The Modified Frailty Index Predicts Major Complications in Oncoplastic Reduction Mammoplasty.

BACKGROUND: An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical complications. The Modified Frailty Index (mFI) calculates risk based on the following five elements: hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR). METHODS: A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 was queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications. RESULTS: 547 patients were included in the study cohort. The average age was 55 and the average body mass index was 33.5. The overall complication rate was 19% (n = 105) and the major complication rate was 9% (n = 49). Higher frailty scores were significantly associated with the development of major complications (P < 0.05). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, body mass index, and resection weights were not associated with complications (P = 0.15, P = 0.87, and P = 0.30 respectively) on continuous analysis. CONCLUSIONS: Elevated mFI scores are associated with an increased major complication profile in patients who are undergoing OCR. Hypertension and diabetes are the most common comorbidities in our population, and this tool may assist with preoperative counseling and risk stratification. Benefits of this risk assessment tool include its ease of calculation and brevity. Our study is the first to demonstrate its utility in OCR; however, further study in high-risk patients would strengthen the applicability of this frailty index.

Periareolar Skin-Sparing Mastectomy and Immediate Implant-Based Reconstruction: A Reappraisal.

INTRODUCTION: Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the nipple-areolar complex (NAC) and an X-shaped purse string closure after implant-based reconstruction. METHODS: A retrospective review was performed on patients undergoing periareolar SSM and immediate implant-based reconstruction from January 2015 through December 2022, specifically identifying those patients who had square NAC excision and skin closure. RESULTS: Twenty-nine patients met the inclusion criteria. They underwent 54 periareolar SSM and immediate implant-based reconstruction (bilateral 25, unilateral 4). Indications for surgery were cancer (30) and prophylactic (24; 2 patients had bilateral cancer). Reconstructive methods included tissue expander (TE) (36 [66.7%]) and direct-to-implant (DTI) (18 [33.3%]). The mean mastectomy weights and final implant sizes were similar between the 2 groups. Overall wound complications occurred in 13 (24.1%) of the breasts: mastectomy skin flap necrosis (MSFN; 10 [18.5%]) and infection (3 [5.6%]). Reconstructive failure occurred in 3 cases: TE, 1 (infection); DTI, 2 (MSFN/exposure). MSFN by reconstructive method: TE, 4 (11.1%); DTI, 6 (33.3%) (P = 0.05, comparing MSFN rates between TE and DTI methods). The mean initial TE fill volume was 247.1 cc; mean implant size in the DTI group was 417.8 cc (P < 0.0001). CONCLUSIONS: The square NAC excision and closure can minimize the surgical incision in implant reconstruction. Two-stage TE reconstruction permits lower initial fill volumes, which reduces the risk of MSFN after box to X closure of SSM and implant-based reconstruction. It is useful in small- to moderate-sized breasts with mild ptosis in patients who are not candidates for NSM.

The Impact of Radiation on Nipple Symmetry After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: An Objective Analysis.

INTRODUCTION: Radiation therapy can adversely affect outcomes of implant-based breast reconstruction, potentially complicating procedures like nipple-sparing mastectomy (NSM), which is increasingly popular in breast cancer management. This study aims to evaluate the impact of radiation on nipple symmetry in patients undergoing bilateral NSM with implant-based reconstruction. METHODS: We conducted a retrospective analysis using data from an Emory University review board-approved database. This encompassed bilateral NSMs coupled with immediate implant-based reconstructions. The BCCT.core software was employed to objectively measure nipple asymmetry preoperatively and postoperatively. Metrics, such as Breast Retraction Assessment values, upper nipple retraction, lower breast contour, and nipple to midline (NML) discrepancies were quantified. The study included 80 patients with a minimum of 1 year of follow-up; among them, 15 received radiation therapy (RT) while 65 did not. RESULTS: The reconstructions were divided into tissue expander, used in 39 cases (48.8%), and direct-to-implant (DTI), employed in 41 cases (51.2%). The DTIs were further categorized based on the location of the implant: 22 subpectoral and 19 prepectoral. Radiation was applied to 15 breasts, distributed among prepectoral DTI (4), subpectoral DTI (6), and tissue expander (5). Breast Retraction Assessment scores significantly differed between the nonirradiated and irradiated groups (1.49 vs 2.64, P < 0.0004). Nipple to midline differences and Upper Nipple Retraction also significantly varied postradiation, especially when comparing subpectoral and prepectoral implant placements. CONCLUSIONS: Radiation therapy has a detrimental effect on nipple symmetry after bilateral NSM and implant-based reconstruction, with variations seen regardless of the implant's placement or the reconstructive technique utilized. Specifically, subpectoral reconstructions irradiated were prone to lateral nipple displacement, likely related to radiation-induced pectoralis muscle changes, while prepectoral irradiated reconstructions tended to have increased vertical displacement. These insights are crucial for patient education and surgical planning in the context of radiation and breast reconstruction.

