Prepectoral Breast Reconstruction in Morbidly Obese Patients.

Prosthetic breast reconstruction via the subpectoral approach in morbidly obese patients (body mass index: ≥40 kg/m2) has been reported to be associated with an increased risk of perioperative complications and poor outcomes. Further, immediate reconstruction appears to carry a higher risk of poor outcomes than delayed reconstruction in this population. The impact of morbid obesity on outcomes after prepectoral breast reconstruction has not yet been evaluated, and such was the purpose of this study. Methods: This retrospective study included all consecutive patients with morbid obesity who underwent prepectoral expander/implant reconstruction between July 2009 and April 2020 in the first author's practice. Patient records were reviewed, and data on demographics, comorbidities, radiotherapy use, type of mastectomy, mastectomy specimen weight, and postoperative complications following reconstruction were retrieved. Complications were stratified and compared by timing of reconstruction (immediate versus delayed). Results: Eighty-five breasts in 45 morbidly obese patients were reconstructed. Postoperative complications occurred in 11 breasts (12.9%) and included major skin necrosis (3.5%), seroma (4.7%), wound dehiscence (5.9%), and reconstructive failure (1.2%). Timing of reconstruction had little impact on postoperative complications other than major skin necrosis, which was significantly higher in the delayed group (11.1% versus 1.5%). Conclusions: Prosthetic breast reconstruction via the prepectoral approach can be successfully performed in morbidly obese patients, with outcomes approaching those seen in nonobese patients when performed by experienced surgeons. Patients with morbid obesity should not be denied this reconstructive approach because of their body mass index.

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.

The breast surgeons' approach to mastectomy and prepectoral breast reconstruction.

The purpose of this review article is to discuss and highlight the data, techniques and our experience performing mastectomies in the setting of prepectoral breast reconstruction. Using a systematic review of the approach to mastectomy in the oncologic setting encompassing patient selection, safety, anatomy and methods including a literature review of mastectomy trends, safety data and outcomes, anatomy and our experience, we are able to illustrate the safety and utility of this technique. The literature strongly supports the oncologic safety of these methods. This review also supports the use of these techniques as a surgical approach to any mastectomy, with or without reconstruction, and addresses many of the factors involved in improving and maximizing outcomes. While, there are multiple and equally efficacious approaches to mastectomy, several surgical techniques can be used to improve outcomes and ensure optimal flap viability.

A novel, adaptable, radiographically opaque, multi-plane continuous filament marker for optimizing tissue identification, radiation planning, and radiographic follow-up.

BACKGROUND: In breast cancer treatment, marking the tumor bed is an important aspect of the surgical component of therapy. Clear delineation of the tumor bed allows radiation oncologists a defined target for planning and delivering postoperative radiation therapy (XRT). Tumor bed marking also allows radiographic follow-up of the tumor bed on subsequent breast imaging. The aim of this assessment is to evaluate the ease and feasibility of utilizing a tumor bed filament marker (VeraFormÒ, Videra Surgical inc., USA) as a marker in post-operative benign surgical sites and malignant breast surgical tumor beds in breast cancer surgery. METHODS: The filament marker is a novel radiopaque surgical filament that in lieu of clips and other markers is implanted in the surgical tumor bed during breast surgery. Following development of the filament marker, the researchers used breast phantoms and radiographic images to develop a series of geometric patterns of placement options that optimize comprehensive multi-plane radiographic interpretation of the exact tumor bed or surgical margin. Three breast surgeons at 3 separate institutions then used this filament as a continuous multi-plane marker in 20 patients during breast conservation surgery. In these patients, the filament marker was thus used to mark the tumor bed (breast cancer surgery) or surgical site (benign breast disease) instead of the more traditional devices such as clips or other metallic open framework devices. We then assessed 2 important factors related to this device; (I) the ease, feasibility, and accuracy of in vivo placement with oncoplastic and non-oncoplastic breast conservation surgery techniques; (II) the radiographic footprint this device left on standard imaging protocols of post-operative mammogram (MMG), computed tomography (CT) scan, breast magnetic resonance imaging (MRI) examinations, and ultrasounds (USs) for both routine follow-up imaging and for standard radiation planning. RESULTS: There were no adverse events reported with the use of this device. The cases were then reviewed by a multidisciplinary team that included the original surgeon, a breast radiologist, and radiation oncologist. Their unanimous evaluation was that the filament marker clearly delineated all sides and planes of the tumor bed (cancer surgery) or surgical site (benign disease). Regardless of surgical technique utilized, this information provided precise 3D guidance for radiation planning and delivery as well as radiographic follow-up. The surgeons involved reported that delineating the bed with the filament marker was a quick and easy procedure and did not interfere with performing the planned surgical technique. Radiologists, surgeons, and radiation oncologists found that the filament marker was not only radiographically opaque on CT and MMG, but also caused no significant artifact on CT, MRI, US, or MMG. CONCLUSIONS: The continuous multi-plane filament marker is a new device that fulfills the heretofore unmet need for safe and improved tumor bed and tissue site marking. It is an easy to place, non-palpable continuous multi-plane radiographic opaque tissue marker that seems to better delineate the tumor bed, regardless of type of breast surgery performed, while providing a more accurate 3D image for radiation planning and radiographic follow-up on MMG MRI, CT and US.

