Inpatient versus Outpatient Immediate Alloplastic Breast Reconstruction: Recent Trends, Outcomes, and Safety.

Background: Immediate alloplastic breast reconstruction was traditionally performed as an inpatient procedure. Despite several reports in the literature demonstrating comparable safety outcomes, there remains hesitancy to accept breast reconstruction performed as an outpatient procedure. Methods: A retrospective review of National Surgical Quality Improvement Program data from 2014 to 2018 was utilized to evaluate recent trends and 30-day postoperative complication rates for inpatient versus outpatient immediate prosthetic-based breast reconstruction. Propensity score matching was used to obtain comparable groups. Results: During the study period, 33,587 patients underwent immediate alloplastic breast reconstruction. Of those, 67.5% of patients were discharged within 24 hours, and 32.4% of patients had a hospital stay of more than 24 hours. Immediate alloplastic reconstruction had an overall growth rate of 16.9% from 2014 to 2018. After propensity score matching, intraoperative variables that correlated with significantly increased inpatient status included increased work relative value units (16.3 ± 2.3 versus 16.2 ± 2.6; P < 0.001), longer operative times (228 ± 86 versus 206 ± 77; P < 0.001), and bilateral procedure (44.0% versus 43.5%; P < 0.001). There were higher rates of pulmonary embolism, wound dehiscence, urinary tract infection, transfusions, sepsis, readmissions, and reoperations in the group with the longer hospital stay. Conclusion: Based on increased complication rates and costs in the inpatient setting, we propose outpatient reconstructive surgery as a safe and cost-effective alternative for immediate alloplastic breast reconstruction.

The Role of Premastectomy Mastopexy and Breast Reduction in the Reconstruction of the Enlarged or Ptotic Breast.

BACKGROUND: The indications for nipple-sparing mastectomy have broadened over time. Patients undergoing nipple-sparing mastectomy who have enlarged or ptotic breasts are at risk for skin flap and/or nipple-areola complex necrosis. Premastectomy mastopexy or breast reduction may reduce the risk for these complications. METHODS: A retrospective review was undertaken in a series of patients who underwent premastectomy reduction mammaplasty or mastopexy followed by nipple-sparing mastectomy and immediate staged tissue expander/implant-based breast reconstruction. In each case, a subnipple biopsy was performed at the premastectomy procedure to clear it of any potential malignant involvement. In addition, the area under the areola was undermined to maximize the effect of the delay phenomenon on the eventual survival of the nipple-areola complex. Final reconstruction involved tissue expander exchange for a permanent implant with associated fat grafting. Data regarding surgical timing and selected postoperative complications were recorded. RESULTS: In total, 39 implant-based reconstructions were performed in 20 patients. There were no cases of mastectomy flap necrosis, and partial necrosis of the nipple-areola complex with delayed wound healing was seen in two breasts in the same patient. All patients eventually completed the reconstructive process successfully. CONCLUSION: Premastectomy mastopexy or breast reduction may afford a protective effect against mastectomy flap or nipple-areola complex necrosis in patients with large or ptotic breasts who subsequently undergo nipple-sparing mastectomy with immediate breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Chronic Persisting Hematoma: Report of a Case and Literature Review.

The authors present a unique case of chronic persisting hematoma formation at the site of a remote congenital melanocytic nevus excision with tissue expander reconstruction. Similarities between chronic persisting hematoma and chronic encapsulated seroma are addressed to provide guidance on the appropriate workup and management for the plastic surgeon. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .