Aim: The use of three-dimensionally printed (3DP), patient-specific models in autologous breast reconstruction is gaining popularity, namely for their benefits in surgical planning and ability to aid in aesthetic outcomes. Furthermore, 3DP patient-specific models serve as a safe alternative to intraoperative surgical training and act as a useful tool for visualizing the intramuscular course of deep inferior epigastric perforator vessels. Despite demonstrated usefulness in other surgical specialties and areas of plastic surgery, there remains a significant gap in the literature exploring specific perioperative, preoperative, and intraoperative uses as well as the educational advantages of 3DP in autologous breast reconstruction. Methods: PubMed, MEDLINE, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched for all English language articles using specific MeSH terms (3dp OR 3D-print* OR three dimension* print*) AND (breast reconstruction). Only studies discussing the use of 3DP for surgical planning or as an educational tool in autologous breast reconstruction were included. Studies using 3DP as interventions or implants were excluded. Results: A total of 168 articles were identified, 13 of which were selected for inclusion. Risk of bias was low for 8 articles and moderate for 5 articles. Seven (53.8%) articles discussed 3DP usage in preoperative planning. Most papers (12, 92.3%) focused on 3DP models as guides for intraoperative identification of anatomical landmarks and 3DP molds as tools to achieve desired breast volume, shape, and projection. Only 4 (30.7%) articles discussed patient outcomes. Of the 4 (30.7%) articles that discussed education, only one of these properly assessed trainees and faculty using pre- and post-intervention surveys. Conclusion: The majority of 3DP research as an intraoperative guide and educational tool is concentrated outside of autologous breast reconstruction. Studies that do discuss this have found significantly higher success rates in dissecting true DIEP flaps when 3DP vascular modeling is used and can result in improved confidence and competence in surgical training for microsurgical anastomosis. Although 3DP has been shown to aid microsurgeons in preoperative planning, most research concentrates on the aid of this novel technology in dynamic, intraoperative decision making. Existing research has identified five 3DP breast molds, but studies have yet to compare these molds in a controlled setting to assess for superiority in feasibility and outcomes. There is little investigation into the usefulness of 3DP as an educational tool, and more research should be conducted as this methodology expands to cover more forms of autologous breast reconstruction.

An abdominal bulge or hernia is a known complication of harvesting autologous tissue from the abdomen, usually in the context of breast reconstruction. To decrease this risk of abdominal wall complications, it is for some surgeons common practice to prophylactically placing mesh to reinforce the abdominal wall. 1 Leon D.S. Nazerali R. Lee G.K. Using mesh to reinforce the abdominal wall in abdominal free flaps for breast reconstruction: is there a benefit? What are the risks. Ann Plast Surg. 2018; 80: S295-S298https://doi.org/10.1097/SAP.0000000000001468 Crossref PubMed Scopus (6) Google Scholar , 2 Vyas R.M. Dickinson B.P. Fastekjian J.H. Watson J.P. DaLio A.L. Crisera C.A. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg. 2008; 121: 1519-1526https://doi.org/10.1097/PRS.0b013e31816b1458 Crossref PubMed Scopus (134) Google Scholar Even when mesh is placed prophylactically, ∼2–5% of these patients still develop a bulge. 3 (3) (PDF) Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction. 〈https://www.researchgate.net/publication/8076907_Lower_Abdominal_Bulge_After_Deep_Inferior_Epigastric_Perforator_Flap_DIEP_Breast_Reconstruction〉 [Accessed 27 April 2022]. Google Scholar One of the potential etiologies of mesh failure is weakness at the anchor points. The T-Line® Mesh has an integrated mesh suture anchoring system to enhance mesh anchoring and resist mesh failure. Pre-clinical data has shown that the T-Line mesh has 275% increased anchoring strength compared to other products. 4 Wan D.C. Tseng C.Y. Anderson-Dam J. Dalio A.L. Crisera C.A. Festekjian J.H. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg. 2010; 126: 367-374https://doi.org/10.1097/PRS.0b013e3181de1b7e Crossref PubMed Scopus (66) Google Scholar To determine the safety and efficacy of T-Line mesh, either T-Line mesh or standard polypropylene mesh was prophylactically used to reinforce the abdominal wall after abdominally based breast reconstruction.

Breast reconstructive surgery utilizing free tissue transfer has revolutionized the restoration of aesthetic and functional outcomes for patients. Even for the most routine free flap procedures, substantial hospital resources and costs are necessary. The effectiveness of free flap surgery, along with any reconstructive procedure, hinges upon meticulous patient selection, thorough pre-operative planning, well-informed peri-operative decision-making, and diligent post-operative monitoring and care for the patient. This article presents a review of standard clinical care monitoring techniques during the post-operative period, as well as the diverse strategies currently employed for post-operative flap monitoring.

