84.7 to 8.4. ConclusionsOpioid prescriptions can be decreased in women undergoing breast reconstruction with the use of patient education and multimodal analgesia.

Breast Reconstruction: Impact of Patient-Centered, Expectations-Based Education on Women Undergoing Reconstructive Surgery After Mastectomy.

Among patients undergoing breast reconstruction, preoperative expectations for improvement may not match postoperative results. Discordance between provided preoperative information and what patients actually hear and understand may be a factor contributing to these unrealistic expectations. The aim of this study was to determine the impact of patient-centered, expectations-based education on women undergoing breast reconstruction. The 27 participants completed a preoperative questionnaire concerning their postoperative expectations. The nurse practitioner tailored preoperative education based on questionnaire results. A postoperative questionnaire was given to assess patient satisfaction with the preoperative information provided. A high percentage of survey participants agreed that they had received an appropriate amount of education, believed they were well prepared for surgery, and knew what to expect in the recovery period.

PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients’ goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

Risk of breast implant associated anaplastic large cell lymphoma (BIA-ALCL) in a cohort of 3546 women prospectively followed long term after reconstruction with textured breast implants

The risk of BIA-ALCL for patients with textured breast implants has been estimated between 1/2832 and 1/30,000 women. Existing studies estimating the numbers exposed and at risk, may have under reported cases, and/or lacked comprehensive follow-up. Our objective is to determine the risk of BIA-ALCL in a defined cohort of patients reconstructed with macro-textured breast implants and consistently followed long-term. A prospective cohort study was conducted in patients who underwent breast reconstruction by a single surgeon at Memorial Sloan Kettering Cancer Center (MSKCC) from December 1992 to December 2017. Major events related to implants were prospectively recorded. We identified cases of BIA-ALCL by cross-checking clinical, pathology and external records data. Patients were followed until lymphoma occurrence or last follow-up. The primary outcomes were incidence rate per person-years and cumulative incidence. From 1992 to 2017, 3546 patients underwent 6023 breast reconstructions, mainly after breast cancer removal, or contralateral prophylactic mastectomy, using macro-textured surface expanders and implants. All reconstructions were performed by a single surgeon (PGC). Median follow-up was 8.1 years (range, 3 months - 30.9 years). Ten women, 1/354, developed ALCL after a median exposure of 11.5 years (range, 7.4-15.8 years). Overall risk of BIA-ALCL in our cohort is 1/355 women or 0.311 cases per 1000 person-years (95% CI 0.118 to 0.503). This study, the first to evaluate the risk of macro-textured breast implants from a prospective database with long term follow-up, demonstrates that the incidence rate of BIA-ALCL may be higher than previously reported. These results can help inform implant choice for women undergoing breast reconstruction.

Immediate Breast Reconstruction Allows for the Timely Initiation of Postmastectomy Radiation Therapy.

Complications from breast reconstruction may delay postmastectomy radiation therapy and impact breast cancer outcomes. The authors hypothesized that immediate breast reconstruction may be associated with delays in the initiation of radiation, but that this delay would not significantly impact overall patient survival. Using the National Cancer Database, the authors identified women with breast cancer who underwent mastectomy and received postmastectomy radiation therapy. Delayed radiation was defined as treatment initiated 6 months or more after surgery in patients who received adjuvant chemotherapy or 12 weeks or more after surgery in patients who received neoadjuvant or no chemotherapy. Women undergoing breast reconstruction had an increased time to postmastectomy radiation therapy, 154 days versus 132 days (p < 0.001), and were more likely to experience a delay in initiating radiation (OR, 1.25; 95 percent CI, 1.188 to 1.314). Other factors associated with delayed radiation included increased Charlson/Deyo scores, neoadjuvant chemotherapy, nonprivate insurance, and black race. Cox proportional hazards models revealed no evidence of a reduced adjusted overall survival in the immediate breast reconstruction group (hazard ratio, 0.836; 95 percent CI, 0.802 to 0.871; p < 0.001). Restricted cubic spline analysis identified the threshold number of days at which the start of radiation began to impact survival at 169 days (95 percent CI, 160 to 190 days), 75 days (95 percent CI, 42 to 90 days), and 71 days (95 percent CI, 41 to 90 days) in patients undergoing adjuvant, neoadjuvant, and no chemotherapy, respectively. Immediate breast reconstruction is associated with a modest delay in initiating postmastectomy radiation therapy but does not impact overall survival. Therapeutic, III.