The effect of a local anesthetic cocktail in a serratus anterior plane and PECS 1 block for implant-based breast reconstruction.

Introduction: Enhanced recovery after surgery (ERAS) protocols have been implemented to decrease opioid use and decrease patient hospital length of stay (LOS, days). Serratus anterior plane (SAP) blocks anesthetize the T2 through T9 dermatomes of the breast and can be applied intraoperatively. The purpose of this study was to compare postoperative opioid (OME) consumption and LOS between a control group, an ERAS group, and an ERAS/local anesthetic cocktail group in patients who underwent implant-based breast reconstruction. Methods: In this study, 142 women who underwent implant-based breast reconstruction between 2004 and 2020 were divided into Group A (46 patients), a historical cohort; Group B (73 patients), an ERAS/no-block control group; and Group C (23 patients), an ERAS/anesthetic cocktail study group. Primary outcomes of interest were postanesthesia care unit (PACU), inpatient and total hospital OME consumption, and PACU LOS. Results: A significant decrease was observed from Group A to C in PACU LOS (103.3 vs. 80.2 vs. 70.5; p = 0.011), OME use (25.1 vs. 11.4 vs. 5.7; p < 0.0001), and total hospital OME (120.3 vs. 95.2 vs. 35.9; p < 0.05). No difference was observed in inpatient OMEs between the three groups (95.2 vs. 83.8 vs. 30.8; p = 0.212). Despite not reaching statistical significance, Group C consumed an average of 50-60 % less opioids per patient than did Group B in PACU, inpatient, and total hospital OMEs. Conclusion: Local anesthetic blocks are important components of ERAS protocols. Our results demonstrate that a combination regional block with a local anesthetic cocktail in an ERAS protocol can decrease opioid consumption in implant-based breast reconstruction.

National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches.

BACKGROUND: Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates. METHOD: Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p < 0.05. RESULTS: Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p < 0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06 ± 0.32) and two-stage IBR (0.05 ± 0.32, p = 0.95). Immediate IBR demonstrated 12% (OR = 0.88, p = 0.0022) and 70% (OR = 0.30, p < 0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66 % lower odds of requiring only fat grafting than ABR (OR = 0.34, p < 0.001). CONCLUSION: ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.

A case report of Parry-Romberg syndrome.

Key Clinical Message: Parry-Romberg syndrome is characterized by progressive dystrophy in one half of the face, which usually begins in childhood. Correct and timely diagnosis of this disease, as well as a multidisciplinary approach and timely surgical treatment to minimize the psychological effects and improve the patient's appearance are of particular importance. Abstract: Parry-Romberg syndrome is characterized by progressive dystrophy or loss of subcutaneous tissue in one half of the face, which usually begins in childhood and continues with skin changes, and can also be associated with linear scleroderma. Although this disease has been known for more than 150 years, its exact cause and pathogenesis are not well understood. The clinical feature of Parry-Romberg syndrome that makes it possible to diagnose is unilateral idiopathic facial atrophy. The reported case is a 14-year-old boy who suffered from hemifacial atrophy of the frontal area since he was 7 years old was referred to a plastic and cosmetic surgery specialist and underwent surgery without systemic symptoms and in the inactive phase of the disease. Correct and timely diagnosis of this disease, as well as a multidisciplinary approach and timely and appropriate surgical treatment to minimize the psychological effects and improve the patient's appearance are of particular importance.

Complications After Prepectoral Versus Subpectoral Breast Reconstruction in Patients Receiving Postmastectomy Radiation Therapy: A Systematic Review and Meta-Analysis.

