Oxylipins in Breast Implant Associated Systemic Symptoms.

BACKGROUND: A subset of women with breast implants have reported a myriad of nonspecific systemic symptoms collectively termed systemic symptoms associated with breast implants (SSBI). SSBI symptoms are similar to manifestations associated with autoimmune and connective tissue disorders Breast tissue is rich in adipose cells, comprised of lipids. Insertion of an implant creates an oxidative environment leading to lipid oxidation. Oxylipins can influence immune responses and inflammatory processes. OBJECTIVES: This study explores the abundance of a spectrum of oxylipins in the peri-prosthetic tissue surrounding the breast implant. Since oxylipins are immunogenic, we sought to determine if they are associated with the SSBI subjects. We have also attempted to determine if the common manifestations exhibited by such subjects have any association with oxylipin abundance. METHODS: The study included 120 subjects divided in three cohorts. Forty-six subjects with breast implants exhibiting manifestation associated with SSBI, 29 in control cohort I subjects with breast implants not exhibiting manifestation associated with SSBI (non-SSBI) and 45 in control cohort II subjects without implants (normal tissue) were analyzed. Lipid extraction and oxylipin quantification was performed using LCMS. LC-MS/MS targeted analysis from the breast adipose tissue was performed. RESULTS: Of the fifteen oxylipins analyzed, four exhibited increased abundance in the SSBI cohort compared to the non-SSBI and normal cohorts. CONCLUSIONS: The study documents the association of the oxylipins with each manifestation reported by the subject. This study provides an objective assessment on the subjective questionnaire highlighting which symptoms could be more relevant than the others.

Evaluating Operative Times for Intraoperative Conversion of Axillary Node Biopsy to Axillary Lymph Node Dissection with Immediate Lymphatic Reconstruction.

BACKGROUND: Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning. METHODS: A single-center retrospective review was performed (2019-2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded. RESULTS: There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001). CONCLUSION: Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.

Quantification of Lymphangiogenesis in the Murine Lymphedema Tail Model Using Intravital Microscopy.

Background: Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. It affects an estimated five million Americans. There is no cure for this disease. Assessing lymphatic growth is essential in developing novel therapeutics. Intravital microscopy (IVM) is a powerful imaging tool for investigating various biological processes in live animals. Tissue nanotransfection technology (TNT) facilitates a direct, transcutaneous nonviral vector gene delivery using a chip with nanochannel poration in a rapid (<100 ms) focused electric field. TNT was used in this study to deliver the genetic cargo in the murine tail lymphedema to assess the lymphangiogenesis. The purpose of this study is to experimentally evaluate the applicability of IVM to visualize and quantify lymphatics in the live mice model. Methods and Results: The murine tail model of lymphedema was utilized. TNT was applied to the murine tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: TNTpCMV6 group receives pCMV6 (expression vector backbone alone) (n = 6); TNTProx1 group receives pCMV6-Prox1 (n = 6). Lymphatic vessels (fluorescein isothiocyanate [FITC]-dextran stained) and lymphatic branch points (indicating lymphangiogenesis) were analyzed with the confocal/multiphoton microscope. The experimental group TNTProx1 exhibited reduced postsurgical tail lymphedema and increased lymphatic distribution compared to TNTpCMV6 group. More lymphatic branching points (>3-fold) were observed at the TNT site in TNTProx1 group. Conclusions: This study demonstrates a novel, powerful imaging tool for investigating lymphatic vessels in live murine tail model of lymphedema. IVM can be utilized for functional assessment of lymphatics and visualization of lymphangiogenesis following gene-based therapy.

Active nerve management for above the knee amputation: A comparison of through the wound versus posterior approach.

Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.

The Lymphedematous Limb as a Donor Site for Breast Fat Grafting.

