Prepectoral versus Subpectoral Breast Reconstruction after Nipple-sparing Mastectomy: A Systematic Review and Meta-Analysis.

Background: Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) presents unique benefits and challenges. The literature has compared outcomes among total submuscular (TSM), dual-plane (DP), and prepectoral (PP) planes; however, a dedicated meta-analysis relevant to NSM is lacking. Methods: We conducted a systematic review of studies on immediate breast reconstruction after NSM using TSM, DP, or PP prosthesis placement in PubMed, Embase, and Cochrane databases. In total, 1317 unique articles were identified, of which 49 were included in the systematic review and six met inclusion criteria for meta-analysis. Pooled descriptive outcomes were analyzed for each cohort for all 49 studies. Fixed-effects meta-analytic methods were used to compare PP with subpectoral (TSM and DP) reconstructions. Results: A total of 1432 TSM, 1546 DP, and 1668 PP reconstructions were identified for descriptive analysis. Demographics were similar between cohorts. Pooled descriptive outcomes demonstrated overall similar rates of reconstructive failure (3.3%-5.1%) as well as capsular contracture (0%-3.9%) among cohorts. Fixed-effects meta-analysis of six comparative studies demonstrated a significantly lower rate of mastectomy flap necrosis in the PP cohort compared with the subpectoral cohort (relative risk 0.24, 95% confidence interval [0.08-0.74]). All other consistently reported outcomes, including, hematoma, seroma, infection, mastectomy flap necrosis, nipple -areola complex necrosis, and explantation were comparable. Conclusions: A systematic review of the literature and meta-analysis demonstrated the safety of immediate prepectoral breast reconstruction after NSM, compared with submuscular techniques. Submuscular reconstruction had a higher risk of mastectomy flap necrosis, though potentially influenced by selection bias.

Artificial Intelligence as a Triage Tool during the Perioperative Period: Pilot Study of Accuracy and Accessibility for Clinical Application.

Background: Given the dialogistic properties of ChatGPT, we hypothesized that this artificial intelligence (AI) function can be used as a self-service tool where clinical questions can be directly answered by AI. Our objective was to assess the content, accuracy, and accessibility of AI-generated content regarding common perioperative questions for reduction mammaplasty. Methods: ChatGPT (OpenAI, February Version, San Francisco, Calif.) was used to query 20 common patient concerns that arise in the perioperative period of a reduction mammaplasty. Searches were performed in duplicate for both a general term and a specific clinical question. Query outputs were analyzed both objectively and subjectively. Descriptive statistics, t tests, and chi-square tests were performed where appropriate with a predetermined level of significance of P less than 0.05. Results: From a total of 40 AI-generated outputs, mean word length was 191.8 words. Readability was at the thirteenth grade level. Regarding content, of all query outputs, 97.5% were on the appropriate topic. Medical advice was deemed to be reasonable in 100% of cases. General queries more frequently reported overarching background information, whereas specific queries more frequently reported prescriptive information (P < 0.0001). AI outputs specifically recommended following surgeon provided postoperative instructions in 82.5% of instances. Conclusions: Currently available AI tools, in their nascent form, can provide recommendations for common perioperative questions and concerns for reduction mammaplasty. With further calibration, AI interfaces may serve as a tool for fielding patient queries in the future; however, patients must always retain the ability to bypass technology and be able to contact their surgeon.

Differential preferences in breast aesthetics by self-identified demographics assessed on a national survey.

There is a paucity of literature examining how preferences differ amongst various demographic groups. This study aimed to assess how perceptions of the ideal breast differ between respondents stratified by self-identified demographic factors. A cohort of 25 patients from the senior surgeon's practice presenting for breast surgery was assembled. Pre-operative anteroposterior photographs of these patients were distributed via Qualtrics (Seattle, WA) to a large sample designed to be representative of the demographics of the United States. Survey questions aimed to measure respondents' impressions of 'breast attractiveness'. Respondents were asked to rate breasts on a Likert scale. Survey responses were analysed for differences in breast aesthetic preferences by sex, gender, sexual orientation, and race. Males rated all breasts higher on the Likert scale for attractiveness than females (2.8 vs 2.5, p < 0.001). Despite this discrepancy, ratings amongst male and female respondents were highly correlated with one another (R = 0.940; p < 0.0001). Considering sexual orientation, individuals attracted to women provided significantly higher attractiveness ratings to all breasts compared to individuals attracted to men only (2.8 vs 2.5, p < 0.001). White or Caucasian individuals ascribed significantly higher breast attractiveness ratings than Asian individuals (2.7 vs 2.2, p < 0.001), but not Black or African American individuals (2.7 vs 2.4, p = 0.23). Despite these racial discrepancies in mean breast attractiveness, ratings amongst the three groups were highly correlated. In a sample representative of the United States, a difference in breast aesthetic appraisal was observed by demographic factors. These findings merit further investigation to understand these trends and observations.

Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM. METHODS: All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics. RESULTS: A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy. CONCLUSIONS: Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Double-Barrel Vascularized Free Fibula Flap for Reconstruction of Sternal Nonunion with Bone Defect: A Case Report.

CASE: Given the rare incidence of sternal nonunion after traumatic injury, literature describing the management of posttraumatic sternal reconstruction is limited. We present a case of a 54-year-old man with a history of traumatic chest wall injury with multiple unsuccessful attempts at sternal repair who presented with chronic sternal nonunion and persistent bone defect. Sternal reconstruction using a vascularized double-barrel free fibula flap with rigid fixation in multiple planes was performed, with confirmed bony union at 6 months. CONCLUSION: This novel approach to sternal nonunion management allowed effective bridging of posttraumatic sternal bone defects while facilitating osseous integration and long-term stabilization.

Do we need acellular dermal matrix in prepectoral breast reconstruction? A systematic review and meta-analysis.

Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM. A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. Pooled rates of patient demographics and outcomes were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complications in studies comparing reconstruction with and without ADM. In total, 515 reconstructions from four studies were included. Most cases were nipple-sparing mastectomies and utilized tissue-expander reconstructions. Meta-analysis demonstrated no significant difference in the rate of complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and 2.8% in no-ADM), seroma (1.2% and 8.3%, respectively), hematoma (1.2% and 2.1%), infection (4.7% and 4.2%), and mastectomy flap ischemia and/or necrosis (2.4% and 5.2%). Long-term complications included rippling (3.3% in ADM and 5.1% in no-ADM cohorts) and capsular contracture (6.8% and 3.4%, respectively). This meta-analysis demonstrated no difference in the rate of complications between cases with and without ADM. However, the outcomes data from no-ADM reconstruction mostly reflect robust mastectomy flaps. Surgeon discretion as informed by specific clinical scenarios should guide decisions regarding the use of ADM in prepectoral breast reconstruction.

No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy.

Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-term data on its efficacy in prevention of breast cancer. The objective of this study was to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years. Methods: Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate. Results: Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort. Conclusions: The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.

General Population and Surgeon Preferences for Pollicization Versus Toe-To-Thumb Transfer for Reconstruction of Traumatic Thumb Loss in Adults: An International, Multi-Center Survey Study.

PURPOSE: Data objectively comparing outcomes following pollicization versus toe-to-thumb transfer for reconstruction after traumatic thumb amputation in adults remains sparse. Given that this decision is reliant on personal preference, it is important to understand the subjective nature of these preferences, particularly in the context of culture. The purpose of this study was to compare Eastern and Western societal and hand surgeon preferences for pollicization versus toe-to-thumb transfer for traumatic thumb reconstruction. METHODS: Investigators from 6 international locations recruited local hand surgeons and members of the general population. Austria, Germany, the United States, and Spain were grouped as "Western" nations. China and India separately represented "Eastern" nations. Participants completed a questionnaire evaluating their personal preferences for pollicization and toe-to-thumb transfer. The questions posed to the general population and hand surgeons were identical. Demographic data were also collected. RESULTS: When comparing the Western nations, China, and India, there was no difference in personal preferences within the general population for pollicization versus toe-to-thumb transfer. In contrast, most Indian hand surgeons favored toe-to-thumb transfer and most Western surgeons were uncertain about which procedure they would favor. Surgeons had more optimistic expectations regarding postoperative hand function, new thumb sensation, and hand appearance following pollicization than the general population. Similarly, for toe-to-thumb transfer, a greater proportion of surgeons predicted good-to-excellent function, sensation, and appearance. CONCLUSIONS: There was no clear, observed "East" versus "West" difference in the general population's personal preferences for pollicization versus toe-to-thumb transfer among study participants. The members of the general population and hand surgeons had different outcome expectations. CLINICAL RELEVANCE: Understanding how culture influences patient and hand surgeon preferences for pollicization versus toe-to-thumb transfer may help guide future decision-making for traumatic thumb reconstruction.

Patient Decision-Making for Management of Style 410 Anatomical Implants in Breast Reconstruction.