BACKGROUND:Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov.METHODS:Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting.RESULTS:A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87).CONCLUSIONS:A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.

Purpose Autologous breast reconstruction remains a versatile option to produce a natural appearing breast after mastectomy. The deep inferior epigastric perforator remains the most commonly used flap choice, but when this donor site is unsuitable or unavailable, the transverse upper gracilis (TUG) or profunda artery perforator (PAP) flaps are popular secondary alternatives. We conduct a meta-analysis to better understand patient outcomes and adverse events in secondary flap selection in breast reconstruction. Methods A systematic search was conducted on MEDLINE and Embase for all articles published on TUG and/or PAP flaps for oncological breast reconstruction in postmastectomy patients. A proportional meta-analysis was conducted to statistically compare outcomes between PAP and TUG flaps. Results The TUG and PAP flaps were noted to have similar reported rates of success and incidences of hematoma, flap loss, and flap healing ( P > 0.05). The TUG flap was noted to have significantly more vascular complications (venous thrombosis, venous congestion, and arterial thrombosis) than the PAP flap (5.0% vs 0.6%, P < 0.01) and significantly greater rates of unplanned reoperations in the acute postoperative period (4.4% vs 1.8%, P = 0.04). Infection, seroma, fat necrosis, donor healing complications, and rates of additional procedures all exhibited high degree of heterogeneity precluding mathematical synthesis of outcomes across studies. Conclusions Compared with TUG flaps, PAP flaps have fewer vascular complications and fewer unplanned reoperations in the acute postoperative period. There is need for greater homogeneity in reported outcomes between studies to enable for synthesis of other variables important in determining flap success.

PURPOSE: Perioperative tamoxifen practices in microvascular breast reconstruction vary widely. However, no prior literature has investigated this issue from a national standpoint. Thus, this study investigated: (1) the impact of tamoxifen therapy on microvascular flap outcomes using nationwide data, and (2) amongst those on tamoxifen therapy, the impact of perioperative tamoxifen use on flap outcomes. METHODS: This was a retrospective cohort investigation using Truven MarketScan Databases (2014-2017). All women who underwent microvascular breast reconstruction were included; prescriptions claims data was used to identify those on tamoxifen. Outcomes were compared between tamoxifen/non-tamoxifen cohorts. Subgroup analyses in the tamoxifen cohort were undertaken to investigate whether perioperative tamoxifen use impacted outcomes. RESULTS: Overall, 5,832 women were included, of whom 1,983 (34%) were on tamoxifen. There were no differences in flap-related adverse events between tamoxifen and non-tamoxifen cohorts (OR: 1.00; 95%CI: 0.79-1.31; p=0.38). However, amongst patients determined to be at high risk for thrombotic complications, those on tamoxifen therapy had a significantly higher risk of 90-day postoperative venous thromboembolism (OR: 1.15; 95%CI: 1.01-1.28; p=0.04). There were no significant differences in flap failure between those who held tamoxifen versus those who continued tamoxifen into the perioperative period. CONCLUSION: Upon review of national data, preoperative tamoxifen therapy did not significantly increase flap complications/failure after microvascular breast reconstruction. However, patients on tamoxifen therapy with thrombotic risk factors as determined by the Caprini risk score were found to have greater risk for postoperative venous thromboembolism- such patients may need special consideration for postoperative chemoprophylaxis.

Background:Recent literature on autologous breast reconstruction suggests that such factors as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin. Since patient satisfaction with plastic surgery procedures can be largely influenced by beauty standards set by the general public, this study used a novel crowdsourcing method to evaluate laypeople's aesthetic preferences for different bilateral autologous breast reconstructions to determine the relative importance of scar and skin paddle symmetry and preservation of native skin. Methods:Using Amazon's Mechanical Turk crowdsourcing marketplace, participants ranked images of reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect 4 types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR). Results:DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34). Friedman rank sum and pairwise tests showed statistical significance for comparisons of all 4 reconstruction types. Likert ratings were higher for IR than for DA reconstructions for skin quality (P = .002), scar visibility (P < .001), scar position (P < .001), and breast symmetry, shape, and position (P < .001). Ratings increased for all aesthetic factors following nipple-areolar-complex reconstruction (P < .001). Conclusions:More symmetric breast scars were rated aesthetically higher than nonsymmetric scarring, and our participants preferred maintenance of scar symmetry over preservation of native breast skin. These findings are consistent with previous studies that surveyed non-crowdsourced participants, which demonstrates the potential for crowdsourcing to be used to better understand the general public's preferences in plastic surgery.

