"No-Touch" Enhancement Significantly Reduces the Risk of Infection-Related Failure in Immediate Breast Reconstruction.

PURPOSE: Infection rates in prosthetic breast reconstruction after mastectomy vary widely, ranging from 1% to 35%, with meta-analyses reporting average infection rates of greater than 5%. This infection rate of greater than 5% is unfortunate for one of today's most commonly performed plastic surgical procedures. In an attempt to reduce infectious events, the author developed a "no-touch" protocol for performing breast reconstruction with tissue expanders and acellular dermis (ADM). This approach utilizes a transparent barrier drape and self-retaining retractor system patterned after similar orthopedic and urologic techniques that have proven to significantly reduce infection of implanted prostheses. Our preliminary results published in 2015 showed a significant improvement in infection rates. With this study, we assess the impact of the no-touch technique on a much larger number of patients. METHODS: Institutional review board approval was granted for a retrospective study of patients who underwent immediate breast reconstruction with tissue expanders and ADM from 2010 to 2017 by the author. Reconstructions prior to the institution of a no-touch protocol in 2014 were compared with those after the enhancement was instituted. A minimum of 60 days' follow-up was used to assess surgical complications. Demographic and outcome data were analyzed. RESULTS: Immediate breast reconstruction with tissue expanders and ADM was performed on 133 patients (217 breasts) from 2010 to 2017. Sixty-nine patients (113 breasts) underwent reconstruction from 2010 to 2014 utilizing the traditional technique, and 64 patients (104 breasts) underwent reconstruction from 2014 to 2017 using the new no-touch enhancement applied by the author. Patients in both groups had similar demographics and comorbidity profiles. The only other technique variable besides the addition of no-touch was the trend toward the use of larger sizes of ADM in the later group (164 vs 108 cm). The rate of infection-related reconstructive failure dropped from 11.5% (13/113) to 1.9% (2/104) (P = 0.0054) after institution of the no-touch protocol. CONCLUSIONS: Institution of a specific no-touch protocol to immediate breast reconstruction with tissue expanders and ADM lowered the risk of reconstructive failure due to infection 6-fold-11.5% to 1.9%. Comparative studies from other surgeons are encouraged.

Early Results Show Reduced Infection Rate Using No-touch Technique for Expander/ADM Breast Reconstruction.

Infection is a common complication of immediate breast reconstruction that often leads to device removal, a result emotionally devastating to the patient and frustrating for her surgeon. "No-touch" techniques have been used in other surgical disciplines and plastic surgery, but they have not been reported for breast reconstruction with tissue expanders or implants and acellular dermis. We report a novel technique of tissue expander and acellular dermis placement using no-touch principles with a self-retaining retractor system that holds promise to decrease infectious complications of breast reconstruction.

Fat injection to correct contour deformities in the reconstructed breast.

BACKGROUND: A ten-year, single-surgeon study of 37 patients from 1993 to 2003 who underwent fat injections to improve contour deformities in their reconstructed breasts was reviewed. METHODS: Fat was harvested from elsewhere in the body using a low-pressure syringe lipoaspiration system, washed gently with saline, and injected into depressions along the margins of reconstructed breasts. Blinded physician observers judged preoperative and postoperative photographs of breasts injected with fat and categorized the degree of contour improvement as substantial, minimal to moderate, or none. Complications of fat injections were noted. A total of 43 breasts in 37 patients were injected with autologous fat during 47 discrete events; some patients had the procedure repeated and some were treated bilaterally. Of the 43 treated breasts, 25 (58 percent) were reconstructed with implants, 17 (40 percent) were reconstructed with a TRAM (transverse rectus abdominis muscle) flap, and one (2 percent) was reconstructed with a TRAM and an implant. RESULTS: There were four complications (8.5 percent) in 47 treated breasts: one breast with cellulitis that resolved with antibiotics and three breasts with small, superficial lumps--two of which were biopsied and found to be liponecrotic cysts. Patient follow-up averaged 49 weeks, ranging from 3 weeks to 6 years. There was a substantial contour improvement in ten breasts (21 percent), minimal to moderate improvement in 30 breasts (64 percent), and no improvement in 7 breasts (15 percent). CONCLUSIONS: Although fat injection in and around the reconstructed breast has limitations, such as fat necrosis and need for repeated injections, our experience indicates that overall it is a very safe technique that can improve or correct significant contour deformities that otherwise would require more complicated, riskier procedures to improve.