Current trends in postmastectomy breast reconstruction.

PURPOSE OF REVIEW: Breast reconstruction is established as integral part of the treatment. New materials, indications and surgical techniques are subject to rapid modification to further improve safety, quality and longevity. RECENT FINDINGS: Skin-sparing-mastectomy is accepted as an appropriate alternative in risk-reducing and many breast cancer patients, further reducing conventional mastectomy patterns.Radiation in combination with reconstruction is still challenging with no clear advances reducing skin-toxicity.Autologous reconstructions, not only in radiation settings, are turning to a first line approach. A trend driven by improved techniques to minimize morbidity and flap-variations.Breast implant surfaces associated with a high risk of Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are now withdrawn. The residual risk for the remaining implant styles is not known, but can be expected considerably lower than estimations published presently.In order to reduce local complications, supplemental material often in combination with prepectoral implant placement is advertised. The present evidence on long-term outcome is limited.Super-microsurgery treating lymphedema is evolving rapidly. Refinements of various techniques and their differential indication are under evaluation to standardize the procedures. SUMMARY: Breast reconstruction evolved to a complex, specialized field with a multitude of options. A multidisciplinary team is required to fully utilize todays potential and offer optimal individual treatments.

Evaluation of the Safety of a GalaFLEX-AlloDerm Construct in Prepectoral Breast Reconstruction.

BACKGROUND: Prepectoral implant-based breast reconstruction is gaining in popularity. Acellular dermal matrices are an integral part of prepectoral reconstruction. However, large quantities of acellular dermal matrix are required for total implant coverage, and the cost of acellular dermal matrices could be a deterrent to reconstruction. To minimize the cost, the authors have resorted to the use of a bioabsorbable mesh, GalaFLEX, as a partial replacement to acellular dermal matrices. This study evaluates the comparative safety of using a GalaFLEX-AlloDerm construct versus AlloDerm alone in prepectoral reconstruction. METHODS: Consecutive patients who underwent immediate, expander-implant, prepectoral breast reconstruction were included in this retrospective study. Patients were stratified into two groups: those who received the GalaFLEX-AlloDerm combination versus AlloDerm alone. In GalaFLEX-AlloDerm reconstructions, the lower third of the expander was covered by the AlloDerm, whereas the rest of the expander was covered by GalaFLEX. Complications following reconstruction were compared between the groups. RESULTS: AlloDerm alone was used in 128 patients (249 breasts) and GalaFLEX-AlloDerm was used in 135 patients (250 breasts). The rate of any complication was 7.6 percent in the AlloDerm-alone group and 6.4 percent in the GalaFLEX-AlloDerm group. The rate of infection, major skin necrosis, seroma, capsular contracture, prosthesis exposure/extrusion, and prosthesis loss were less than or equal to 3.0 percent in the GalaFLEX-AlloDerm group and did not differ significantly from those in the AlloDerm-only group. CONCLUSIONS: GalaFLEX bioabsorbable matrix is a less costly alternative to acellular dermal matrices in two-stage, prepectoral reconstruction with comparable safety outcomes. Further long-term data and clinical experience are needed to better understand the safety of this matrix for use in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The use of closed incision negative pressure therapy for incision and surrounding soft tissue management: Expert panel consensus recommendations.

As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full-coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full-coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full-coverage dressings. High-quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues.

Assessing Postsurgical Outcomes with Prepectoral Breast Reconstruction: A Literature Review and Meta-analysis Update.

BACKGROUND: Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction. METHODS: This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included. RESULTS: Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction. CONCLUSIONS: Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.

Povidone-iodine Does Not Affect Acellular Dermal Matrix Integration in Patients Undergoing 2-staged, Prepectoral, Breast Reconstructive Surgery.

BACKGROUND: Povidone-iodine has been traditionally used as an antimicrobial agent to irrigate the breast pocket and rinse the prosthesis before placement in the pocket. Use of povidone-iodine with breast implants was banned from 2000 to 2017. During this period, acellular dermal matrix (ADM) was introduced to breast surgery. In nonclinical studies, povidone-iodine can impair collagen synthesis and kill fibroblasts. Cellular repopulation was critical for ADM integration. Whether povidone-iodine impacts ADM integration was unknown. METHODS: Patients who underwent immediate, prepectoral, 2-staged breast reconstruction were included in this retrospective study. Study population was divided into povidone-iodine-treated patients and triple-antibiotic-treated patients. The breast pockets were rinsed with the antimicrobial agent, and the prostheses and ADMs were presoaked in the agent perioperatively. At implant exchange, the extent of ADM integration was clinically assessed. ADM integration was defined as >25% of matrix vascularization. ADM integration and postoperative complications were compared between the groups. RESULTS: A total of 111 patients (257 reconstructions) were included-58 patients (111 reconstructions) were exposed to povidone-iodine and 53 patients (97 reconstructions) to triple-antibiotic solution. ADM integration was noted in 97% of breasts in each group. Integrated matrices appeared healthy, had no signs of foreign body reaction, and demonstrated punctate bleeding. Complications did not differ between the groups, including the rate of infections, seroma, and expander loss. CONCLUSION: Irrigation of the breast pocket and presoaking of the prosthesis and ADM with povidone-iodine appear to have no adverse consequences on clinical outcomes and did not impede matrix integration.

Dual-Plane versus Prepectoral Breast Reconstruction in High-Body Mass Index Patients.

BACKGROUND: Breast reconstruction in patients with a high body mass index (BMI) (≥30 kg/m) is technically challenging and is associated with increased postoperative complications. The optimal reconstructive approach for these patients remains to be determined. This study compared outcomes of prepectoral and dual-plane reconstruction in high-BMI patients to determine whether there was an association between postoperative complications and the plane of reconstruction. METHODS: High-BMI patients who underwent immediate dual-plane or prepectoral expander/implant reconstruction were included in this retrospective study. Patients were stratified by reconstructive approach (dual-plane or prepectoral), and postoperative complications were compared between the groups. Multivariate logistic regression analysis was performed to determine whether the plane of reconstruction was an independent predictor of any complication after adjusting for potential confounding differences in patient variables between the groups. RESULTS: Of 133 patients, 65 (128 breasts) underwent dual-plane and 68 (129 breasts) underwent prepectoral reconstruction. Rates of seroma (13.3 percent versus 3.1 percent), surgical-site infection (9.4 percent versus 2.3 percent), capsular contracture (7.0 percent versus 0.8 percent), and any complication (25.8 percent versus 14.7 percent) were significantly higher in patients who had dual-plane versus prepectoral reconstruction (p < 0.05). Multivariate logistic regression identified dual-plane, diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant, independent predictors of any complication (p < 0.05). Dual-plane reconstruction increased the odds of any complication by 3-fold compared with the prepectoral plane. CONCLUSION: Compared with the dual-plane approach, the prepectoral approach appears to be associated with a lower risk of postoperative complications following immediate expander/implant breast reconstruction and may be a better reconstructive option in high-BMI patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Effect of Body Mass Index on Outcomes after Prepectoral Breast Reconstruction.

BACKGROUND: Body mass index has been shown to be a predictor of outcomes after subpectoral expander/implant reconstruction, with every unit increase in body mass index increasing the risk of complications by approximately 6 percent. The effect of body mass index on complications after prepectoral reconstruction has not yet been evaluated and is the purpose of this study. METHODS: A total of 366 reconstructed breasts from 197 patients were stratified into five body mass index groups (normal; overweight; and class I, class II, and class III, obese) and postoperative complications were compared across the groups. Additional analyses were performed using broad classifications of body mass index into nonobese and obese in addition to normal, overweight, and obese. Body mass index as an independent predictor of complications was assessed using multivariate logistic regression analysis. RESULTS: Complication rates did not differ significantly across body mass index groups when using the broad classifications. With five-group stratification, significantly higher rates of return to operating room, expander/implant loss, skin necrosis, wound dehiscence, and overall complications were seen in class II and/or class III obese versus overweight patients. However, on multivariate logistic regression analyses, body mass index, as a continuous variable, did not independently predict any complication. Diabetes and smoking emerged as significant predictors of any complication, indicating that these factors, rather than body mass index, were driving the increased rates of complications seen in the high-body mass index groups. CONCLUSION: Body mass index alone is not a predictor of outcomes after prepectoral expander/implant breast reconstruction and should not be used to estimate risk of postoperative complications or exclude patients for prepectoral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Outcomes Utilizing Inspira Implants in Revisionary Reconstructive Surgery.