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.

What Drives Patient Choice: Preferences for Approaches to Surgical Treatments for Breast Cancer Beyond Traditional Clinical Benchmarks.

IMPORTANCE: Understanding what drives breast cancer (BC) patient's surgical decision-making and why, as survival continues to improve, are women continuing to choose mastectomy in increasing numbers. OBJECTIVE: We sought to understand better what drives patient choice in surgical decision-making regarding BC treatment options. DESIGN: We used a dynamic model, adaptive conjoint-based survey experiment, to assess multiple factors concurrently impacting patient choice, conducted from December 2016 to January 2017 using the Army of Women. SETTING: Army of Women, is a U.S.-based nation-wide registry of women, both healthy and previous BC patients. PARTICIPANTS: An e-mail invitation was sent to the AWOL's 108,933 members, with 1,233 signing up to participate and 858 responding (548 healthy, 310 previous BC). Two hundred thirty-nine BC patients who underwent treatment > 5 years were excluded due to potential recall bias and changes in BC treatment paradigms. All subjects who did not complete the adaptive conjoint-based survey were also excluded due to inability to calculate preferences. The final sample consisted of 522 healthy women and 71 previous BC patients. INTERVENTIONS OR EXPOSURES: Study of patient preference and decision drivers, without, interventions or exposures. MAIN OUTCOMES AND MEASURES: Shares of preferences for various surgical treatment options were calculated using the highest-ranked factors, by the importance that drove patient decision-making. RESULTS: Survey response rate was 69.5%. Among healthy women, the most important of the 9 factors in making a surgical choice were doctor's recommendation at 21.4% (SD, 13.6%) and overall survival (OS) at 20.5% (SD, 9.8%) while among previous BC patients, the most important factor was OS at 19% (SD, 9%) and doctor's recommendation at 17.2% (SD, 10.3%). CONCLUSION AND RELEVANCE: While OS accounted for the largest single driver of patient choice at ~20 %, it is notable that 80% of patient decision-making was driven by factors unrelated to survival such as cost, intensity and recovery time, and breast image. By understanding what drives choice, we can provide better patient-centric education and treatments.

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.

Prepectoral Breast Reconstruction: The Breast Surgeon's Perspective.

Prepectoral breast reconstruction has been reemerging as a technique for postmastectomy implant-based reconstruction. Due to its advantage in eliminating animation deformity, shortening length of hospital stay and decreasing the amount of narcotics used for pain control, the technique has been embraced by patients and surgeons alike. The authors examined the breast surgeon's perspective regarding prepectoral reconstruction taking into consideration oncologic criteria, breast cancer recurrence, surgical technique, and the team approach to patient care.

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.

Evaluation of an ultra-lightweight, single-patient-use negative pressure wound therapy system over dermal regeneration template and skin grafts.