BACKGROUND: Outcomes of immediate breast reconstructions can be influenced by postoperative radiotherapy. However, there is no clarity on the use of prepectoral or subpectoral breast reconstruction in the setting of postmastectomy radiation therapy (PMRT). We reviewed evidence on the complication rates of prepectoral and subpectoral breast reconstruction in women undergoing PMRT. METHODS: PubMed, Web of Science, and Embase databases were scanned for studies comparing complication rates of prepectoral and subpectoral breast reconstruction with PMRT. All complications were pooled in a random-effect meta-analysis to obtain odds ratio (OR). RESULTS: Eight observational studies were included. Meta-analysis showed no difference in the risk of infections (OR: 1.22 95% CI 0.79, 1.88 I2=0%), implant loss (OR: 0.86 95% CI 0.50, 1.50 I2=14%), seroma (OR: 1.01 95% CI 0.43, 2.34 I2=50%), hematoma (OR: 0.44 95% CI 0.12, 1.71 I2=0%), wound dehiscence (OR: 0.95 95% CI 0.42, 2.17 I2=0%), and skin necrosis (OR: 0.61 95% CI 0.21, 1.75 I2=36%), contracture (OR: 0.46 95% CI 0.15, 1.48 I2=54%) and the need for revision surgeries (OR: 0.85 95% CI 0.45, 1.60 I2=15%) between the prepectoral and subpectoral groups. CONCLUSIONS: Data from observational studies indicates that in appropriately selected patients there may not be any difference in the risk of early complications with prepectoral or subpectoral breast reconstruction with PMRT. Current evidence is limited by the small number of studies, short follow-up and selection bias. There is a need for randomized controlled trials comparing the two approaches to obtain robust evidence on long-term outcomes. LEVEL OF EVIDENCE III: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Restoring Severely Atrophic Edentulous Ridge of Mandible Using Self-Expanding Tissue Expander-A Case Report.

This report describes the use of Self Inflating Tissue Expanders (SITEs) to rehabilitate severely atrophic edentulous mandibular ridges, enabling successful bone grafting and implant placement. The treatment resulted in stable and complication-free implants over a seven-year follow-up, demonstrating SITEs' effectiveness in providing sufficient bone volume and soft tissue coverage for dental implants.

Pre-pectoral breast reconstruction with tissue expander entirely covered by acellular dermal matrix: feasibility, safety and histological features resulting from the first 64 procedures.

Background: Reconstructive options that can be used following conservative mastectomy, skin-, nipple-sparing and skin-reducing mastectomies, allow a remarkable variety of safe methods to restore the natural shape and aesthetics of the breast mound. In case of two-stage breast reconstruction, tissue expanders (TEs) are usually placed in a subpectoral position. The purpose of this retrospective cohort study is to evaluate the feasibility and safety of two-step reconstruction with TE in pre-pectoral position covered by acellular dermal matrix (ADM). Methods: Between March 2021 and May 2023, at the Azienda Ospedaliero Universitaria Careggi, University of Florence, 55 patients with BRCA 1/2 mutations or early breast cancer underwent conservative mastectomy with immediate pre-pectoral reconstruction using TE covered with ADM, followed by a second surgery with replacement of the expander with definitive prosthesis. Demographic, oncological, and histological data along with surgical complications were recorded. Results: A total of 64 conservative mastectomies were performed. In 2 patients (3.1%) complications were found that required reintervention and, in both cases, the TE had to be removed. Two patients developed hematoma and one patient developed seroma. Two patients showed wound dehiscence, both healed after conservative treatment and without implant exposure. No case of necrosis of the skin or nipple-areola complex has been observed, neither of capsular contracture. Capsule formed around TE was populated with cells and blood vessels and showed a thin area of synovial metaplasia. Conclusions: In selected cases it may be more cautious to perform a two-stage breast reconstruction after radical breast surgery by means of TEs. The placement of TEs in pre-pectoral position combines the excellent aesthetic and functional results of the pre-pectoral philosophy with a quite safer and more prudent two-step approach. Our experience reports optimistic results: the ADM covering the TE is seen successfully integrating during tissue expansion and becoming a vascularised new self-tissue. Complications rates are low and such ADM-assisted two-stage pre-pectoral reconstructive technique is a safe, practical, and reproducible method.

Superficial Temporal Artery Island Flap Combined With Laser Hair Removal for Inadequate Skin Expansion Following Tissue Expansion: A Case Report of Congenital Melanocytic Nevus of the Forehead in an Adult.

Tissue expansion is a handy reconstructive technique for the head and neck region; however, its implementation requires careful planning and surgical experience. If tissue expansion is inadequate, forced closure results in wound tension and risks complications, such as postoperative deformity, wide scarring, and wound dehiscence. We report a case of adult forehead melanocytic nevus excision using a tissue expander (TE) where complications caused by insufficient tissue expansion were avoided by creating a flap using a dog ear. The patient was a male in his 20s who underwent surgery with a TE for a congenital melanocytic nevus sized 15 × 10 cm on the left forehead. Resection was performed by tissue expansion using two TEs; however, simple advancement flaps led to excessive wound tension, risk of elevation of the eyebrow on the affected side, and postoperative scarring. Hence, a superficial temporal artery fasciocutaneous island flap with left superficial temporal vessels as a pedicle was raised at the dog ear and moved to the site of strong tension, and the wound was closed without difficulty. Although postoperative laser hair removal was required, both the appearance and functional results were satisfactory. Using anatomical flaps obtained from the surroundings during tissue expansion helps avoid complications associated with forced wound closure.

Modeling of a tissue expander with a radiofrequency identification port in postmastectomy radiation therapy planning.

The purpose of this study was to evaluate the dose attenuation of Motiva Flora® (Flora, Establishment Labs, Alajuela, Costa Rica) tissue expander with a radiofrequency identification port locator and to develop a model for accurate postmastectomy radiation therapy planning. Dose attenuation was measured using an EBT3 film (Ashland, Bridgewater, NJ), and the optimal material and density assignment for the radiofrequency identification coil for dose calculation were investigated using the AcurosXB algorithm on the Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system. Additionally, we performed in vivo dosimetry analysis using irradiation tangential to the Flora tissue expander to validate the modeling accuracy. Dose attenuations downstream of the Flora radiofrequency identification coil was 1.29% for a 6 MV X-ray and 0.99% for a 10 MV X-ray when the coil was placed perpendicular to the beam. The most suitable assignments for the material and density of the radiofrequency identification coil were aluminum and 2.27 g/cm3, respectively, even though the coil was actually made of copper. Gamma analysis of in vivo dosimetry with criteria of 3% and 2 mm did not fail in the coil region. Therefore, we conclude that the model is reasonable for clinical use.

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results.

INTRODUCTION: Current breast cancer treatment trends advocate nipple-sparing mastectomy (NSM) as the preferred technique for selected patients. A considerable and ptotic breast is often considered a relative contraindication for NSM due to the increased risk of skin and nipple necrosis. METHODS: A retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts eligible for NSM for therapeutic or prophylactic purpose. Exclusion criteria comprised a preoperative nipple-sternal notch distance greater than 30 cm, previous radiotherapy, pinch test <1 cm, body mass index (BMI) greater than 34 and active smoke. We present our short-term results with this technique. RESULTS: During the study period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years [The Interquartile Range (IQR 50.0-68.6)] with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472 g (341-578). Median implant volume was 465 g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients experienced total nipple-areolar complex (NAC) necrosis (3.9%), and partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p = 0.003). CONCLUSION: If oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

The current use of tissue expanders in breast reconstruction: device design, features, and technical considerations.