BACKGROUND: Inspira round implants have a higher fill ratio than standard round implants and the 3 available implant types have increasing gel cohesivity. Collectively, these features may help provide a fuller upper pole and help reduce the risk of rippling, visible implant edges, and palpability and may be particularly beneficial in patients undergoing prepectoral reconstruction. Patient outcomes after prepectoral revision reconstruction with these implants are reviewed in this study. METHODS: This retrospective study included consecutive patients who had previously undergone subpectoral (dual plane), implant-based, breast reconstruction and presented for revision reconstruction between June 2015 and January 2018. Reasons for revision included animation deformity, pain, asymmetry implant malposition, size change, capsular contracture, and rippling. Revision reconstruction involved implant removal, site change from subpectoral to prepectoral, and immediate implant replacement in all patients. Complications after revision reconstruction were obtained from patient records. RESULTS: A total of 64 patients (124 breasts) met the inclusion criteria. During a mean follow-up period of 18.9 months, complications occurred in 4 breasts (3.2%) and included implant loss (1.6%), seroma (1.6%), hematoma (0.8%), surgical site infection (0.8%), and skin necrosis (0.8%). There was no incidence of capsular contracture and presenting complaints were resolved in all cases. CONCLUSIONS: Prepectoral reconstruction, in conjunction with Inspira round implants, appears to be a safe and effective approach in suitable patients presenting for revision surgery, at least in the short term. Implant features facilitate prepectoral implant placement, resulting in pleasing aesthetic outcomes. Whether these outcomes will withstand the test of time remains to be seen.

Prepectoral breast reconstruction and radiotherapy-a closer look.

BACKGROUND: Prosthetic breast reconstruction in the setting of post-mastectomy radiation therapy (PMRT) has historically been plagued by complications and poor outcomes. We study the effects of PMRT in the setting of prepectoral prosthetic breast reconstruction in an attempt to ascertain the value of this muscle sparing technique as it relates to complications and outcomes. METHODS: A retrospective analysis was performed on patients who underwent immediate, prepectoral, direct-to-implant or two-staged expander/implant breast reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and had postmastectomy radiotherapy. Results and complications were recorded. RESULTS: In patients who underwent two-staged reconstruction, at the second stage, on visual inspection, the acellular dermal matrix was noted to be completely integrated in all breasts, including those that had been irradiated after expander placement. Postoperative complications in irradiated breasts were limited to two breasts. In one breast, there was one incidence of wound dehiscence after expander irradiation, which led to expander removal and salvage with transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. In the second breast, there was one incidence of seroma after implant irradiation, which was managed conservatively as an outpatient. The seroma was drained and the patient treated with oral antibiotics. There were no complications in nonirradiated breasts. There was no incidence of clinically significant capsular contracture (grade III/IV) in irradiated or nonirradiated breasts. CONCLUSIONS: Prepectoral breast reconstruction has been an important addition to our reconstructive armamentarium and is proving to be a safe and effective means of performing prosthetic breast reconstruction in a wide array of patient populations. We have seen excellent physiologic and aesthetic outcomes in our patients following PMRT with minimal complications. Indeed, long-term follow-up will be required to elucidate the true effectiveness of this technique but preliminary results are quite promising.

The Impact of Closed Incision Negative Pressure Therapy on Postoperative Breast Reconstruction Outcomes.

BACKGROUND: Studies report that incision management with closed incision negative pressure therapy (ciNPT) may provide clinical benefits, including protecting surgical incisions, for postsurgical closed incisions (eg, orthopedic, sternotomy, and colorectal). This retrospective analysis compared postoperative outcomes in patients who received ciNPT versus standard of care (SOC) for incision management after breast reconstruction postmastectomy. METHODS: Patient demographics, chemotherapy exposure, surgical technique, ciNPT use, number of drains, time to drain removal, and 90-day postoperative complication rates were analyzed from records of 356 patients (ciNPT = 177, SOC = 179) with 665 closed breast incisions (ciNPT = 331, SOC = 334). RESULTS: Overall complication rate was 8.5% (28/331) in ciNPT group compared with 15.9% (53/334) in SOC group (P = 0.0092). Compared with the SOC group, the ciNPT group had significantly lower infection rates [7/331 (2.1%) versus 15/334 (4.5%), respectively; P = 0.0225], dehiscence rates [8/331 (2.4%) versus 18/334 (5.4%), respectively; P = 0.0178], necrosis rates [17/331 (5.1%) versus 31/334 (9.3%), respectively; P = 0.0070], and seroma rates [6/331 (1.8%) versus 19/334 (5.7%), respectively; P = 0.0106]. The ciNPT group required significantly fewer returns to operating room compared with the SOC group [8/331 (2.4%) versus 18/334 (5.4%), respectively; P = 0.0496]. Time to complete drain removal per breast for ciNPT versus SOC groups was 9.9 versus 13.1 days (P < 0.0001), respectively. CONCLUSIONS: Patients who received ciNPT over closed incisions following postmastectomy breast reconstruction experienced a shorter time to drain removal and significantly lower rates of infection, dehiscence, necrosis, and seromas, compared with the SOC group. Randomized controlled studies are needed to corroborate the findings in our study.