Techniques in Nipple Areolar Reconstruction: A Retrospective Analysis of Surgical Interventions and Patient-reported Satisfaction Scores.

Background: Nipple areolar complex (NAC) reconstruction often signifies completion of the breast reconstruction process for some patients and has been shown to improve both psychosocial and sexual well-being. Several techniques have been described; however, there currently exists little evidence in the literature describing outcomes or patient satisfaction. Methods: A retrospective analysis of NAC reconstructions over the last decade was queried for patient demographics, operative technique, and postoperative outcomes. A standardized, validated survey was also utilized to evaluate overall satisfaction, with a focus on aesthetic outcome, shape, color, and projection. Results: Eighty-three patients were identified, with 49 (59.0%) completing the survey. The modalities used for reconstruction include the C-V flap (45.7%), the modified skate flap technique (42.2%), and free nipple grafting (FNG, 12.0%). No significant differences in age, BMI, or comorbidities were found among the three types. The most utilized donor site for skate flap reconstruction was the suprapubic area (37.1%). There were also no significant differences in complication rate (C-V 10.5%, FNG 10%, skate 5.7%, P = 0.630) or revision surgery (C-V 2.6%, FNG 0%, skate 5.7%, P = 0.732). The most common complication was nipple necrosis. Adjusting for time to follow-up using multivariate analysis, there was a significant difference in overall patient satisfaction when compared across all three techniques, with the modified skate flap having the highest mean overall satisfaction scores. Conclusions: NAC reconstruction can be completed safely and effectively with a variety of techniques. The modified skate flap technique was associated with high levels of patient satisfaction and a low complication rate.

Time to Radiation after Oncoplastic Reduction versus After Lumpectomy.

Prior studies contrasting oncoplastic reduction (OCR) to traditional lumpectomy have validated oncoplastic reduction surgery with similar survival and oncological outcomes. The purpose of this study was to evaluate if there was a significant difference in the time to initiation of radiation therapy after OCR in comparison with the standard breast-conserving therapy (lumpectomy). Methods: The patients included were from a database of breast cancer patients who all underwent postoperative adjuvant radiation after either OCR or lumpectomy at a single institution between 2003 and 2020. Patients who experienced delays in radiation for nonsurgical reasons were excluded. Comparisons were made between the groups in the time to radiation and complication rates. Results: A total of 487 patients underwent breast-conserving therapy, with 220 having undergone OCR and 267 lumpectomy patients. There was no significant difference in days to radiation between patient cohorts (60.5 OCR, 56.2 lumpectomy, P = 0.059). There was a significant difference in the number of complications between OCR and lumpectomy patients (20.4% OCR, 2.2% lumpectomy, P < 0.001). However, of patients who had complications, there was no significant difference in the number of days to radiation (74.3 OCR, 69.3 lumpectomy, P = 0.732). Conclusions: Compared with lumpectomy, OCR was not associated with an increased time to radiation but was associated with higher complications. Statistical analysis did not reveal surgical technique or complications to be independent, significant predictors of increased time to radiation. Surgeons should be aware that although complications may remain higher in OCR, this does not necessarily translate to delays in radiation.

Close the GAPS: A Standardized Perioperative Protocol Reduces Breast Reconstruction Implant Infections.