Background Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov. Methods Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting. Results A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87). Conclusions A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.

Background: Direct-to-implant breast reconstruction is an attractive choice for appropriately selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value health care, therefore, it is important to investigate use of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis. Methods: This was a retrospective investigation of direct-to-implant reconstruction between 2010 and 2018 in the United States, using the National Inpatient Sample database. All study analyses were undertaken using Stata version 15.0. Results: The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010 and 2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures increased significantly ( P = 0.03), relative to staged and delayed implant-based procedures. Although direct-to-implant patients were younger and more likely to be White and privately insured, the proportion of non-White, publicly insured patients undergoing direct-to-implant reconstruction increased significantly by 2018 ( P < 0.05). Furthermore, direct-to-implant use among Medicaid patients was 2.2 times the rate in Medicaid expansion states compared with nonexpansion states. Direct-to-implant patients had significantly higher All Patient Refined Diagnosis Related Group risk scores in 2018 than in 2010 ( P = 0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures ( P = 0.03), when considering expander placement and expander-to-implant exchange. Conclusions: Overall, use of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: Open access publishing in plastic surgery has rapidly gained traction in the past decade. This study investigated the digital landscape of plastic surgery open access publishing. Methods: This was a cross-sectional bibliometric investigation of plastic surgery-focused journals. Three publication models were investigated: subscription-only journals, hybrid journals offering both paywalled and open access publishing, and open access-only journals. Results: Eighty-two journals were investigated. In 2010, open access journals comprised 18 percent of all plastic surgery journals online, subscription journals comprised 79 percent, and hybrid journals comprised 3 percent. Conversely, in 2020, open access journals comprised 55 percent of all journals, hybrid journals comprised 45 percent, and there were no subscription-only journals. Multivariable linear regression adjusting for article type/content demonstrated that open access articles from hybrid journals [beta coefficient, 1.3; F(4, 18) = 790; p = 0.05] and high-quality open access journals [beta coefficient, 0.9; F(4, 19) = 738; p = 0.04] were significantly positively associated with number of full-text views. Although impact factor and article processing charges were positively correlated [Pearson correlation coefficient: r(25) = 0.39, p = 0.04] for open access publishing, some high-quality open access journals were found to offer fee waivers/free publishing. Lastly, level of evidence offered by articles from open access versus hybrid journals differed. Conclusions: Overall, this study highlighted important distinctions between trustworthy and predatory journals offering open access publishing in plastic surgery. Open access publishing in trustworthy sources offers greater visibility and is not necessarily cost-prohibitive, but some open access journals can be limited in scope (i.e., less coverage of subspecialty topics) and quality of content. Study findings were used to generate recommendations for navigating open access publishing in plastic surgery.

BACKGROUND:Traditionally, saline is used for intraoperative/postoperative expansion in two-stage alloplastic breast reconstruction. Recently, intraoperative expansion with air has been proposed, to reduce pressure on the mastectomy skin flap in the immediate postoperative setting. The authors examined whether the intraoperative tissue expansion medium (i.e., air versus saline) affected postmastectomy complications in two-stage prepectoral reconstruction.METHODS:This was a retrospective cohort study of 87 patients (144 breasts) undergoing prepectoral breast reconstruction at the authors' institution. Patient data were abstracted from medical records. Stepwise, multivariable-adjusted logistic regression using robust variances was used to identify predictors of postmastectomy complications. Statistical and power analyses were completed.RESULTS:Of the 87 study patients, 29 (33.3 percent) received intraoperative saline fill and 58 (66.7 percent) received air fill. Demographic/clinical data were well-matched between cohorts. Median follow-up was 165 days, and average patient age was 46.7 years. Initial tissue expander fill volumes were similar between study cohorts ( p = 0.2). The crude association between air versus saline fill on overall complication rates suggested that air-filled tissue expanders may be protective (OR = 0.4; p = 0.03), and the suggested protective effect was maintained with borderline significance even after potential confounders (i.e., American Society of Anesthesiologists class III or higher, body mass index, diabetes, mastectomy specimen weight, smoking status) were added to the model (OR = 0.4; p = 0.05). In addition, fewer complications requiring salvage reoperation were observed with air-filled tissue expanders (adjusted OR = 0.3; p = 0.02).CONCLUSIONS:The medium used for immediate intraoperative tissue expansion impacted postmastectomy outcomes in patients undergoing two-stage prepectoral breast reconstruction. The results demonstrated that air-filled tissue expanders were associated with fewer postoperative complications/salvage reoperations relative to saline-filled tissue expanders.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