Early assessment of post-surgical outcomes with pre-pectoral breast reconstruction: A literature review and meta-analysis.

BACKGROUND: Pre-pectoral breast reconstruction is an emerging surgical approach. This study provides an early assessment of outcomes with the technique. METHODS: A comprehensive literature review was performed through searches of PubMed® /MEDLINE® to identify studies on pre-pectoral reconstruction. Patient characteristics and outcomes were extracted from studies and pooled. Linear relationships between complication rates and patient characteristics with pre-pectoral reconstruction were analyzed. A meta-analysis compared complication rates between pre-pectoral and dual-plane reconstruction. RESULTS: Fourteen studies (406 women/654 breasts) were included. The most common complications with pre-pectoral reconstruction were flap necrosis (7.8%), seroma (6.7%), capsular contracture (5.8%), and explantation (4.6%). No hyperanimation was reported. Significant correlation between previous radiation and flap necrosis, post-operative chemotherapy and infection, hypertension and flap necrosis, diabetes and dehiscence, and smoking and explantation were found. A meta-analysis of four studies comparing pre-pectoral (135 women/219 breasts) and dual-plane (230/408) reconstruction found no significant difference for likelihood of infection (odds ratio, 0.46; 95% confidence interval, 0.16-1.30), explantation (0.83; 0.29-2.38), necrosis (1.61; 0.77-3.36), seroma (1.88; 0.71-5.02), dehiscence (1.84; 0.68-4.95), or capsular contracture (0.14; 0.02-1.14). CONCLUSIONS: Complication rates are comparable following pre-pectoral and dual-plane reconstruction, indicating the pre-pectoral technique may be a feasible option for appropriate patients.

Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions.

BACKGROUND: Animation deformity is a direct consequence of subpectoral implant placement for breast reconstruction following mastectomy. Current treatment options ameliorate but do not address the source of the problem. Moving the implant from subpectoral to prepectoral has the potential to eliminate animation deformity. OBJECTIVES: Describe the technique and outcomes of prepectoral revision reconstruction in over 100 cases and discuss patient selection criteria for a successful outcome. METHODS: Patients who presented with animation deformity following two-stage implant reconstruction were included in this retrospective study. Revision surgery involved removal of the existing implant via the previous incision site along the inframammary fold, suturing of the pectoralis major muscle back to the chest wall, creation of a prepectoral pocket for the new implant, use of acellular dermal matrix to reinforce the prepectoral pocket and completely cover the implant, and fat grafting to enhance soft tissue. Patients were evaluated for resolution of animation deformity and occurrence of complications during follow up. RESULTS: Fifty-seven patients (102 breasts) underwent prepectoral revision reconstruction with complete resolution of animation deformity. Complications occurred in 4 breasts (3.9%) and included seroma (2 breasts), skin necrosis (3 breasts), and wound dehiscence (1 breast). All 4 breasts with complications had their implants removed and replaced. There were no incidences of infection or clinically significant capsular contracture in this series. CONCLUSIONS: Revision reconstruction with prepectoral implant placement and complete coverage with acellular dermal matrix resolves animation deformity and results in aesthetically pleasing soft breasts. Patient selection is critical for the success of this technique.

Options in Acellular Dermal Matrix-Device Assembly.