Breast cancer-related lymphedema results in chronic upper limb swelling with subcutaneous deposition of fluid and fibroadipose tissue. Morbidity includes psychosocial distress, infection, and difficulty using the extremity. Operative management includes excisional procedures such as suction-assisted lipectomy to reduce abnormal subcutaneous fibroadipose tissue to improve limb volume. Patients who have had postmastectomy breast reconstruction often benefit from fat grafting. This report introduces the concept of fat grafting the breast using the lymphedematous arm as a donor site. This technique improves the volume of the limb by removing the excess subcutaneous adipose, and at the same time reconstructs the breast without adding a donor site not related to the breast cancer-related lymphedema.

Trends in Immediate Lymphatic Reconstruction.

Background and objective Immediate lymphatic reconstruction (ILR) is emerging as a useful adjunct after axillary lymph node dissection (ALND), leading to a decrease in lymphedema rates from 30 to 3-13% in breast cancer patients. ILR requires coordination between two surgical specialties for oncologic ALND and microsurgical axillary lymphatic anastomosis. This study aimed to assess the trends in the frequency of ILR performed after ALND at our institution. Methods This study involved a retrospective review of breast cancer patients undergoing ALND with and without ILR at our institution (2017-2022). Data on patient demographics, tumor characteristics, and treatments received were gathered and analyzed. Results A total of 316 patients underwent ALND at our institution and 30.7% (97/316) of them received ILR. There was no significant difference in clinical breast cancer stages between patients who underwent ALND with or without ILR (p>0.05). Neoadjuvant chemotherapy was given to 51.1% (112/219) of patients with ALND only compared to 60.8% (59/97) of patients who underwent ALND with ILR (p=0.09). All patients received adjuvant radiation therapy. ILR was performed after ALND in 4.2% (2/47) in 2017, 25.8% (3/58) in 2018, 17.6% (12/68) in 2019, 35% (21/60) in 2020, 56.9% (41/72) in 2021, and 54.5% (6/11) in 2022. When comparing the first year of the ILR program with the last year of the study period, the odds ratio of receiving ILR after ALND was 1.8 (p=0.04). Conclusions The frequency of performing ILR after ALND in breast cancer patients at our institution witnessed a substantial increase during the study period. The implementation of an established ILR program at an institution can increase procedure uptake accompanied by continued growth in utilization.

Same day discharge following mastectomy and immediate tissue expander reconstruction: The effect of patient expectations.

BACKGROUND AND PURPOSE: Within, we compare the short-term outcomes of patients receiving same day mastectomy and tissue expander reconstruction for those discharged on postoperative day one versus those discharged immediately following surgery to explore the safety, efficacy, and potential impact on hospital processes. METHODS: This was a retrospective review of patients undergoing mastectomy with immediate TE reconstruction from March 2019 to March 2021. Patients were stratified into two cohorts; observation overnight (OBS), and discharge on same day of surgery (DC). RESULTS: In total, 153 patients underwent 256 mastectomies with immediate TE reconstruction. All patients were female and the mean age was 48 years old. The DC cohort contained 71 patients (125 mastectomies) and there were 82 patients (131 mastectomies) within the OBS cohort. On average the DC cohort had a lower BMI than the OBS group (mean ± SD; DC 26.8 kg/m2 ± 5.3 kg/m2, OBS 28.7 kg/m2 ± 6.1 kg/m2, p = 0.05), the DC cohort had higher rates of adjuvant chemotherapy (DC 40.1%, OBS 23.2%, p = 0.02), and were more likely to undergo bilateral TE reconstruction (DC 76%, OBS 60%, p = 0.03) than the OBS group. No differences were observed between cohorts in complication rates regarding primary or secondary outcomes. CONCLUSION: These findings indicate that it is safe and effective within the immediate 7-day post-operative period to immediately discharge patients undergoing mastectomy with immediate TE reconstruction. Additionally, alteration of patient management practices can have a profound impact on the operational flow within hospitals.

Topical tissue nanotransfection of Prox1 is effective in the prophylactic management of lymphedema.

Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.