INTRODUCTION: The use of tissue expanders (TE) in post-mastectomy breast reconstruction is a widely accepted practice, especially in patients desiring implant-based breast reconstruction. It has become the standard of care to perform a two-staged breast reconstruction using tissue expanders for the past 50 years due to its reliability, safety, cost-effectiveness, and versatility. Due to its popularity, there are numerous types and features of breast tissue expanders and various surgical approaches available for plastic surgeons. AREAS COVERED: In this article, we will review the role of tissue expanders in breast reconstruction, the types and features of breast tissue expanders, and technical considerations. EXPERT OPINION: The use of tissue expanders in breast reconstruction offers significant advantages of preserving the breast skin envelope and reestablishing the breast mound. With evolving approaches to breast reconstruction, tissue expander design, and application underwent several refinements and modifications. Due to these advances, studies on its long-term efficacy and safety profile typically fall behind and more studies with higher levels of evidence are needed to better evaluate the efficacy and safety profile of tissue expanders. With increased understanding, reconstructive surgeons can minimize complications and maximize reconstructive, aesthetic outcomes with high patient satisfaction.

Safety and factors affecting same-day discharge following mastectomy and immediate alloplastic reconstruction.

BACKGROUND AND OBJECTIVES: Patients undergoing breast reconstruction following mastectomy are often admitted overnight. In 2020, our institution implemented a protocol change to discharge clinically stable patients immediately. In this study, we examine the safety of same-day discharge following mastectomy and reconstruction. METHODS: Our retrospective study included female adults undergoing mastectomy and immediate alloplastic reconstruction from August 2019 to January 2020, before implementation of the same-day discharge protocol, and from March 2020 to September 2021, after the protocol implementation. Independent t-test and chi-square analysis was conducted to examine statistical differences. RESULTS: Two hundred and eighty-five patients were included. Forty-two patients underwent reconstruction before the protocol change (Group 1) and 243 patients underwent reconstruction after the protocol change (Group 2). Group 2 had a greater percentage of prepectoral implant placement. There was no difference in demographics, complications, readmission, or reoperation. Within Group 2, 157 patients were discharged the same day (Group 2a) and 88 patients required overnight admission (Group 2b). Group 2b had higher body mass index, higher percentage of bilateral mastectomy, and larger mastectomy weights. Despite no differences in complications, Group 2b exhibited higher rates of requiring intravenous antibiotics and reoperation. CONCLUSIONS: Patients may be safely discharged the same day following mastectomy and alloplastic reconstruction without an increase in complications.

Chest wall depression caused by tissue expander use in breast reconstruction with recoiling following expander removal: a case report.

Background: While the number of implant-based immediate breast reconstructions has increased, two-stage reconstructions still comprise a significant proportion. Some studies have reported chest wall depression (CWD) following tissue expander insertion; however, there have been no reports on chest wall recoiling following expander removal. Here, we present a case of CWD resulting from tissue expander use for breast reconstruction, with subsequent chest wall recoiling following expander removal. Case Description: A 40-year-old woman had previously undergone skin-sparing mastectomy and tissue expander insertion at another hospital 7 months previously. She presented to our institute and complained of pain and restricted shoulder movement, desiring the removal of the tissue expander. A preoperative computed tomography (CT) scan showed CWD on the expander-inserted side; the antero-posterior (AP) length of the right chest wall was 127.2 mm and that of the left side was 150.2 mm. During the surgical procedure, a capsulectomy was performed, followed by the reconstruction of the right breast using a free transverse rectus abdominis myocutaneous flap. The patient exhibited symptom improvement immediately after the surgery and a 12-month follow-up CT scan revealed recoiling of the chest wall (right side, 147.4 mm; left side, 153.7 mm). Conclusions: This case highlights the potential for CWD and recoil following tissue expander use in breast reconstruction. It is essential for surgeons to be aware of this phenomenon and to provide thorough explanations to patients who have undergone expander insertion, particularly those who have received radiation therapy.

Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction.

