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Roughly 80% of patients undergoing mastectomy in the United States opt for reconstruction with implants. The introduction of acellular dermal matrices has allowed for placement of breast prostheses in the prepectoral plane, while a new carbon dioxide tissue expander (TE) (AeroForm) allows for needle-free, patient-controlled expansion. These 2 novel technologies have ushered in a new patient-centered era of breast reconstruction, with the possibility of reducing patient morbidity for the first time in decades. We hypothesize that AeroForm expanders placed in the prepectoral plane reduce time to second-stage reconstruction, reduce the number of clinic visits, and have lower complications than traditional saline TEs., Methods: This is a retrospective review of all patients undergoing breast mastectomy and TE placement in the prepectoral plane over a 21-month period (169 patients, 267 breasts), comparing AeroForm expanders to TEs., Results: The AeroForm group (n = 57) had a shorter period to second-stage reconstruction than the TE group (n = 210) (135.4 versus 181.7 days; P = 0.01) and required fewer clinic visits (5.1 versus 6.9; P < 0.01). Partial thickness (25.6% versus 12.3%, P = 0.03) and full thickness (8.7% versus 0.0%, P = 0.02) necrosis were more common in the saline cohort. The rates of infection, hematoma, and seroma requiring drainage were not statistically significant between the 2 groups., Conclusions: Two-staged breast reconstruction with the use of AeroForm expanders in the prepectoral space marks progress in improving care for breast cancer patients by demonstrating a reduction in some adverse events, the number of clinic visits, and the time to second-stage reconstruction., Competing Interests: Disclosure: Dr. Sacks is a former consultant to Allergan, Inc., receives educational research funding from Vioptix, and is Co-Founder of Lifesprout, Inc. Dr. Chopra previously owned stock in AirXpanders Inc. The other authors report no conflicts., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Enhanced recovery after surgery pathways are well established in other surgical specialties but are relatively new in plastic surgery. These guidelines focus on improving patient care by incorporating evidence-based recommendations. Length of stay is shorter, and overall hospital costs are lower without compromising patient satisfaction. When care is standardized, ambiguity is removed and physician acceptance is improved. Yet, implementation can be challenging on an institutional level. The Johns Hopkins microsurgical breast reconstruction team identified areas of dogmatic dissonance during 3 focus groups to formalize an enhanced recovery pathway for microsurgical breast reconstruction. Six microsurgeons used nominal group technique to reach consensus. Four discussion points were identified: multidisciplinary buy-in, venous thromboembolism (VTE) chemophylaxis, early feeding, and dietary restrictions. Evidence-based recommendations and our enhanced recovery after surgery protocol are provided.

Background: Traditionally, tissue expanders (TEs) for breast reconstruction have been placed beneath the pectoralis major muscle with or without acellular dermal matrix. More recently, full acellular dermal matrix coverage has been described for prepectoral TE placement. Our study aims to explore differences in clinical and quality-of-life (QOL) outcomes for prepectoral versus subpectoral TE breast reconstruction., Methods: We identified patients who underwent postmastectomy breast reconstruction with prepectoral or subpectoral TE placement between 2011 and 2015 and completed QOL surveys. Primary outcomes were postoperative pain and QOL scores. Secondary outcomes were clinical outcomes. We used Wilcoxon rank-sum test, chi-square test, and linear regression to compare outcomes. Postoperative follow-up for each patient was at least 60 days, except that of pain scores, which were at least 30 days. Mean age was 49 ± 10 years., Results: Twenty-six prepectoral TE patients and 109 subpectoral TE patients met inclusion criteria. Pain scores were significantly lower at 12 hours, 1 day, 7 days, and 30 days postoperatively for the prepectoral group, compared with the subpectoral group, even after adjusting for confounding variables [PO12H: Sub-Pectoral (SP) median (interquartile range), 7 (5-8), Pre-Pectoral (PP), 5 (2.5-7.5), P value = 0.004; PO1D: SP, 5 (4-6), PP 3 (2-4), P value = < 0.001; PO7D: SP, 2 (0-4), PP, 0 (0-2), P value = 0.004; PO30D: SP, 0 (0-2), PP, 0 (0-0), P value = 0.039)]. Breast-Q scores were not significantly different between study groups. RAND-36 Physical Health scores were lower among prepectoral TE patients., Conclusions: Prepectoral TE breast reconstruction presents an opportunity to improve upon current reconstructive methods and does result in significantly lower pain scores. The associated risks have yet to be fully described and are important considerations, as these prepectoral patients had lower physical health outcome scores., Competing Interests: Disclosure: The Johns Hopkins Department of Plastic Surgery receives research support from LifeCell Corp. (Branchburg, N.J.), and educational support from LifeCell Corp. (Branchburg, N.J.), Integra Lifesciences (Plainsboro, N.J.), and Sientra (Santa Barbara, Calif.). Dr. Justin Sacks is a consultant/speaker for LifeCell. Dr. Rosson has licensed IP to Aegeria Soft Tissue, Inc., which is not related to the subject material of this study. All other authors do not have any financial conflict of interests. The Article Processing Charge was paid for by the authors.