Background: Textured tissue expanders (TTEs) were introduced to limit migration and reduce capsular contracture, which were inherent to smooth tissue expanders (STEs). Previous reports suggest that textured devices have increased rates of bacterial contamination and biofilm formation in comparison with smooth devices. Recently, the relative increased association of anaplastic large cell lymphoma (ALCL) with textured versus smooth devices has led to increased adoption of smooth devices. The aim of our study is to evaluate the post-operative surgical site infection (SSI) rates of STEs versus TTEs. Methods: A retrospective case series was conducted at a single academic teaching hospital from April 2016 to December 2019. The primary outcome variable was the development of a post-operative SSI. Results: One hundred seventy-seven breasts underwent reconstruction with TTEs and 109 breasts underwent reconstruction with STE. In total, 54 SSIs were recorded (n = 34 TTE; n = 20 STE), with the majority of infections occurring within the first 30 post-operative days (TTE 65%, STE 70%). There was no statistically significant difference in overall post-operative infection rates between TTE and STE groups when broken down into the following time points: <30 day, 30-60 days, and >90 days (p = 0.924). There was no statistically significant difference between infection type (superficial vs. deep, p = 0.932), infection management (medical, surgical, or both, p = 0.409) or salvage results (p = 0.078) seen in STE versus TTE cohort. On multivariate analysis, seroma history was associated with SSI development (OR 3.18, p = 0.041). Conclusion: There was no significant difference in the rate of post-operative SSI following breast reconstruction with STE relative to TTE. (c) 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background Abdominal flaps and latissimus dorsi flaps can be used to provide soft tissue coverage and recreate the breast mound following breast conservation therapy (BCT), which consists of lumpectomy and radiation. This study compares complication rates and the need for revision surgery between the two flap groups. Methods This study retrospectively reviewed charts for all patients who underwent BCT and presented for delayed partial breast reconstruction with either a free abdominal flap (MS-TRAM, DIEP, SIEA) or pedicled latissimus dorsi flap at our institution between January 2005 and August 2017. Charts were reviewed for basic demographics, comorbidities, oncologic data, postoperative complication incidence, and whether patients underwent revisionary surgery. Results A total of 21 patients met inclusion criteria, which included 12 latissimus (LD) and 9 abdominal (Abd) flap-based reconstructions. Demographics and comorbidities were similar between cohorts. Overall complication rates were similar between groups for both recipient site (LD: 16.7%, Abd: 22.2%; p = 0.748) and donor site (LD: 8.3%, Abd: 0.0%; p = 0.375). Overall rates of revisionary surgery were also similar in both groups (p = 0.445). Mean follow-up time was similar between the two cohorts (p = 0.227). Conclusions The flap choice in partial reconstruction is multi-factorial and is based largely upon surgeon experience, surgeon and patient preference, and body habitus. Our study shows that both abdominal flaps and the latissimus dorsi flap are able to reconstruct partial mastectomy defects with relatively low and comparable complication rates. Revision rates are similar between the autologous flap options as well. Level of evidence: Level IV, Therapeutic.

Background: Breast cancer resulting from a genetic mutations, such as BRCA1 or BRCA2 , is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures. Methods: The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals. Results: Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p = 0.02). Patients undergoing tissue expander–based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days; p < 0.001). Conclusions: The authors’ data indicate that combining breast and ovarian operations is associated with a higher risk of postoperative complications related to the breast procedure and increases the duration of hospital stay in patients with tissue expander–based reconstructions. The authors’ study provides valuable information for preoperative counseling of patients considering both breast and ovarian surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Introduction Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions. Methods Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions. Results Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034). Conclusions Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

BACKGROUND:Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane.METHODS:A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications.RESULTS:A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870).CONCLUSIONS:Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

Background: Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure. Methods: We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions. Results: Complication rates were lower when fat grafting was performed during the second stage (p= 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008). Conclusions: These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries. (C) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated. Methods We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88). Results Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications. Conclusions Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.

To have met inclusion criteria, the patient must have undergone delayed breast reconstruction without having had any prior breast reconstruction The transverse rectus abdominis Muscle (TRAM) flap was used in 2 breasts, and the muscle-sparing TRAM flap was used in 6 breasts (Table 1) Dear Sir, We thank Mantelakis et al [[1]] for their interest in our article Delayed, two-staged autologous breast reconstruction: an approach to improving delayed reconstructive outcomes [[2]] [Extracted from the article] Copyright of European Journal of Plastic Surgery is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Introduction Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts. Methods Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected. Results A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069). Conclusions When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.