Biofilm-derived oxylipin 10-HOME-mediated immune response in women with breast implants.

This study investigates a mechanistic link of bacterial biofilm-mediated host-pathogen interaction leading to immunological complications associated with breast implant illness (BII). Over 10 million women worldwide have breast implants. In recent years, women have described a constellation of immunological symptoms believed to be related to their breast implants. We report that periprosthetic breast tissue of participants with symptoms associated with BII had increased abundance of biofilm and biofilm-derived oxylipin 10-HOME compared with participants with implants who are without symptoms (non-BII) and participants without implants. S. epidermidis biofilm was observed to be higher in the BII group compared with the non-BII group and the normal tissue group. Oxylipin 10-HOME was found to be immunogenically capable of polarizing naive CD4+ T cells with a resulting Th1 subtype in vitro and in vivo. Consistently, an abundance of CD4+Th1 subtype was observed in the periprosthetic breast tissue and blood of people in the BII group. Mice injected with 10-HOME also had increased Th1 subtype in their blood, akin to patients with BII, and demonstrated fatigue-like symptoms. The identification of an oxylipin-mediated mechanism of immune activation induced by local bacterial biofilm provides insight into the possible pathogenesis of the implant-associated immune symptoms of BII.

A Novel Framework for Optimizing Efficiency and Education in Microsurgical Breast Reconstruction.

Deep inferior epigastric perforator (DIEP) flaps are becoming the most frequent choice for autologous breast reconstruction. There are many benefits to DIEP flaps, but the procedures can be lengthy and have a steep learning curve. The balance of efficiency and education can be difficult to achieve. A framework was implemented to focus on both efficiency and education at each stage of the DIEP flap procedure. The author's methods to improve efficiency include a two-team approach with assigned roles for faculty and residents. The roles are consistent across the institution. Methods to enhance education include practice in a laboratory-based microsurgical training course and assigning goals for the rotation. Trainees include independent and integrated plastic surgery residents without microsurgical fellows. Bilateral DIEPs are performed with two attendings, and unilateral DIEPs, with one attending. A retrospective review identified patients undergoing DIEP flap reconstruction from 2017 to 2020. Outcome measures include operative time and complications, which are comparable to previously published data. Focusing on education allows residents to learn each stage of the case. The authors present a framework for training residents in DIEP flap reconstruction to optimize efficiency and education.

Prophylactic Absorbable Antibiotic Beads for High-risk, Implant-based Prepectoral Reconstruction.

Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) (P < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects.

BACKGROUND: Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. METHODS: A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. RESULTS: Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. CONCLUSIONS: Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Evaluation of Prepectoral Breast Tissue Expander Reconstruction Intraoperative Fill: Air or Saline?

SUMMARY: Staged implant-based breast reconstruction with immediate tissue expanders (TEs) is the most common method of breast reconstruction after mastectomy. TEs traditionally are filled with saline for expansion. Some surgeons have advocated initial intraoperative fill of the TE with air to avoid excess pressure on ischemic mastectomy skin flaps. The purpose of the study was to compare intraoperative air versus saline tissue fills. All patients who underwent prepectoral TE reconstruction after mastectomy from 2017 to 2019 were reviewed. The primary predictive variable was whether saline or air was used for initial tissue expansion. Outcome variables included mastectomy skin necrosis, nipple necrosis, infection, number of expansions, hematoma, and explantation. A total of 53 patients (88 TEs) were included in the study: 28 patients (44 TEs) who underwent initial intraoperative fill with air and 25 patients (44 TEs) who underwent an initial saline fill were assessed. There were no significant differences in complication rates between initial TE fill with saline versus air, including nipple necrosis, wound dehiscence, cellulitis, abscess, or TE removal ( P = 1.0). The number of postoperative TE fills in the initial air fill group was 3.2 compared to 2.7 in the initial saline fill group ( P = 0.27). Prepectoral TE initial fill with air has similar postoperative outcomes compared to initial saline fill. The authors found no benefit to initially filling prepectoral TEs with air intraoperatively. Given the additional effort of exchanging air for saline during the first postoperative fill, there was no clinical advantage of filling prepectoral TEs with air. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The no-vertical scar technique for oncoplastic breast reconstruction.