INTRODUCTION: Pre-pectoral implant-based breast reconstruction (IBR) is becoming increasingly popular, permitting optimal implant positioning on the chest wall, prevention of animation deformity, and reduced patient discomfort. There are, however, concerns related to increased rates of breast implant rippling in pre-pectoral (versus submuscular) IBR, which can prompt a patient to seek revisionary surgery. The aim of this study is to identify factors that can be implemented to reduce implant rippling in the setting of pre-pectoral IBR. METHODS: A literature review was conducted using the PubMed database to determine the rate of rippling in pre-pectoral IBR. Clinical studies in English were included. Further review was then performed to explore technical strategies associated with reduced rates of rippling in pre-pectoral two-stage breast reconstruction. RESULTS: Implant rippling has been reported with a rate varying from 0 to 53.8% in 25 studies of pre-pectoral IBR (including both direct-to-implant and two-stage IBR). The majority of studies reviewed did not demonstrate a significant association between BMI and rippling, suggesting that other factors, likely technical and device-related, contribute to the manifestation of implant rippling. Hence, we explored whether specific technical modifications could be implemented that would reduce the risk of rippling in patients undergoing pre-pectoral IBR. Specifically, we highlight the need for close attention to expansion protocol and pocket dimension, expander fill medium and implant characteristics, and the rationale behind adjunctive procedures to reduce implant rippling. CONCLUSION: Surgical modifications may reduce the incidence of rippling in pre-pectoral breast reconstruction. 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 .

Less is more? One-stage versus two-stage implant-based breast reconstruction: A systematic review and meta-analysis of comparative studies.

BACKGROUND: Most breast reconstructions are implant-based and can be performed either in a one-stage, direct-to-implant or in a two-stage, expander-implant-based reconstruction. The objective of this systematic review is to compare the safety and patient satisfaction of the two reconstruction approaches. METHODS: A literature search was conducted on 27 September 2022 using various databases. Studies comparing one-stage and two-stage implant reconstructions and reporting the following outcomes were included: patient satisfaction, aesthetics, complications, and/or costs. Reviews, case reports, or series with less than 20 patients and letters or comments were excluded. Comparisons were made between the one-stage reconstruction with and without acellular dermal matrix (ADM) and two-stage implant-based breast reconstruction groups. The data extracted from all articles were analysed using random-effects meta-analyses. RESULTS: Of the 1381 records identified, a total of 33 articles were included, representing 21529 patients. There were no significant differences between the one-stage and two-stage groups, except for the costs. The one-stage operation without ADM had lower costs than the two-stage operation without ADM, although the use of an ADM substantially increased the price of the operation to more than a two-stage reconstruction. DISCUSSION: Equal patient satisfaction, aesthetic outcomes, and complication rates with lower costs justify one-stage breast reconstruction in carefully selected patients. This review shows that there is no evidence-based superior surgical approach. Future research should focus on the costs of the ADM versus an additional stage and patient-reported outcomes.

Case Report: Cumulative proton dose reconstruction using CBCT-based synthetic CT for interfraction metallic port variability in breast tissue expanders.

Introduction: Dose perturbation of spot-scanning proton beams passing through a dislocated metallic port (MP) of a breast tissue expander may degrade target dose coverage or deliver excess dose to the ipsilateral lung and heart. The feasibility of utilizing daily cone-beam computed tomography (CBCT)-based synthetic CTs (synCTs) for dose reconstruction was evaluated, and the fractional and cumulative dosimetric impact due to daily MP dislocation is reported. Methods: The synCT was generated by deforming the simulation CT to daily CBCT. The MP structure template was mapped onto all CTs on the basis of daily MP position. Proton treatment plans were generated with two and three fields on the planned CT (pCT, Plan A) and the first verification CT (vCT, Plan B), respectively, for a fractional dose of 1.8 Gy(RBE). Plan A and Plan B were used alternatively, as determined by the daily MP position. The reconstructed fractional doses were calculated with corresponding plans and synCTs, and the cumulative doses were summed with the rigid or deformed fractional doses on pCT and vCT. Results: The planned and reconstructed fractional dose demonstrated a low-dose socket around the planned MP position due to the use of field-specific targets (FSTs). Dose hot spots with >120% of the prescription due to MP dislocation were found behind the planned MP position on most reconstructed fractional doses. The reconstructed cumulative dose shows two low-dose sockets around the two planned MP positions reflecting the two plans used. The doses at the hot spots behind the planned MPs averaged out to 114% of the prescription. The cumulative D95% of the CTV_Chest Wall decreased by up to 2.4% and 4.0%, and the cumulative V20Gy(RBE) of the left lung decreased to 16.1% and 16.8% on pCT and vCT, respectively. The cumulative Dmean of the heart decreased to as low as 0.7 Gy(RBE) on pCT but increased to as high as 1.6 Gy(RBE) on vCT. Conclusion: The robustness of proton plans using FSTs around the magnet in the MP of the tissue expander can be improved by applying multiple fields and plans, which provides forgiveness of dose heterogeneity incurred from dislocation of high-Z materials in this single case.