BACKGROUND: Implant-based breast reconstruction (IBBR) is a complex process with significant practice variability. Infections after IBBR are associated with higher rates of readmission, reoperation, and reconstructive failure. To reduce process variability and postoperative infections, the authors implemented an evidence-based, standardized protocol for IBBR. METHODS: The protocol was applied to all patients undergoing IBBR at a single institution from December of 2019 to February of 2021. Intraoperative protocol adherence was recorded, and infection events were considered minor (managed with outpatient antibiotics) or major (managed with readmission or reoperation). A historic control group was retrospectively analyzed for comparison. RESULTS: Sixty-nine patients (120 breasts) in the protocol group were compared with 159 patients (269 breasts) in the retrospective group. No differences were found in demographic characteristics, comorbidities, or type of reconstruction (expander versus implant). Intraoperative protocol adherence was 80.5% (SD, 13.9%). Overall infection rate was significantly lower in the protocol group versus controls (8.7% versus 17.0%; P < 0.05). When dichotomized, protocol patients had a lower rate of both minor (2.9% versus 5.7%; P = 0.99) and major (5.8% versus 11.3%; P = 0.09) infections, although this was not statistically significant. Rate of reconstructive failure secondary to infection was significantly lower in the protocol group (4.4% versus 8.8%; P < 0.05). Among protocol patients, those without infection had higher protocol adherence (81.5% versus 72.2%; P < 0.06), which neared statistical significance. CONCLUSION: A standardized perioperative protocol for IBBR reduces process variability and significantly decreases rate of overall infections and reconstructive failure secondary to infection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Symmetry of Nipple Position After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: The Impact of Reconstructive Method.

PURPOSE: Asymmetry of nipple position is common in the female population. There are scant data on the impact of bilateral nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction on nipple asymmetry. METHODS: A retrospective review was performed of an institutional review board approved prospective database of NSM and immediate implant-based reconstruction was performed. BCCT.core software was used to examine preoperative and postoperative nipple asymmetry. It directly calculates the quantitative differences in nipple position between the breasts expressed as breast retraction assessment (BRA). Nipple to sternal notch (N-SN) asymmetry was calculated from the collected data. RESULTS: Sixty-eight patients undergoing bilateral NSM and implant reconstruction were reviewed. Reconstructive methods were tissue expander (TE) 39 (57.4%) and direct to implant (DTI) (prepectoral 13, submuscular 16) 29 (42.6%). The TE group had greater body mass index (BMI) (23.5 vs 22.1, P = 0.02), mastectomy weight (390.7 vs 243.8, P = 0.001) and higher preoperative N-SN asymmetry (TE 0.89 vs DTI 0.59, P = 0.02). Ten patients received radiation (TE group 4, DTI group 6). The TE group had larger implant size (479.1 vs 375.0, P = 0.0001). Overall, TE reconstruction resulted in an increase in nipple asymmetry (mean BRA: preoperative, 1.50 vs postoperative, 1.65), which was not significant. Direct to implant reconstruction increased nipple asymmetry: mean N-SN asymmetry preoperative 0.59 versus postoperative 0.97 (P = 0.04) and mean BRA scores 1.40 and 1.82 (P = 0.06). Both implant locations in the DTI group resulted in an increase in postoperative asymmetry but was significant for the prepectoral group: mean BRA preoperative 1.19 versus postoperative 1.85, P = 0.02 and mean N-SN asymmetry preoperative 0.48 vs postoperative 0.94, P = 0.04. Radiation impacted the final mean BRA score: radiation 2.24 versus no radiation 1.63 (P = 0.05). CONCLUSIONS: Patients who underwent TE reconstruction had significantly larger breasts and greater preoperative N-SN asymmetry than the DTI group. Despite this, the TE group resulted in mild increase in nipple asymmetry. Both implant locations in DTI reconstruction resulted in increased postoperative asymmetry but was significant for the prepectoral group. Radiation therapy has a significant impact of nipple asymmetry.

The Impact of Tissue Expander Nipple Asymmetry on Final Implant Symmetry After Bilateral Nipple Sparing Mastectomy.