INTRODUCTION: Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri­areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction. METHODS: Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation. RESULTS: Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required. CONCLUSION: The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

Fundamentals of Microsurgery: A Novel Simulation Curriculum Based on Validated Laparoscopic Education Approaches.

BACKGROUND: Microsurgical techniques have a steep learning curve. We adapted validated surgical approaches to develop a novel, competency-based microsurgical simulation curriculum called Fundamentals of Microsurgery (FMS). The purpose of this study is to present our experience with FMS and quantify the effect of the curriculum on resident performance in the operating room. METHODS: Trainees underwent the FMS curriculum requiring task progression: (1) rubber band transfer, (2) coupler tine grasping, (3) glove laceration repair, (4) synthetic vessel anastomosis, and (5) vessel anastomosis in a deep cavity. Resident anastomoses were also evaluated in the operative room with the Stanford Microsurgery and Resident Training (SMaRT) tool to evaluate technical performance. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) and Short-Form Spielberger State-Trait Anxiety Inventory (STAI-6) quantified learner anxiety and workload. RESULTS: A total of 62 anastomoses were performed by residents in the operating room during patient care. Higher FMS task completion showed an increased mean SMaRT score (p = 0.05), and a lower mean STAI-6 score (performance anxiety) (p = 0.03). Regression analysis demonstrated residents with higher SMaRT score had lower NASA-TLX score (mental workload) (p < 0.01) and STAI-6 scores (p < 0.01). CONCLUSION: A novel microsurgical simulation program FMS was implemented. We found progression of trainees through the program translated to better technique (higher SMaRT scores) in the operating room and lower performance anxiety on STAI-6 surveys. This suggests that the FMS curriculum improves proficiency in basic microsurgical skills, reduces trainee mental workload, anxiety, and improves intraoperative clinical proficiency.

SPINE: An Initiative to Reduce Pressure Sore Recurrence.

The recurrence rate after pressure sore reconstruction remains high. Primary inciting factors can be organized into efforts aimed at wound prevention: spasticity relief, pressure off-loading, infection and contamination prevention, nutrition optimization, and maximizing extremity function. This article presents our detailed protocol, SPINE, to address each inciting factor with a summary of cases at our facility and review best practices from evidence-based medicine in the literature.

Comparison of Breast Reconstruction Outcomes Using Oxychlorosene versus Triple Antibiotic Solution for Pocket Irrigation.

Background: Breast pocket irrigation with antiseptic solutions is performed to reduce contamination with breast implants. The optimal antiseptic irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium is frequently used at our institution. Oxychlorosene is bactericidal with a mechanism of action of oxidation and hypochlorination. The purpose of our study was to compare the outcomes of oxychlorosene sodium irrigation with triple antibiotic solution (TAS) in implant-based breast reconstruction. Methods: All patients who underwent implant-based reconstruction after mastectomy were reviewed. The primary predictive variable was type of solution used for pocket irrigation (TAS or oxychlorosene). Outcome variables included surgical site infection, device removal, and wound complications. Results: Between 2013 and 2018, 331 implant-based breast reconstructions were performed. Of these, 62% (n = 206) received oxychlorosene for surgical pocket irrigation (group I), and 38% (n = 125) received TAS (group II). Group I had an 11.7% (n = 24) 90-day surgical site infection rate, with 4.9% (n = 10) requiring oral antibiotics, 2.4% (n = 5) requiring intravenous antibiotics without device removal, and 4.4% (n = 9) requiring prosthetic removal. Group II had an 11.2% (n = 14) 90-day infection rate, with 5.6% (n = 7) requiring oral antibiotics, 2.4% (n = 3) requiring intravenous antibiotics without device removal, and 3.2% (n = 4) requiring removal (P = 0.90). When comparing the cost of oxychlorosene irrigation with TAS irrigation, oxychlorosene was less expensive. Conclusions: Oxychlorosene and TAS have similar surgical site infection rates in prosthetic breast reconstruction. Ease of preparation and cost make oxychlorosene a more favorable option for antibiotic irrigation in reconstructive breast surgery with prosthetic devices.

