Background:The purpose of this study was to assess the utility of the BREAST-Q in identifying patients with persistent postmastectomy pain (PPMP) and to determine predictors of pain among a large reconstructive cohort. Methods:We retrospectively reviewed BREAST-Q physical well-being of the chest (PWBC) scores for patients who underwent breast reconstruction from 2010-2023. PPMP was defined by an International Classification of Diseases diagnosis of pain 3 months to 2 years after mastectomy. Linear regression modeled the association between PWBC score and PPMP, and separately modeled associations with demographic and clinical covariates. Multivariable linear mixed-effects regression was used to analyze PWBC scores over time. Results:A total of 6988 patients (implant N = 5466; autologous N = 1522) had at least 1 PWBC score preoperatively or 1-5 years postoperatively. PPMP (3.2% of patients) was associated with a lower PWBC score (β = -14, P < 0.001). Factors associated with greater odds of PPMP were marital status, number of psychiatric diagnoses, chemotherapy, and radiation. At 1-2 years postoperatively, factors associated with a lower PWBC score included Asian race, Hispanic ethnicity, radiation, and axillary lymph node dissection. Autologous reconstruction demonstrated more favorable long-term PWBC scores compared with implant-based reconstruction. Conclusions:PPMP was associated with worse PWBC scores. Radiation was the only common predictor of both PPMP and PWBC scores. This correlation, along with differences in predictors, suggests that the BREAST-Q captures some, but not all, elements of postmastectomy pain. Additional validated measures are needed to measure chronic postoperative pain in the breast cancer population.

BACKGROUND:Federal price transparency regulations require disclosure of negotiated commercial prices, but whether these policies improve affordability for reconstructive surgery remains uncertain. We evaluated post-regulation changes in negotiated prices, price convergence, price variation, and overall inflation-adjusted price levels. STUDY DESIGN:Retrospective longitudinal observational study of nationwide hospital price transparency data (December 2021-June 2024). Facility rates for 125 reconstructive surgery CPT codes were linked across 403 hospitals, 51 core-based statistical areas, and four national commercial insurers, yielding 496,868 observations and 16,028 negotiated rate groups. Annualized real rate change (ARRC) was modeled using linear mixed-effects regression with hospitals nested within geographic markets, adjusting for initial within-market price percentile, service category, payer, and market structure. RESULTS:Prices converged in 677 of 886 local markets (76.4%), with the gap between high- and low-priced hospitals narrowing by 13.4 percentage points annually. Overall inflation-adjusted negotiated prices remained stable (ARRC intercept -0.012; p=0.289). Price dispersion showed no robust directional change. Greater convergence was observed among initially higher-priced hospitals, with significant variation by payer and service category but not market structure. Hospital-level heterogeneity explained substantially more variance than measured covariates (conditional R² 0.577; marginal R² 0.132; hospital ICC 0.326). Convergence remained consistent across multiple sensitivity analyses. CONCLUSIONS:Following implementation of price transparency regulations, negotiated prices for reconstructive surgery services converged between high- and low-priced hospitals without meaningful changes in overall inflation-adjusted price levels or price variation. These findings suggest that transparency alone is unlikely to improve affordability and should be complemented by additional policy strategies targeting healthcare costs.

BACKGROUND:The objectives of this study were to determine if financial considerations affect reconstructive decision-making, and conversely if reconstructive choice affects downstream financial burden. METHODS:We conducted mixed-methods study with a convergent design. Patients undergoing mastectomy with or without reconstruction were administered the Comprehensive Score for Financial Toxicity (COST) questionnaire before and after surgical treatment, where COST ≤20 indicated financial toxicity (FT). Multivariable regression models were used to identify predictors of FT and changes in COST score. Additionally, we conducted semi-structured interviews with patients who screened positive for FT to comprehensively capture experiences with financial burden. RESULTS:There were 1,029 patients with a COST score prior to mastectomy, with a 30.6% rate of FT. Significant predictors of FT included age (OR 0.97), race (Asian OR 2.12, Black OR 2.66, compared to White), marital status (divorced/separated OR 2.70, single OR 2.43, compared to partnered), and neighborhood-level socioeconomic deprivation (OR 1.15) (p<0.02). Receipt of reconstruction was not significantly associated with baseline FT, nor were type and timing among those who underwent reconstruction (N=739). Additionally, receipt, type, and/or timing of reconstruction were not significantly associated with a change in COST score (full cohort N=446, reconstruction cohort N=297). Interviews yielded 3 themes: prioritizing outcomes over financial implications, difficulties navigating and maintaining insurance coverage, and a need for greater transparency and access to financial resources. CONCLUSION:Bidirectional relationships between FT and receipt, type, and timing of reconstruction did not reach statistical significance. Additional patient-centric financial navigation and price transparency are warranted to mitigate financial burden.