BACKGROUND: Asymmetry of nipple position is common in the female population and very difficult to correct after nipple sparing mastectomy (NSM). There are scant data on the impact of tissue expander (TE) nipple asymmetry on final implant nipple symmetry after bilateral NSM. METHODS: A retrospective review of an institutional review board-approved prospective database of NSM and immediate 2-stage implant reconstruction between June 2014 and December 2019 was performed. BCCT.core software was used to examine TE and final implant nipple asymmetry as well as relative breast implant position. Horizontal and/or vertical asymmetry and breast retraction assessment (BRA) were evaluated. Moderate asymmetry was defined as ≥1 cm and severe asymmetry as ≥2 cm. Lower breast contour ≥1 cm defined implant malposition. RESULTS: Twenty-three patients met the inclusion criteria. Linear regression analysis showed a significant relationship between TE BRA and final BRA (R2 = 0.2321, P = 0.02) with a mean TE BRA of 2.04 and a mean final BRA of 1.53 (P = 0.05). Tissue expander nipple asymmetry was predictive of final BRA score: no TE asymmetry, 0.87, versus TE nipple asymmetry, 1.67 (P = 0.02). Tissue expander lower breast contour ≥1 cm occurred in 8 patients (36.4%) and was associated with implant nipple asymmetry in 7 (87.5%). The second stage of reconstruction significantly improved the nipple asymmetry in those with TE malposition (TE BRA, 2.34, vs final BRA, 1.67; P = 0.05). Two patients who received radiation had increased BRA scores (radiation, 2.14, vs no radiation, 1.47; P = 0.004). CONCLUSIONS: Tissue expander nipple asymmetry as measured by BRA score or nipple asymmetry was predictive of final nipple symmetry. The second stage of TE reconstruction improves the nipple asymmetry. Final implant exchange can allow for pocket and implant manipulation, improving nipple symmetry. Radiation therapy to TE reconstruction has a negative impact on nipple symmetry after the final stage.

Drain Removal Time in Pre-pectoral versus Dual Plane Prosthetic Breast Reconstruction following Nipple-sparing Mastectomy.

Pre-pectoral prosthetic breast reconstruction following nipple-sparing mastectomy (NSM) has become a popular approach compared with the dual plane technique. Our objective was to determine if there was a difference in time to postoperative breast drain removal in direct-to-implant or tissue expander reconstruction following NSM when comparing pre-pectoral with dual plane technique. Methods: A total of 200 patients (335 breasts) received NSM followed by implant or expander reconstruction at our institution between the years 2009 and 2020. Direct-to-implant reconstruction had 113 pre-pectoral versus 67 dual plane, and tissue expander reconstruction had six pre-pectoral versus 149 dual plane. Our analysis included age at mastectomy, body mass index, history of preoperative breast radiation, and smoking history. Case complications included seroma or hematoma, breast or axillary infection requiring antibiotics or operative washout, device replacement due to extrusion or infection, skin necrosis, and capsular contracture. Statistical analysis was completed with Pearson chi-square test, Fisher exact test, and the two-sample T-test using IBM SPSS Statistics 24.0 (IBM Corp., Armonk, N.Y.). Results: The average time until breast drain removal in dual plane implant patients was significantly less than in pre-pectoral implant patients (9.42 versus 14.01 days). The average time until breast drain removal in dual plane expander patients was significantly less than in pre-pectoral expander patients (11.47 versus 20.30 days). Conclusion: In both implant and expander reconstruction following NSM, patients receiving dual plane device placement had a shorter postoperative time until breast drain removal when compared with patients receiving pre-pectoral device placement.

The Impact Oncoplastic Reduction Has on Long-Term Recurrence in Breast Conservation Therapy.