BACKGROUND: In July of 2019, the U.S. Food and Drug Administration (FDA) recalled the Allergan Natrelle 410 Highly Cohesive Anatomically Shaped Silicone-Filled Textured Breast Implants because of a heightened risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The objective of this study was to describe patient decision-making in management of preexisting 410 textured implants. METHODS: A single-institution retrospective chart review was conducted to determine all patients who received 410 anatomical implants from two surgeons. Patients who received these implants were contacted in July to September of 2019 regarding the FDA recall and asked to schedule a consultation to discuss explant/exchange versus surveillance. Outcomes analyzed included decision of surveillance versus explantation and subsequent reconstructive operations. RESULTS: Eighty-nine patients had received 410 implants from 2013 to 2017. Of the 147 breasts that were reconstructed, 58.5% were oncologic mastectomies and 41.5% were prophylactic. The majority of patients (71.9%) cited BIA-ALCL as the predominant influencing factor in their decision for management. Other factors included appearance, implant concerns unrelated to BIA-ALCL, and other medical conditions. Twenty patients (22.5%) underwent explantation of the Style 410 implants. The remaining 77.5% of patients elected for monitored surveillance. There was a significant association between a history of breast cancer and explantation of the Style 410 implants ( P = 0.0335). CONCLUSIONS: The majority of patients with Style 410 textured implants elected to undergo surveillance for BIA-ALCL. When deciding to explant or exchange the Style 410 implants, plastic surgeons should work in conjunction with their patients to carefully outline management options.

Aesthetic Characteristics of the Ideal Female Breast.

The female breast is a subject of significant focus within plastic surgery. Little work to date has examined public perceptions of attractiveness with respect to breast anatomy and morphology. This study provides a comprehensive assessment of anatomic and aesthetic breast characteristics valued by the general population. Methods: A single-institution retrospective review was conducted of patients presenting for aesthetic or reconstructive breast surgery between 2009 and 2019. A cohort of 25 patients were included in a nationwide survey designed to assess subjective impressions of overall "breast attractiveness." Survey responses were assessed, and the five patients with the highest mean scores were identified. An in-depth analysis of this subgroup was performed, evaluating anatomic metrics on both two-dimensional photographs and three-dimensional imaging. Statistical analysis examined correlations between objective breast characteristics and subjective perceptions of "attractiveness." Results: There were 1021 survey responses. Across the entire patient cohort, the mean age was 47.4 years and mean BMI was 24.9 kg/m2. On a five-point Likert scale, the mean "breast attractiveness" score for the highest-scoring subgroup patients (n = 5) was 3.1 ± 0.1. Within this group, all patients had minimal ptosis and a projected contour. Average breast size was moderate, with mean volume of 299.4 ± 115.8 cm3. Conclusions: This study reverse engineers the aesthetically appealing female breast, beginning with overall impressions of attractiveness and subsequently analyzing the influence of objective anatomic parameters on subjective perceptions. In surveying a large and diverse population, moderately sized, projected breasts with upper pole fullness were found to be associated with increased "attractiveness" scores.

Catch-22: Acellular Dermal Matrix and U.S. Food and Drug Administration Premarket Approval-How Can We Construct Studies?

SUMMARY: As a biologic product derived from human tissue, acellular dermal matrices did not require premarket approval for their initial use as a soft-tissue support product. Since their first use in breast surgery, acellular dermal matrices have allowed for numerous advances in breast reconstruction. They quickly gained popularity in breast surgery and are used frequently in various applications. During an investigation into potential factors leading to breast implant-associated anaplastic large-cell lymphoma, the U.S. Food and Drug Administration made an official statement that acellular dermal matrices were not approved for use in breast reconstruction and that using them in breast surgery was considered off-label. This special topic article details the history of acellular dermal matrices in breast surgery and describes the ongoing evolution of the relationship between the U.S. Food and Drug Administration and acellular dermal matrices.

Long-Term Cancer Recurrence Rates following Nipple-Sparing Mastectomy: A 10-Year Follow-Up Study.