MRI-Conditional Breast Tissue Expander: First In-Human Multi-Case Assessment of MRI-Related Complications and Image Quality.

This study aims to assess potential complications and effects on the magnetic resonance imaging (MRI) image quality of a new MRI-conditional breast tissue expander (Motiva Flora®) in its first in-human multi-case application. Twenty-four patients with 36 expanders underwent non-contrast breast MRI with T1-weighted, T2-weighted, and diffusion-weighted imaging (DWI) sequences on a 3 T unit before breast tissue expander exchange surgery, being monitored during and after MRI for potential complications. Three board-certified breast radiologists blindly and independently reviewed image quality using a four-level scale ("poor", "sufficient", "good", and "excellent"), with inter-reader reliability being assessed with Kendall's τb. The maximum diameters of RFID-related artifacts on T1-weighted and DWI sequences were compared with the Wilcoxon signed-rank test. All 24 examinations were completed without patient-related or device-related complications. The T1-weighted and T2-weighted sequences of all the examinations had "excellent" image quality and a median 11 mm (IQR 9-12 mm) RFID artifact maximum diameter, significantly lower (p < 0.001) than on the DWI images (median 32.5 mm, IQR 28.5-34.5 mm). DWI quality was rated at least "good" in 63% of the examinations, with strong inter-reader reliability (Kendall's τb 0.837, 95% CI 0.687-0.952). This first in-human study confirms the MRI-conditional profile of this new expander, which does not affect the image quality of T1-weighted and T2-weighted sequences and moderately affects DWI quality.

Perioperative considerations for postpneumonectomy syndrome: A case report.

Postpneumonectomy syndrome is a rare complication of a pneumonectomy. Patients may experience dyspnea, stridor, recurrent pulmonary infections, or dysphagia due to rotation and shift of the mediastinum. The current intervention of choice involves the placement of a tissue expander in the empty hemithorax to realign the mediastinum. Because this treatment can present with intraoperative anesthetic challenges and requires close monitoring, we present this case to highlight specific concerns that may need to be addressed including difficulties ventilating, complete airway collapse, hemodynamic instability, and pain control perioperatively.

Decreasing length of stay in breast reconstruction patients: A national analysis of 2019-2020.

BACKGROUND: The effects of COVID-19 on breast reconstruction included shifts toward alloplastic reconstruction methods to preserve hospital resources and minimize COVID exposures. We examined the effects of COVID-19 on breast reconstruction hospital length of stay (LOS) and subsequent early postoperative complication rates. METHODS: Using the National Surgical Quality Improvement Program, we examined female patients who underwent mastectomy with immediate breast reconstruction from 2019 to 2020. We compared postoperative complications across 2019-2020 for alloplastic and autologous reconstruction patients. We further performed subanalysis of 2020 patients based on LOS. RESULTS: Both alloplastic and autologous reconstruction patients had shorter inpatient stays. Regarding the alloplastic 2019 versus 2020 cohorts, complication rates did not differ (p > 0.05 in all cases). Alloplastic patients in 2020 with longer LOS had more unplanned reoperations (p < 0.001). Regarding autologous patients in 2019 versus 2020, the only complication increasing from 2019 to 2020 was deep surgical site infection (SSI) (2.0% vs. 3.6%, p = 0.024). Autologous patients in 2020 with longer LOS had more unplanned reoperations (p = 0.007). CONCLUSIONS: In 2020, hospital LOS decreased for all breast reconstruction patients with no complication differences in alloplastic patients and a slight increase in SSIs in autologous patients. Shorter LOS may lead to improved satisfaction and lower healthcare costs with low complication risk, and future research should examine the potential relationship between LOS and these outcomes.