BACKGROUND: The use of oncoplastic reduction techniques have many proven benefits over lumpectomy alone in the management of women with breast cancer. The impact it has on tumor recurrence is unclear. The purpose of this review was to evaluate the incidence of recurrence in patients who underwent oncoplastic reduction techniques compared to lumpectomy alone. METHODS: A prospectively maintained database of patients at Emory Hospital who underwent oncoplastic reduction techniques at the time of tumor resection was queried. These patients were compared to a series of patients who had lumpectomy alone over a similar period. For inclusion in the study, patients were at least 10 years since the time of the tumor resection. The main outcome of interest was tumor recurrence. RESULTS: There were 97 patients in the lumpectomy-only group and 95 patients in the oncoplastic reduction group, with an average follow-up of 7.8 years and 8.5 years, respectively. Patients in the oncoplastic group were younger (lumpectomy only, 61.4 years; oncoplastic reduction, 51.6 years; p < 0.001) and had larger tumors (lumpectomy only, 1.1 cm; oncoplastic reduction, 1.6 cm; p < 0.001). Local recurrence was 13 percent in the lumpectomy-only group and 9 percent in the oncoplastic reduction group (p = 0.34), and overall recurrence rates were similar (lumpectomy only, 15 percent; oncoplastic reduction, 24 percent; p = 0.13). Overall, surgical intervention (lumpectomy alone versus oncoplastic reduction) was not associated with local recurrence or any recurrence on univariate and multivariate analyses. CONCLUSION: Despite the oncoplastic reduction patients having a higher risk of recurrence and a more generous tumor resection, the long-term recurrence rates were equivalent when compared to breast-conserving therapy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Incidence and Outcomes of Completion Mastectomy following Oncoplastic Reduction: A Case Series.

Background: Patients occasionally need completion mastectomy (CM) following oncoplastic reduction for various reasons necessitating definitive reconstructive techniques. The purpose of this study was to evaluate those patients who required CM following oncoplastic reduction and evaluate indications, technique, and outcomes. Methods: Patients who underwent a completion mastectomy at some time point following the oncoplastic reduction were identified. Factors that influenced CM and additional reconstruction were analyzed. All statistical analysis was conducted using the IBM SPSS Statistics 27.0 (IBM Corp.). Results: A total of 29 patients (5.3%) underwent CM during the study period with an average follow-up of 3 years since the original procedure. The most common reasons were positive margins (20/29, 69.0%) and recurrence (8/29, 27.6%). Twenty-two had reconstructive procedures (75.9%) and seven did not (24.1%). The patients who underwent CM and reconstruction were significantly younger (49.2 years) than those who had no reconstruction (64.3 years, P = 0.004). The most common type of reconstruction was transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap (12/22, 54.5%), followed by latissimus (6/22, 27.3%) and tissue expander (3/22, 13.6%). The complication rate in the CM group was 24% (N = 7/29), which included two seromas (6.9%), followed by infection, fat necrosis, mastectomy skin necrosis, and donor site necrosis (3.4% each). Conclusions: Completion mastectomy is indicated typically for positive margins or recurrence. Reconstruction is performed more frequently in younger patients, with the TRAM/DIEP flap and latissimus dorsi reconstruction being the most common technique.

Skin Reducing Mastectomy and Immediate Tissue Expander Reconstruction: A Critical Analysis.

BACKGROUND: Complications of implant-based reconstruction have been shown to be related to increasing body mass index (BMI) and breast size. The impact of skin reducing mastectomy (SRM) with a dermal flap is examined. METHODS: A retrospective review of a single surgeon's experience with immediate submuscular tissue expander (TE) reconstruction from 2011 to 2019 was performed. The outcomes of SRM were compared with those of skin sparing mastectomy (SSM). RESULTS: A total of 162 patients (292 breasts) were identified. Mastectomy types were as follows: SRM, 73 (136 breasts) and SSM, 89 (156 breasts). Acellular dermal matrix (ADM) was used to supplement TE coverage in 65.4% of SRM cases. Mean BMI was 29.2 among SRM patients and 25.9 in SSM patients (P < 0.001). Obesity (BMI ≥ 30) was more prevalent in the SRM group (SRM, 38.4% vs SSM, 22.5%; P = 0.03). Mean mastectomy weight was higher in the SRM group (SRM, 833.6 g vs SSM, 425.6 g; P < 0.001). Mean BMI and mastectomy weight were lower in SRM patients who were reconstructed with ADM (ADM, 28.1 vs no ADM, 30.8; P = 0.01; ADM, 746.1 g vs no ADM, 1006.3 g; P < 0.001). Minor complications were more prevalent in the SRM group (SRM, 22.8% vs SSM, 4.5%; P < 0.001). Mastectomy skin flap necrosis (MSFN) was more common in the SRM group (SRM, 22.8% vs SSM, 7.7%; P < 0.001), but MSFN necessitating operative debridement was similarly low in both groups (SRM: 1.9% vs SSM: 4.5%). Major complication rates (SRM 11.0% vs SSM 10.9%) and reconstructive failure rates (SRM 5.9% vs SSM 5.1%) were similar between groups. Mastectomy weight 800 g or higher and BMI of 30 or higher were found to be risk factors for complications on analysis of the SRM cohort (P < 0.05). CONCLUSIONS: Mastectomy weight and BMI were positive predictors of complications after immediate TE reconstruction. Mastectomy skin flap necrosis is more common after SRM than SSM. The use of SRM with a dermal flap has a similar major complication rate as SSM despite its use in obese, large-breasted women. The dermal flap provides soft tissue coverage, which prevents implant exposure and seroma. The use of ADM does not adversely affect the complication rate of SRM.