INTRODUCTION:Acellular dermal matrix (ADM) is frequently used in two-stage prepectoral breast reconstruction; however, concerns persist regarding increased infection rates with its use and overall benefits. This randomized controlled trial evaluated whether ADM in prepectoral reconstruction is noninferior to the alternative of no ADM with regard to major postoperative complications. METHODS:In this single-center, cluster-randomized noninferiority trial, 368 patients (623 breasts) undergoing two-stage prepectoral reconstruction were assigned to ADM or no ADM groups. The primary endpoint was the proportion of breasts with at least one major complication (infection, reoperation, or explantation) within 90 days. Noninferiority was defined as the upper bound of the one-sided 95% confidence interval (CI) for the difference in complication rates (with ADM minus no ADM) being less than the pre-specified margin of 7%. Secondary outcomes included minor complications, BREAST-Q scores, and pain. RESULTS:Major complications were similar between groups (ADM: 13.2% vs. no ADM: 13.1%; one-sided 95% CI upper bound below 7%), confirming noninferiority. Minor complications, including seroma (ADM: 20%, no ADM: 27.4%; p=0.056) showed no significant difference. BREAST-Q scores were comparable at 30 (ADM: 60, no ADM: 55; p=0.2) and 90 days (76 in both groups; p=0.3). Postoperative pain was similar between groups. CONCLUSION:Two-stage prepectoral breast reconstruction with ADM was noninferior to reconstruction without ADM regarding major 90-day postoperative complications, with comparable minor complications, patient-reported outcomes, and pain. These findings support the routine use of ADM as a safe option. Long-term follow-up comparing relevant clinical outcomes is needed to clarify the benefits of ADM.Trial Registration: Clinicaltrials.gov NCT05316324.

BACKGROUND:Peripheral nerve block (PNB) use in breast reconstruction (BR) improves postoperative pain with minimal risks. This study examines outcomes of patients receiving PNB for postoperative analgesia in BR. METHODS:A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database identified women who underwent BR from 2012 to 2021. Patients who received regional anesthesia in addition to general anesthesia were included, and those who received other forms of anesthesia were excluded. Postoperative complications were compared between PNB and non-PNB groups, as well as among BR timing, modality, operative time, and American Society of Anesthesiologists classification. Group differences were assessed using t tests and Fisher exact tests. Multivariate logistic regression assessed whether complications were independently associated with receiving PNBs. RESULTS:Of the 25,188 patients, 9429 patients (37.4%) received PNBs for perioperative BR analgesia. Patients who received PNBs had longer operative times and more wound complications, reoperations, and readmissions. PNB use was associated with an increased likelihood of surgical site infection even when BR modality, timing, operative time, and American Society of Anesthesiologists classification were isolated ( P < 0.05). Further, subgroup analysis revealed that PNB use was associated with surgical site infection for all BR modalities and timing. CONCLUSIONS:The decision to use PNBs in BR should be made with awareness of the associated risk of increased wound complications. Despite this, benefits of PNBs may still very well outweigh these risks for all our patients. However, based on our findings, we still suggest increased surveillance and more comprehensive consultation. Further research into the association of PNB use and wound complications should be performed so that our patients can obtain maximal benefit and minimize unwanted side effects.

Breast cancer-related lymphedema (BCRL) is a common and debilitating sequela of axillary lymph node dissection (ALND). Although machine learning (ML)-based prediction models have been proposed, few focus exclusively on patients undergoing ALND, and direct comparisons with traditional statistical models remain limited. This study aimed to develop accurate and clinically feasible prediction models for BCRL using supervised ML and multivariable logistic regression. Demographic and clinical data were prospectively collected from women undergoing unilateral ALND for breast cancer at Memorial Sloan Kettering Cancer Center between 2016 and 2024. Supervised ML and multivariable logistic regression models to predict BCRL were trained and internally validated. Model performance was evaluated using area under the receiver operator characteristic curve (AUC), accuracy, sensitivity, specificity, and Brier score. Shapley additive explanations were used for model interpretability. A total of 474 eligible patients were included. BCRL developed in 113 (23.8