BACKGROUND: Despite the increased use of nipple-sparing mastectomies, there are limited data examining long-term cancer recurrence rates in these patients. The objective of this study was to analyze breast cancer recurrence in patients who underwent therapeutic nipple-sparing mastectomy with a median of 10 years of follow-up. METHODS: All patients undergoing nipple-sparing mastectomy at a single institution were retrospectively reviewed temporally to obtain a median of 10 years of follow-up. Patient demographic factors, mastectomy specimen pathologic findings, and oncologic outcomes were analyzed. Univariate analysis was performed to identify independent risk factors for locoregional recurrence. RESULTS: One hundred twenty-six therapeutic nipple-sparing mastectomies were performed on 120 patients. The most frequently observed tumor histology included invasive ductal carcinoma (48.4 percent) and ductal carcinoma in situ (38.1 percent). Mean tumor size was 1.62 cm. Multifocal or multicentric disease and lymphovascular invasion were present in 31.0 percent and 10.3 percent of nipple-sparing mastectomy specimens, respectively. Sentinel lymph node biopsy was performed in 84.9 percent of nipple-sparing mastectomies, and 17.8 percent were positive. The rate of positive frozen subareolar biopsy was 7.3 percent ( n = 82) and that of permanent subareolar pathology was 9.5 percent ( n = 126). The most frequently observed pathologic tumor stages were stage I (44.6 percent) and stage 0 (33.9 percent). The incidence of recurrent disease was 3.17 percent per mastectomy and 3.33 percent per patient. On univariate analysis, no demographic, operative, or tumor-specific variables were independent risk factors for locoregional recurrence. CONCLUSIONS: Overall recurrence rates are low in patients undergoing nipple-sparing mastectomy at a median follow-up of 10-years. Close surveillance should remain a goal for patients and their providers to promptly identify potential recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Picking the Right Plane: A Comparison of Total Submuscular, Dual-Plane, and Prepectoral Implant-Based Breast Reconstruction.

BACKGROUND: Implant-based breast reconstruction has evolved, with a recent resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been elucidated fully among the total submuscular, dual-plane, and prepectoral planes of implant placement. METHODS: All immediate implant-based breast reconstructions from March of 2017 through August of 2019 were reviewed retrospectively. Cases were divided into total submuscular, dual-plane, and prepectoral cohorts. Demographics, operative techniques, and reconstructive outcomes and complications were compared among groups. RESULTS: A total of 826 cases (510 patients) were identified and divided into total submuscular ( n = 392), dual-plane ( n = 358), and prepectoral ( n = 76) cohorts. Average follow-up for all patients was 27 months. The prepectoral cohort had a higher average body mass index and rate of previous reduction or mastopexy. Overall complications were lowest in the total submuscular group, although this difference was not statistically significant. Major infection occurred more frequently in the dual-plane group compared with the total submuscular cohort. The prepectoral cohort had a significantly increased incidence of wound dehiscence than the total submuscular group; both the dual-plane and prepectoral groups had higher rates of seroma formation and explantation compared with the total submuscular group. CONCLUSIONS: Overall reconstructive complication rates were comparable among the cohorts. Compared with those undergoing total submuscular reconstruction, the dual-plane cohort was more likely to develop a major infection or require explantation, whereas the prepectoral group had significantly higher rates of isolated dehiscence, seroma formation, and explantation. This suggests that the absence of overlying vascularized muscle may lead to an inherent inability to tolerate wound-healing complications, although further research is needed to clarify these observations. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Research Promotion Is Associated with Broader Influence and Higher Impact of Plastic Surgery Publications.

BACKGROUND: Social media have altered the mechanisms by which published research is disseminated and accessed. The objective of this study was to measure the effect of promotion on research article dissemination, influence, and impact in Plastic and Reconstructive Surgery . METHODS: All articles published in Plastic and Reconstructive Surgery from January 1, 2016, to December 31, 2018, were obtained and reviewed to determine inclusion/exclusion and for the Altmetric Attention Score, citations, relative citation rate, and 16 unique promotional tags (e.g., journal club, editor's pick, press release, patient safety, and so on) as indexed on the Plastic and Reconstructive Surgery website. The analysis included 1502 articles. Statistical analysis was completed using descriptive statistics, Pearson correlations, and t tests where appropriate with a predetermined level of significance of p ≤ 0.05. RESULTS: A total of 637 articles (42.4 percent) had a promotional tag, whereas 252 (16.8 percent) had multiple tags. Articles with promotional tags had a higher Altmetric Attention Score (30.35 versus 8.22; p < 0.001), more citations (11.96 versus 8.47; p < 0.001), and a higher relative citation rate (2.97 versus 2.06; p < 0.001) compared to articles without a tag. Articles with multiple tags had a higher Altmetric Attention Score (50.17 versus 17.39; p < 0.001), more citations (15.78 versus 9.47; p < 0.001), and a higher relative citation rate (3.67 versus 2.51; p < 0.001) compared to articles with only one tag. As the number of tags increased for an article, Altmetric Attention Score ( p < 0.001), citation count ( p < 0.001), and relative citation rate ( p < 0.001) likewise increased. CONCLUSION: This analysis strongly suggests that promotion of research articles is associated with significantly wider dissemination, broader visibility, and more subsequent citations in the literature.

Hematoma following gender-affirming mastectomy: A systematic review of the evidence.

BACKGROUND: Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence. METHODS: A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE). RESULTS: The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma. CONCLUSIONS: Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma. LEVEL OF EVIDENCE: III.