As the use of negative pressure wound therapy (NPWT) over skin grafts has increased, traditional methods of NPWT system reimbursement and application are increasingly being challenged. A simplified method of accessing and operating NPWT in the outpatient setting is needed, particularly in cases where immediate outpatient use of NPWT is optimal. We evaluated use of a new ultra-lightweight, off-the-shelf, disposable, single-patient-use NPWT system (SP-NPWT; V.A.C.Via™ Therapy, KCI USA, Inc., San Antonio, TX) over dermal regeneration template (DRT) and/or skin grafts. SP-NPWT was initiated over a DRT and/or skin graft in 33 patients with 41 graft procedures. Endpoints were recorded and compared to a historical control group of 25 patients with 28 grafts bolstered with traditional rental NPWT (V.A.C.® Therapy, KCI USA, Inc.). Average length of inpatient hospital stay was 0·0 days for the SP-NPWT group and 6·0 days for the control group (P < 0·0001). The average duration of SP-NPWT post-DRT or skin graft was 5·6 days for the SP-NPWT group and 7·0 days for the control (P < 0·0001). Preliminary data suggest that, compared to traditional NPWT, off-the-shelf SP-NPWT may provide a quicker, seamless transition to home, resulting in decreased hospital stay and potential cost savings.

Advances in nipple-sparing mastectomy: oncological safety and incision selection.

BACKGROUND: With the evolution of breast reconstruction and oncoplastic techniques, more aesthetic mastectomies are being offered to patients. Nipple-sparing mastectomy (NSM) has been controversial, but an expanding body of published experience has allowed this concept to gain momentum. OBJECTIVES: The authors review their experience with NSM. METHODS: From 2007 to 2009, 112 consecutive patients (204 breasts) who were candidates for NSM presented to one of two private plastic surgery practices. All patients underwent preoperative magnetic resonance imaging to assess the size of the tumor, its distance from the nipple, and any additional disease within the ipsilateral/contralateral breast or axillae. Exclusion criteria included tumors larger than 3 cm, clinical invasion of the nipple-areolar complex, tumors within 2 cm of the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, or nodal disease (excluding isolated immunohistochemistry positivity). Fourteen patients were excluded from the study for one of these reasons, leaving a total of 98 patients (186 breasts) who underwent NSM. RESULTS: Risk-reducing mastectomies were performed on 45 patients. Therapeutic mastectomies were performed for Stage 0 cancer (ductal carcinoma in situ) in 26 patients, for Stage 1A in 24 patients, and for Stage 1B in three patients. Disease-free survival was calculated from the date of surgery to any local, regional, or distant relapse (whichever occurred first). As of the writing of this article, follow-up ranged from nine months to three years, and there has been no local or regional recurrence in any patient. CONCLUSIONS: NSM is evolving and should be considered a good treatment option in carefully-selected patients. These findings add to the growing body of evidence showing that, with proper patient selection and operative technique, NSM is a safe and effective intervention for patients requiring therapeutic or prophylactic mastectomy.

What have we learned over the past 20 years about appendicitis in the elderly?

BACKGROUND: This study evaluates appendicitis in the elderly, comparing our findings to those previously published a decade earlier. METHODS: Comparison of appendicitis in the elderly (aged 60 years and older) from 1978 to 1988 with the following 10 years, 1988 to 1998. RESULTS: Overall (1978-1998) 26% of patients presented typically, one third delayed seeking care, with only half diagnosed correctly on admission. Computed tomography (CT) use increased (44% versus rarely in the previous decade). Perforation rates declined (72% first group versus 51% second group) with a concomitant drop in complications from 32% to 21% respectively. Overall, three fourths of complications occurred in patients with perforated appendicitis. Mortality rates remained constant. CONCLUSIONS: Appendicitis in the elderly is a difficult problem with delays in medical care, non-typical presentation resulting in incorrect diagnosis, relatively high rates of perforation often with associated postoperative complications and mortality. A higher index of suspicion with liberal early utilization of CT in uncertain cases may result in more appropriate management.