OBJECTIVES:Cancer imposes a significant economic burden on the US healthcare system and its patients. We quantified changes in price levels and variation for oncologic services after federal price transparency regulations and evaluated whether the prevalence and granularity of disclosures were associated with these changes. METHODS:This retrospective longitudinal study used nationwide hospital price transparency data from December 2021 to June 2024. The data set included billing codes across 4 oncology service categories (inpatient, chemotherapy administration, radiation, and surgery). A linear mixed-effects model evaluated the annualized real rate change (ARRC) as a function of local market-specific percentile price rank, transparency measures, service category, payer, market structure, and health system. RESULTS:Data were extracted for 89 billing codes from 228 hospitals, yielding 11 290 negotiated rate groups and 349 990 monthly observations. Each 10-percentage-point increase in code-level transparency was associated with a 0.82-percentage-point decrease in ARRC (P < .001). Within local markets, hospitals in initially low- or high-price deciles demonstrated inflation-adjusted price increases and decreases, respectively, with a -21.2 percentage point ARRC differential between the lowest and highest rates (P < .001). Price changes and convergence varied by service category, payer, and hospital size (P < .05). Price dispersion declined over time (P < .01). CONCLUSIONS:After federal price transparency regulations, markets with greater code-level transparency experienced larger price reductions, and prices converged as variation between high- and low-priced hospitals declined. These findings suggest transparency may promote more efficient and affordable cancer care, although the overall impact on spending and access remains uncertain.

Background and Objective:Venous thromboembolism (VTE) remains a leading cause of preventable morbidity and mortality in surgical patients, with individuals undergoing abdominal-based free flap breast reconstruction representing a particularly high-risk group. Despite the widespread use of risk assessment tools such as the Caprini Risk Assessment Model (RAM), prophylaxis strategies remain inconsistent across institutions. This literature review aims to synthesize current literature on VTE incidence, risk stratification, and chemoprophylaxis in abdominal-based free flap breast reconstruction to identify best practices and areas for future research. Methods:A narrative review of the literature was performed, focusing on studies evaluating VTE incidence, prevention strategies, and outcomes in patients undergoing abdominal-based autologous breast reconstruction. Emphasis was placed on risk stratification models, pharmacologic and mechanical prophylaxis, and the timing, dosing, and duration of anticoagulation regimens. Key Content and Findings:Validated tools such as the Caprini RAM effectively stratify surgical patients by VTE risk; however, specific recommendations for abdominal-based reconstruction are lacking. Extended-duration prophylaxis appears beneficial in high-risk patients, with recent studies supporting preoperative initiation. Despite concerns about flap loss or hematoma, evidence suggests that appropriately dosed chemoprophylaxis does not significantly increase complications. Oral agents like apixaban show promise for improving adherence without increased bleeding risk. The majority of VTE events occur after discharge, supporting the rationale for outpatient prophylaxis. Future directions include machine learning-enhanced risk prediction and multicenter trials to standardize prophylaxis. Conclusions:Patients undergoing abdominal-based breast reconstruction face substantial VTE risk, and tailored chemoprophylaxis is essential. While current evidence supports individualized risk-based strategies, practice variability underscores the need for a standardized chemoprophylaxis algorithm. Future prospective studies are critical to establish optimal prophylaxis regimens, timing, and duration in this high-risk surgical population.

Breast cancer-related lymphedema (BCRL) is commonly diagnosed using limb volume criteria; however, diagnostic thresholds vary and lack empirical validation. This variability may lead to underdiagnosis, particularly in patients using compression garments that can reduce limb size. This study evaluated how different diagnostic criteria and compression therapy influence the reported incidence of BCRL. A single-institution analysis was conducted on 165 female patients with breast cancer originally enrolled in a randomized controlled trial comparing axillary lymph node dissection with and without immediate lymphatic reconstruction from 2020 to 2025. Limb volumes were measured preoperatively and at 12, 18, and 24 months postoperatively. BCRL incidence was assessed using 5