The Incidence of Occult Malignant and High-Risk Pathologic Findings in Breast Reduction Specimens.

BACKGROUND: The goal of this study was to determine the incidence of occult malignancy and high-risk breast pathologic findings in patients who undergo breast reduction procedures. METHODS: Medical records of consecutive patients who underwent reduction mammaplasty performed by the senior authors (A.L. and G.W.C.) at Emory University Hospital between 1997 and 2018 were reviewed. Data regarding patient demographics, personal or family history of malignancy, operative technique, pathologic findings, and follow-up were extracted. Patients were categorized into two groups, those with and those without breast cancer. Group A patients underwent reduction for symptomatic macromastia, and group B underwent contralateral reduction for unilateral breast cancer treated with oncoplastic partial or total breast cancer reconstruction. Pathologic findings were divided into four groups; normal, benign, high-risk, and malignant. RESULTS: A total 1014 patients (1419 breast reductions) were included in the study. Comparing groups A and B, mean age was 37.8 ± 16.2 years versus 54.5 ± 11.1 years (p < 0.001), mean body mass index was 34.1 ± 7.6 kg/m2 versus 33.3 ± 7.4 kg/m2 (p = 0.2), and average reduction weight was 875.6 ± 491 g versus 723.7 ± 438 g (p < 0.001). The incidence of high-risk or malignant lesions was 1.8 percent (n = 15) in group A and 8 percent (n = 49) in group B (p < 0.001). On multivariable logistic regression analysis, age and personal history of breast cancer were positive predictors for high-risk and malignant lesions. CONCLUSIONS: The incidence of abnormal pathologic findings in breast reduction specimens is not uncommon, and occult malignancy or high-risk lesions can be found, especially in patients with contralateral breast cancer. Appropriate specimen orientation, diligence with checking the pathologic findings, and open communication with the pathologist are crucial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Ischemic Complications After Bilateral Nipple-sparing Mastectomy and Implant-based Reconstruction: A Critical Analysis.

PURPOSE: Nipple-sparing mastectomy (NSM) has a higher incidence of mastectomy skin flap necrosis (MSFN) than skin-sparing mastectomy. The purpose of this study is to analyze predisposing factors for nipple and skin necrosis after bilateral NSM with immediate implant reconstruction. METHODS: Sixty-two consecutive patients (124 breasts) from a single breast/plastic surgeon underwent bilateral NSM with immediate implant-based breast reconstruction were included. Factors influencing MSFN were analyzed. RESULTS: The mean age was 45.7 years, and mean body mass index was 22.9. Reconstructive methods were as follows: tissue expander (TE), 76 (61.3%); and direct to implant, 48 (38.7%). Mastectomy skin flap necrosis occurred in 39 (31.5%) breasts, nipple necrosis 38 and skin flap necrosis 19. Thirty-seven breasts healed uneventfully, and 2 (1.6%) required reoperation. Cancer pathology, mastectomy weight greater than 279 g, TE reconstruction, and nipple-notch (N-N) distance greater than 23 cm were predictive of nipple necrosis on univariate analysis. The mean mastectomy weight (380.1 g vs 220.7 g, P < 0.0001), N-N distance greater than 23 cm (30 vs 0, P < 0.0001), and mean implant size (490 cm3 vs 373 cm3, P < 0.0001) were greater in the TE group. On logistic regression model controlling for all significant variables, predictors of MSFN were as follows: diagnosis of cancer (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.41-8.03; P = 0.006), TE reconstruction (OR, 2.87; 95% CI, 1.03-8.03; P = 0.04), and N-N distance (OR, 1.31; 95% CI, 1.03-1.66; P = 0.03). CONCLUSIONS: Mastectomy skin flap necrosis after NSM and implant reconstruction is common. In this series, only 2 (1.6%) cases required surgical intervention with no implant loss. Treatment of breast cancer, TE reconstruction, and increasing N-N notch distance were positive predictors of MSFN.

Secondary Surgeries After Oncoplastic Reduction Mammoplasty.

PURPOSE: The oncoplastic reduction approach is a popular option for women with breast cancer and macromastia. Although the benefits of this approach are numerous, data on the need for secondary surgeries are limited. We evaluated the need for all secondary surgeries after oncoplastic reduction in an attempt to understand the incidence and indications. METHODS: All patients with breast cancer who underwent an oncoplastic breast reduction at the time of the tumor resection were queried from a prospectively maintained database from 1998 to 2020 (n = 547) at a single institution. Secondary surgical procedures were defined as any unplanned return to the operating room. Demographic and clinical variables were analyzed, and secondary surgeries were classified and evaluated. The timing and rates of secondary surgery were evaluated and compared with clinical variables. RESULTS: There were 547 patients included in this series with a mean age of 55 years and body mass index of 33.5. Mean duration of follow-up was 3.8 years. One hundred and seventeen (21%) patients underwent 235 secondary surgeries, with an average of 1.4 operations until stable reconstruction was obtained. The reason for the secondary surgery was involved margins (7.5%), major complications (8.6%), aesthetic improvement (13.3%), and completion mastectomy (5.3%). Age 65 years and younger age was associated with any subsequent procedure (P = 0.023) and revision for cosmesis (P = 0.006). Patients with body mass index greater than 35 had increased secondary surgeries for operative complications (P = 0.026). CONCLUSIONS: Secondary surgeries after oncoplastic breast reduction procedures are common. Management of margins and complications, such as hematoma and infection, are early indications, with aesthetic improvement, wound healing complications, fat necrosis, and recurrence being late reasons. The most common reason for reoperation is aesthetic improvement, especially in younger patients. Attention to surgical technique and patient selection will help minimize secondary surgeries for the nononcological reasons.

A Systematic Review of Breast Irrigation in Implant-Based Breast Surgery.

BACKGROUND: Aesthetic and reconstructive implant-based breast surgeries are some of the most frequently performed procedures by plastic surgeons. As such, prevention of implant infection is of high importance. However, there remains no criterion-standard protocol for irrigation of the breast pocket. This review focuses on current irrigation practices in implant-based breast surgery. METHODS: Four databases were used to search for all studies, including randomized controlled trials, retrospective cohort, and prospective cohort, containing original data related to the outcomes investigated in this study. Search terms included "breast," "irrigation," and "infection" in different combinations to isolate studies that focused on irrigation methods in both reconstructive and augmentation surgeries. Our selection criteria specifically concentrated on those studies that explicitly related irrigation procedures to rates of clinical infection and/or capsular contracture. Each was compiled into a table in chronological order to make comparisons between the differing irrigation methods. RESULTS: Our search returned 239 full-text articles eligible for our review. Two independent screeners identified 9 studies that met the inclusion criteria. This included 1 prospective study and 8 retrospective studies. Two studies reported the use of chlorhexidine gluconate irrigation resulting in protection from clinical infection. Two studies investigated the role of triple antibiotic solution (TAS) either alone or combined with something else on risk of infection, and 3 reported TAS use on rates of capsular contracture. Two additional studies investigated the role of single antibiotic irrigation, concluding that some antibiotic regimen for irrigation may be sufficient in the breast pocket. Interestingly, one study noted the potential use of povidone-iodine (Betadine) as a method of irrigation. CONCLUSIONS: These data suggest that chlorhexidine gluconate, Betadine, and TAS irrigation of the breast pocket can provide protection against infection and implant loss in both reconstruction and augmentation surgeries.

The impact of axillary node surgery on outcomes following immediate breast reconstruction.