Prepectoral prosthetic breast reconstruction has become increasingly popular during the last several years. Original shortcomings and poor outcomes in the 1970s have been overcome with the use of the bioengineered breast concept-namely, use of improved form stable breast implants, autologous fat grafting, and acellular dermal matrices (ADMs). Careful use of these reconstructive tools combined with improved mastectomy skin flaps has lead to successful early outcomes. Prepectoral breast reconstruction mitigates the animation deformities and muscle tightness previously associated with dual-plane prosthetic breast reconstruction while at the same time producing reproducible and outstanding aesthetic outcomes. The use of ADM is a critical component to performing prepectoral breast reconstruction. There are many techniques utilized to inset the ADM. Various methods of direct in vivo inset have been performed. These techniques are employed following completion of the mastectomy and are performed with both 2-stage as well as single-stage direct-to-implant reconstruction. Various ex vivo techniques have also been used for prepectoral breast reconstruction. Various prefabricated constructs of ADM and implant/tissue expander can be created on the back table while the mastectomy is in progress, which decreases operative time and improves surgical efficiency. This article will describe briefly the history of prepectoral reconstruction as well as describing the various techniques used for creating the ADM-device interphase.

Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results.

Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prepectoral Implant-Based Breast Reconstruction and Postmastectomy Radiotherapy: Short-Term Outcomes.

BACKGROUND: Prosthetic breast reconstruction in the setting of radiotherapy is associated with poor outcomes. Until recently, prosthetic breast reconstruction was predominantly performed by placing the prosthesis in a subpectoral space. Placement of the prosthesis in a prepectoral space is currently emerging as a simpler, alternative approach to subpectoral placement. The impact of postmastectomy radiotherapy (PMRT) on prepectoral reconstruction has not yet been specifically assessed. This study compared the outcomes of patients who underwent immediate, direct-to-implant, or 2-staged, prepectoral breast reconstruction followed by PMRT with those from patients who did not receive PMRT. METHODS: Patients with well-perfused skin flaps and without contraindications, including uncontrolled diabetes-mellitus, previous irradiation, and current tobacco use, were offered the prepectoral approach. Following implant or expander placement, patients underwent planned or unplanned radiotherapy. Complications after each stage of reconstruction were recorded. RESULTS: Thirty-three patients underwent 52 breast reconstructions via the prepectoral approach. Sixty-five percentage of the breasts were irradiated, including 21% after expander and 44% after implant placement. Patients were followed for a mean of 25.1 ± 6.4 months. Complication rate in irradiated breasts was 5.9% (1 incidence of seroma and 1 incidence of wound dehiscence followed by expander removal) and 0% in nonirradiated breasts. Capsular contracture rate was 0% in both irradiated and nonirradiated breasts. CONCLUSIONS: Immediate implant-based prepectoral breast reconstruction followed by PMRT appears to be well tolerated, with no excess risk of adverse outcomes, at least in the short term. Longer follow-up is needed to better understand the risk of PMRT in prepectorally reconstructed breasts.

Initial Experience Using Closed Incision Negative Pressure Therapy after Immediate Postmastectomy Breast Reconstruction.

Although immediate postmastectomy breast reconstruction is favored over delayed reconstruction, it remains associated with high complication rates. Potential complications include seroma formation, dehiscence, infection, and tissue necrosis along incision edges. Closed incision negative pressure therapy (ciNPT; Prevena Incision Management System, KCI, an Acelity company, San Antonio, Tex.) has been reported to help hold incision edges together, protect incisions from external contamination, and remove fluid and infectious material. We investigated outcomes of applying ciNPT with a customizable dressing over closed incisions in 13 patients (25 breasts) who received immediate postmastectomy reconstruction as part of 2-stage expander/implant breast reconstruction. Nipple-sparing mastectomy was performed on 14 breasts, reduction-pattern mastectomy on 6 breasts, and skin-sparing mastectomy on 5 breasts. All breasts had ciNPT with a customizable dressing applied over the entire clean closed incision immediately after surgery at -125 mmHg for an average of 4.3 days. At 3-month follow-up, 24 of the 25 (96%) breasts had achieved healing. Delayed hematoma occurred on postoperative day 13 in 1 breast in the nipple-sparing mastectomy group and resolved. In the reduction-pattern mastectomy group, superficial dehiscence occurred on 3 breasts and resolved with local wound care. One breast in that group developed flap necrosis requiring surgical revision. Less drainage was observed in attached closed-suction drains, so time to drain removal was reduced from an estimated average of 12-14 days to 8.2 days. Based on the initial experience in this study, larger studies are warranted to evaluate the use of ciNPT with customizable or peel-and-place dressings after immediate postmastectomy breast reconstruction.