BACKGROUND:Infection is a major complication of implant-based breast reconstruction (IBBR), leading to implant loss, increased healthcare costs, and poor outcomes. Local antibiotic delivery systems offer targeted infection prevention by providing sustained antibiotic release at the surgical site. The aim of this study is to review the existing literature on the efficacy of local antibiotic delivery systems in preventing infection in IBBR. METHODS:A systematic review following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was conducted in Medline, Cochrane, and Embase (1990-2025). Studies assessing local antibiotic delivery in IBBR were included, while those evaluating systemic antibiotics, augmentation, and salvage procedures were excluded. Data on infection rates, implant loss, and complications were extracted and analyzed. RESULTS:Of 163 identified articles, 6 met inclusion criteria. Two studies examined calcium sulfate biodegradable antibiotic beads, which significantly lower implant loss rates (1.6% vs 9.4%, P = 0.031 and 1.5% vs 11.9%, P = 0.024). Two studies on polymethylmethacrylate antibiotic plates showed significant SSI reduction from 12.6% to 4.8% ( P < 0.01) and from 14% to 4% ( P = 0.047), with implant loss rates significantly lower in polymethylmethacrylate cohort (6% vs 18%, P = 0.036). Continuous postoperative antibiotic irrigation studies demonstrated SSI reduction from 6.4% to 1.9% ( P = 0.007) and decreased explant rate from 20% to 2.9% ( P = 0.037), but one study reported a higher seroma rate (4.7% vs 1.4%, P = 0.033). CONCLUSIONS:Preliminary studies suggest local antibiotic delivery may reduce infection and implant loss in breast reconstruction, but retrospective designs and methodological limitations preclude definitive conclusions. Prospective studies are needed to confirm efficacy, safety, and clinical value.

BACKGROUND:Patients diagnosed with having the breast cancer gene ( BRCA1 or BRCA2 ) face a critical choice between prophylactic mastectomy and serial surveillance screening. This study aimed to evaluate the cost effectiveness of prophylactic mastectomy with autologous reconstruction compared with surveillance strategies for this patient population. METHODS:Markov chain Monte Carlo simulations comprising 100,000 patients were used. All models assumed a baseline of women aged 25 years with BRCA1 or BRCA2 mutations. In the standard-of-care model, patients underwent annual screening (magnetic resonance imaging plus mammography) until age 75 years. Positive screenings led to mastectomy followed by 2-stage breast reconstruction using tissue expanders and implants. This approach was compared with prophylactic mastectomy with autologous flap reconstruction (free transverse rectus abdominis myocutaneous, gluteal, thigh, or deep inferior epigastric perforator [DIEP] flaps) at ages 30, 35, or 40 years. Evaluation parameters included cost, quality of life, and incremental cost-effectiveness ratios. RESULTS:The incremental cost-effectiveness ratios of all autologous flaps were below the willingness-to-pay threshold of $50,000, suggesting cost effectiveness, with DIEP flaps being the lowest. Prophylactic mastectomy with autologous reconstruction was more cost effective for BRCA1 patients than for BRCA2 patients, and sensitivity analysis revealed that prophylaxis became cost effective earliest for DIEP flaps (ages 50 to 63 years) and latest for gluteal flaps (ages 58 to 73 years). CONCLUSIONS:Prophylactic mastectomy with autologous reconstruction performed at ages 30, 35 or 40 years, was found to be a cost-effective alternative to breast cancer surveillance and disease treatment in women with BRCA1/2 mutations. DIEP and free transverse rectus abdominis myocutaneous flaps were the most cost-effective techniques, and prophylaxis was more cost effective in BRCA1 patients than in BRCA2 patients.

BACKGROUND:Tissue expanders used in breast reconstruction can be placed in a complete submuscular, partial submuscular, or prepectoral plane. Comparative studies assessing the relationship between plane placement, infection risk, and patient-reported outcomes (PROs) remain limited. The authors hypothesize that decreasing muscle coverage is associated with higher infection risk but more favorable PROs. METHODS:In this retrospective analysis of patients who underwent immediate breast reconstruction with TE placement between 2017 and 2023, patients were grouped into complete submuscular, partial submuscular with acellular dermal matrix, or prepectoral groups. Postoperative complications and BREAST-Q Physical Well-Being of the Chest (PWBC) were evaluated before second-stage reconstruction. RESULTS:A total of 3707 patients were included. Prepectoral placement had a higher incidence of surgical-site infection (9.1%) compared with complete submuscular (3.1%) or partial submuscular (7.1%) placement ( P < 0.001). Prepectoral reconstruction was associated with increased odds of infection (OR 2.64 [95% CI, 1.72 to 4.06]; P < 0.001) compared with complete submuscular reconstruction. However, patients with prepectoral reconstruction had higher PWBC scores (median, 76) than patients with complete or partial submuscular reconstruction (median, 72). Prepectoral reconstruction (β = 3 [95% CI, 2.0 to 4.1]; P < 0.001) and partial submuscular reconstruction (β = 1.6 [95% CI, 0.1 to 3.1]; P = 0.037) were associated with higher PWBC scores at 6 months compared with complete submuscular reconstruction. CONCLUSIONS:With decreasing muscle coverage, patients with tissue expander reconstruction were more likely to develop infection and less likely to have unfavorable PWBC scores. The choice among prepectoral, partial submuscular, or complete submuscular reconstruction should balance the risk of infection with PROs. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.