Background: Neoadjuvant radiotherapy (NRT) enhances breast-conserving surgery outcomes, reducing local recurrence of breast cancer and increasing median survival. However, its effect on postoperative morbidity remains under-studied. We sought to assess the impact of NRT on 30-day postoperative morbidity after mastectomy., Methods: We analyzed data from women undergoing mastectomy (with or without immediate reconstruction) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2011 datasets. ACS-NSQIP is a prospective, risk-adjusted, outcomes-based registry. Data included demographic and perioperative factors. Outcomes studied included surgical site (wound and prosthesis/flap complications), systemic (cardiac, respiratory, neurological, urinary, and venous thromboembolism events), and overall morbidity. Logistic regression was used to estimate the unadjusted odds ratio (uOR) and adjusted odds ratio (aOR) between NRT and postoperative 30-day morbidity., Results: The study population included 77,902 women, of which 61,039 (78.4%) underwent mastectomy only and 16,863 (21.6%) underwent mastectomy with immediate breast reconstruction. NRT was administered to 266 (0.4%) mastectomy-only and 75 (0.4%) immediate breast reconstruction patients. In the mastectomy-only group, there were no significant differences in the rates of postoperative surgical site morbidity (aOR = 1.41; 95% confidence interval (CI): 0.76-2.63; P = 0.276), systemic morbidity (aOR = 0.72; 95% CI: 0.40-1.26; P = 0.252), and overall morbidity (aOR = 0.85; 95% CI: 0.54-1.33; P = 0.477) between NRT and control groups. Similarly, no significant differences were found for these three outcomes in the immediate breast reconstruction population. Statistical power for every comparison was >80%., Conclusions: This study suggests that NRT is not associated with significantly higher 30-day postoperative complications among breast cancer patients undergoing mastectomy with or without immediate breast reconstruction.

Background: This study examines the effect of timing (immediate vs delayed) on postoperative morbidity in diabetic women undergoing breast reconstruction after mastectomy., Methods: We reviewed the National Surgical Quality Improvement Program (NSQIP) databases from 2005 to 2012 for all diabetic women undergoing breast reconstruction. Multivariable logistic regression was used to estimate the risk of 30-day overall complications in the immediate versus delayed cohorts. Additionally, we retrospectively reviewed outcomes for all Johns Hopkins Hospital diabetic patients undergoing breast reconstruction from 2005 to 2014., Results: In the NSQIP, 1,408 diabetic women underwent breast reconstruction: 958 (68%) immediate and 450 (32%) delayed. In the immediate group, 10.75% of patients developed a 30-day overall complication, compared with 7.78% of patients in the delayed group. On multivariable analysis, the odds of developing 30-day overall complications were significantly higher (adjusted odds ratio = 1.68; P = 0.033) for the immediate compared with the delayed cohort. In the Johns Hopkins Hospital cohort, 114 reconstructions were performed in 52 diabetic women: 59 (51.8%) immediate and 55 (47.2%) delayed. On long-term follow-up (median = 16.5 months), 41.0% of immediate reconstructions developed a surgical complication compared with 27.8% of delayed reconstructions. Deep infections ( P = 0.026), seroma formation ( P = 0.003), reconstruction failure ( P = 0.001), and reoperation rates ( P = 0.001) were significantly increased in the immediate cohort., Conclusions: Among diabetics seeking breast reconstruction, delaying the reconstructive surgery from the mastectomy is associated with decreased postoperative morbidity. It also appears that the 30-day postoperative time point available in the NSQIP does not fully reflect the magnitude of the long-term complications these diabetic patients will develop.

Introduction: Impaired vascular perfusion in tissue expander (TE) breast reconstruction leads to mastectomy skin necrosis. We investigated factors and costs associated with skin necrosis in postmastectomy breast reconstruction., Methods: Retrospective review of 169 women with immediate TE placement following mastectomy between May 1, 2009 and May 31, 2013 was performed. Patient demographics, comorbidities, intraoperative, and postoperative outcomes were collected. Logistic regression analysis on individual variables was performed to determine the effects of tissue expander fill volume and mastectomy specimen weight on skin necrosis. Billing data was obtained to determine the financial burden associated with necrosis., Results: This study included 253 breast reconstructions with immediate TE placement from 169 women. Skin necrosis occurred in 20 flaps for 15 patients (8.9%). Patients with hypertension had 8 times higher odds of skin necrosis [odd ratio (OR), 8.10, P < 0.001]. Patients with TE intraoperative fill volumes >300 cm(3) had 10 times higher odds of skin necrosis (OR, 10.66, P =0.010). Volumes >400 cm(3) had 15 times higher odds of skin necrosis (OR, 15.56, P = 0.002). Mastectomy specimen weight was correlated with skin necrosis. Specimens >500 g had 10 times higher odds of necrosis and specimens >1000 g had 18 times higher odds of necrosis (OR, 10.03 and OR, 18.43; P =0.003 and P <0.001, respectively). Mastectomy skin necrosis was associated with a 50% increased inpatient charge., Conclusion: Mastectomy flap necrosis is associated with HTN, larger TE volumes and mastectomy specimen weights, resulting in increased inpatient charges. Conservative TE volumes should be considered for patients with hypertension and larger mastectomy specimens.