Optimizing tissue expander breast reconstruction in nicotine users: An algorithmic approach.

INTRODUCTION: Smoking is a risk factor for post-operative complications following breast reconstruction. Abruptly refraining from all nicotine products may be difficult for patients with a new cancer diagnosis. The goal of this study is to assess complications following a distinct approach to tissue expander reconstruction in nicotine users. METHODS: Patients who underwent tissue expander reconstruction after mastectomy were retrospectively reviewed. The approach to optimize outcomes in smokers was to delay reconstruction at least 7 days after the mastectomy and place the expander submuscularly (Group I). The other patients underwent standard immediate reconstruction on the day of mastectomy and were divided into Group II (active smokers) and Group III (non-smokers). Group III was considered the control group. RESULTS: There was a total of 195 patients (323 breast reconstructions): Group I (10 patients, 19 expanders); Group II (11 patients, 19 expanders) and Group III (174 patients, 285 expanders). In Group I, n = 1/19 breasts had wound dehiscence requiring surgical management, compared to n = 18/285 in Group III (p = 1.0). Group II exhibited more wound dehiscence (n = 6/19) compared to Group III (p = 0.002). There was no significant difference when comparing wound dehiscence in prepectoral expander placement (7.0%) versus submuscular placement (4.8%) in Group III (p = 0.60). CONCLUSION: Nicotine users who are offered tissue expander breast reconstruction 1) at least 7 days after the mastectomy (to allow for vascular delay and demarcation) and 2) in the submuscular plane can normalize their risk of skin necrosis to that of non-smokers who have standard (prepectoral or submuscular) reconstruction on the day of mastectomy.

Breast Implant-Associated Immunological Disorders.

Background: Breast implants are commonly placed postbreast cancer reconstruction, cosmetic augmentation, and gender-affirming surgery. Breast implant illness (BII) is a systemic complication associated with breast implants. Patients with BII may experience autoimmune symptoms including fatigue, difficulty concentrating, hair loss, weight change, and depression. BII is poorly understood, and the etiology is unknown. The purpose of this literature review is to characterize BII autoimmune disorders and determine possible causes for its etiology. Methods: The PubMed, Google Scholar, Embase, Web of Science, and OVID databases were interrogated from 2010 to 2020 using a query strategy including search term combinations of "implants," "breast implant illness," "autoimmune," and "systemic illness." Results: BII includes a spectrum of autoimmune symptoms such as fatigue, myalgias/arthralgias, dry eyes/mouth, and rash. A review of epidemiological studies in the past ten years exhibited evidence affirming an association between breast implants and autoimmune diseases. The most commonly recognized were Sjogren's syndrome, rheumatoid arthritis, systemic sclerosis, chronic fatigue syndrome, and Raynaud's syndrome. Explantation resulted in alleviation of symptoms in over 50% of patients, strengthening the hypothesis linking breast implants to BII. Studies have shown that silicone is a biologically inert material and unlikely to be the cause of these symptoms. This is supported by the fact that increased risk of autoimmune disease was also reported in patients with other implantable biomaterials such as orthopedic implants. Recent studies shed light on a possible role of bacterial biofilm and subsequent host-pathogen interactions as a confounding factor to this problem. Conclusion: BII could be dependent on biofilm infection and the microenvironment around the implants. The true pathophysiology behind these complaints must be further investigated so that alternative treatment regimens other than explantation can be developed. Translational significance of these studies is not limited to breast implants but extends to other implants as well.