Immediate breast reconstruction (IBR) has become the most common method for postmastectomy reconstruction. Axillary lymph node dissection is performed for the staging of patients, but the impact of IBR with nodal surgery on postoperative complications remains elusive. The present study aims to investigate the impact of concomitant axillary lymph node surgery on postoperative complications. We conducted a retrospective study of patients who underwent IBR from 2000 to 2014. We recorded and analyzed patient data to determine the association between nodal surgery and postsurgical complications. Univariate and multivariate analyses were utilized to elucidate the risk of a complication given nodal surgery, sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), and type of incision for nodal access. A total of 986 breast reconstructions were included for analysis. Overall incidence of postoperative complications per breast that received nodal surgery was 35.9% (n = 230/642), compared to 25.6% (n = 88/344) in breasts that did not have concomitant nodal surgery (P = .001). Nodal surgery was found to increase risk of all complications with an odds ratio of 1.62 (P = .001). Moreover, complications were significantly higher in patients whose nodes were accessed via mastectomy incision (39.4%) when compared to a separate incision (33.5%). Multivariate analysis showed that nodal sampling through the mastectomy incision is a significant risk factor for seroma, with an odds ratio of 3.60 (P = .002). We did not observe differences in breast complications in patients who underwent SLNB vs ALND. These factors should be taken into account in the approach to breast reconstruction during lymphadenectomy.

A multicenter, prospective 2-year analysis of the Sidus stem-free shoulder arthroplasty system.

BACKGROUND: The purpose of this multicenter, prospective study was to evaluate the efficacy and safety of a stemless total shoulder arthroplasty compared with a traditional stemmed control. METHODS: Ninety-five shoulders were selected for participation in this Food and Drug Administration investigational device exemption clinical trial and underwent stemless total shoulder arthroplasty. Subjects returned for follow-up at 6 weeks, 6 months, 12 months, and 2 years postoperatively. Outcome measures included pain; range of motion; American Shoulder and Elbow Surgeons, Western Ontario Osteoarthritis of the Shoulder, and Short Form 12 scores; and radiographic review. Baseline data were compared with 2-year follow-up data to determine the rate of composite clinical success compared with the stemmed control. RESULTS: All outcome assessments demonstrated significant improvements (P ≤ .007). The mean American Shoulder and Elbow Surgeons score improved from 20 to 89 (P < .0001), and the mean shoulder pain score decreased from 8.3 ± 1.6 to 0.7 ± 1.5 (P < .0001). The mean Western Ontario Osteoarthritis of the Shoulder score decreased from 1443 ± 256 to 203 ± 267 (P < .0001). On the Short Form 12, the mean physical health score increased from 33 ± 7 to 48 ± 9 (P < .0001) and the mean mental health score increased from 50 ± 13 to 54 ± 8 (P = .007). Mean active forward elevation increased from 97° ± 27° to 143° ± 25° (P < .0001), and mean active external rotation increased from 21° ± 16° to 53° ± 18° (P < .0001). Kaplan-Meier analysis showed an implant survivorship rate of 98% at 2 years. The composite clinical success rate was 87% compared with 85% for the stemmed control. CONCLUSIONS: This study showed that a stemless rough-blasted humeral implant with metaphyseal bone fixation provides good clinical and radiographic outcomes and survivorship at 2 years, with outcomes comparable to a traditional stemmed implant.

Nipple malposition after bilateral nipple-sparing mastectomy with implant-based reconstruction: Objective postoperative analysis utilizing BCCT.core computer software.

Nipple-sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912-0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.

The changing surgical treatment of breast cancer in the United States: The tipping point.

The surgical management of breast cancer began to change in the middle of the last decade. The use of unilateral mastectomy decreased while the rate of contralateral prophylactic mastectomy for unilateral cancer increased sixfold from 1998 to 2011. The use of immediate breast reconstruction increased from 30% in 2005 to 45% in 2012. Four changes came together in the middle of the last decade to cause this paradigm shift in the surgical management of early breast cancer. (a) Breast MRI would be available in nearly 75% of breast imaging centers. (b) Genetic counseling would become a standard of care for patients with potential hereditary breast cancer. (c) In 2006, the FDA would approve the use of silicone-gel implants. (d) Nipple-sparing mastectomy would become a standard of care in the treatment of early breast cancer.