Patient and procedure characteristics associated with postoperative pain after prophylactic versus therapeutic ambulatory bilateral breast surgery.

BACKGROUND AND OBJECTIVES: We investigated whether age, body mass index (BMI), and tissue expander placement were related to postoperative opioid requirement for patients undergoing therapeutic versus prophylactic breast surgery. METHODS: Postoperative opioid consumption was evaluated for patients who underwent bilateral mastectomy with immediate implant-based reconstruction at a freestanding ambulatory cancer surgery center between 2016 and 2021. Ordinal regression tested whether surgical indication was associated with increased postoperative opioid requirements after adjusting for age, BMI, and tissue expander placement. RESULTS: Of 2447 patients, 6% underwent prophylactic surgeries. Therapeutic mastectomy patients had lower postoperative opioid requirement (OR = 0.67; 95% CI: 0.50-0.91; p = 0.030), but this was not significant after adjusting for covariates (OR = 0.75; 95% CI: 0.53-1.07; p = 0.2). Opioid use increased with higher BMI (OR = 1.06; 95% CI: 1.05-1.08; p < 0.001) and decreased with age (OR = 0.97; 95% CI: 0.96-0.98; p < 0.001) with therapeutic mastectomy patients being older (median 46 vs. 39). The subpectoral tissue expander group had nearly double the postoperative opioid requirement compared to prepectoral placement (OR = 1.86; 95% CI: 1.55-2.23; p < 0.001). CONCLUSIONS: Increased postoperative opioid requirement in women undergoing prophylactic procedures is best explained by age. Mastectomy patients should be counseled similarly about postoperative pain irrespective of indication. A larger prophylactic mastectomy sample is required to provide more precise estimates.

A modified tissue expander method for ear reconstruction in patients with excessively insufficient postauricular skin.

OBJECTIVE: For microtia patients with excessively insufficient postauricular skin, it is difficult to obtain a satisfied outcome with existing strategies. In this study, we developed a modified tissue expander method for auricular reconstruction. METHODS: The modified tissue expander method divided into 4 stages. In the first stage, a 30 ml or 50 ml kidney-shaped tissue expander was implanted in the mastoid region. A short time expansion (average 33.5 days) was conducted subsequently. In the second stage, the expander was removed and a modified cartilage framework without tragus was inserted through the same incision. A crescent-shaped cartilage pad was inserted into the incision of cartilage-harvest site at the same time. In the third stage, the reconstructed ear was elevated. Lobule rotation and remanent modification were performed in the fourth stage. The patients were followed up between half a year and 10 years. The outcomes of the reconstructed ears were scored with evaluation criteria. RESULTS: From January 2010 to December 2019, a total of 45 microtia patients with excessively insufficient postauricular skin were performed the modified tissue expander method. Fourty-two patients showed satisfied outcomes. Complications such as hyperpigmentation in the skin graft area (3, 6.7%), scar hyperplasia (3, 6.7%) and folliculitis (1, 2.2%) were found. There were no complications related to the tissue expander. CONCLUSION: The modified tissue expander method is an effective and safe technique for auricular reconstruction in patients having excessively insufficient postauricular skin, with satisfying medium-term results.