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Purpose: Estimating resection weight for patients undergoing reduction mammoplasty (RM) informs surgical planning and outcomes. Existing formulas have limitations that make insurance coverage and accurate surgical planning challenging. We identified the most commonly used scales to evaluate their accuracy in estimating resection weight by applying them to a database of patients to compare calculated and actual resection weights., Methods: A database search was conducted using combinations of relevant terms. A regression analysis was conducted using formulas with strong R2 values (0.72-0.93) on a cohort of 1128 RM patients at a single institution., Results: A total of 570 articles were identified. Fourteen manuscripts (n = 2232 patients [3320 breasts]) were ultimately included for review. Data on incisional patterns, pedicle supply, and breast measurements, such as sternal notch to nipple distance (n = 8 [57.1%]) or nipple to inframammary fold distance (n = 5 [35.7%]), were recorded. R2 values in our cohort (>500 g, n = 891; <500 g, n = 237) were calculated via regression analyses with five formulas: Appel (0.391 vs 0.146), Boukovalas (0.3552 vs 0.043), Descamps (0.391 vs 0.238), Eder (0.328 vs 0.114), and Kocak (0.3283 vs R2 indeterminate)., Conclusions: Our analysis suggests that formulas reporting strong R2 values may have resulted from tailoring to surgeons' technique. Variation between cohorts is inevitable; however, we expect reliable results given our large sample. It is reasonable to conclude that existing formulas are not accurate representations of resection weights and thus are unreliable for surgical planning., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Autologous breast reconstruction confers favorable patient reports of satisfaction and quality of life compared with implant-based reconstruction over a lifetime. The latissimus dorsi with immediate fat transfer (LIFT) is an alternative approach to abdominally based free flaps (Ab-FF), which expands fully autologous reconstruction to nonmicrosurgeons. This study compared the 2 procedures concerning their clinical and patient-reported outcomes 1 year postoperatively., Methods: The authors conducted a retrospective review of LIFTs and Ab-FFs performed between March of 2017 and August of 2022. The primary outcomes were postoperative complications, reoperations, and longitudinal BREAST-Q scores. BREAST-Q modules included Satisfaction with Breasts, Satisfaction with Abdomen, Satisfaction with Back, Psychosocial Well-being, Physical Well-being: Chest, Physical Well-being: Abdomen, Physical Well-being: Back, and Sexual Well-being., Results: Of the 281 included patients (408 breasts), 211 received Ab-FF and 70 received LIFT. One-year follow-up (median [interquartile range], 12 [12] months) demonstrated that Ab-FF independently predicted dehiscence, reoperation procedures, and revisional surgery. LIFT independently increased the odds of seroma. Obesity predicted dehiscence, and bilateral reconstructions predicted revisional fat grafting. BREAST-Q scores fluctuated over time but were similar across all measured domains by 1 year postoperatively., Conclusions: Although Ab-FF is the standard approach for fully autologous reconstruction, LIFT procedures may be associated with a less complicated postoperative course while eliciting similar patient-reported outcomes. LIFT may be preferred to limit postoperative complications, particularly in patients with obesity. LIFT can be used by plastic surgeons who are not trained in microsurgical procedures or do not have an environment that fosters Ab-FF., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections., Methods: We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact., Results: Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species . The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO 2 and direct costs by $7.84 per item., Conclusions: The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction., Competing Interests: Financial Disclosure Statement: Dr. Song receives royalties from Elsevier. The remaining authors have no financial disclosures, commercial associations, or other conditions posing a conflict of interest to report. Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Few studies compared the use of the deep venous system alone versus combined superficial and deep venous drainage in deep inferior epigastric perforator (DIEP) flaps. The objective of this study was to compare DIEP flap breast reconstruction using either the deep venous system alone versus dual-system venous drainage and to propose an algorithm for flap design and orientation and vein selection to facilitate consistent use of dual-system venous drainage., Methods: Patients undergoing DIEP flap breast reconstruction between March of 2017 and April of 2021 were reviewed retrospectively. Flaps were divided into 2 groups: deep venous system only (group 1) or dual system (group 2). Outcomes included take-back to the operating room, flap loss and thrombosis, and operative time., Results: A total of 244 DIEP flaps in 162 patients met inclusion criteria. A total of 130 flaps were included in group 1 (53.3%) and 114 flaps were included in group 2 (46.7%). Sixteen flaps (6.6%) required immediate take-back to the operating room, and take-back rates were not significantly different between groups ( P = 0.606). The flap loss rate was significantly higher in group 1 at 2.5% versus group 2 at 0% ( P = 0.031). Flap thrombosis occurred in 8 flaps (3.3%) and tended to occur more frequently in group 1, but this finding did not reach significance (group 1, 5.4%; group 2, 0.9%; P = 0.071)., Conclusions: The use of dual-system venous drainage in DIEP flap breast reconstruction decreases the rate of flap loss. The authors' algorithm can be used to guide selection of flap laterality, rotation, and veins and recipient vessels to facilitate routine use of dual-system venous drainage., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Although nipple-sparing mastectomy (NSM) and immediate breast reconstruction (IBR) have long been praised for excellent cosmetic results and the resultant psychosocial benefits, the feasibility and safety of these procedures in patients older than 60 years have yet to be demonstrated in a large population., Methods: Patients undergoing NSM with or without IBR at the MedStar Georgetown University Hospital between 1998 and 2017 were included. Patient demographics, surgical intervention, and complication and recurrence events were retrieved from electronic medical records. Primary outcomes were recurrence and complication rates by age groups older and younger than 60 years., Results: There were 673 breasts from 397 patients; 58 (8.6%) older than 60 years and 615 (91.4%) younger than 60 years with mean follow-up of 5.43 (0.12) years. The mean age for those older than 60 was 63.9 (3.3) years, whereas that for those younger than 60 was 43.1 (7.9) years (P < 0.001). The older than 60 group had significantly higher prevalence of diabetes, rates of therapeutic (vs prophylactic) and unilateral (vs bilateral) NSM, and mastectomy weight. However, there were no significant differences by age group in complication rates or increased risk of locoregional or distant recurrence with age., Conclusions: Based on similar complication profiles in both age groups, we demonstrate safety and feasibility of both NSM and IBR in the aging population. Despite increased age and comorbidity status, appropriately selected older women were able to achieve similar outcomes to younger women undergoing NSM with or without IBR., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Nipple-sparing mastectomy (NSM) offers improved, patient-centered outcomes with demonstrated oncologic safety ( Ann Surg Oncol 2020;27:344-351). Indications for NSM continue to expand to patients outside of the traditional eligibility criteria, including those with prior breast-conserving therapy (BCT) with radiotherapy. Currently, limited data exist evaluating both short- and long-term outcomes in patients proceeding to NSM after prior BCT., Methods: All patients undergoing bilateral NSM in a single institution from 2002 through 2017 with history of prior BCT were included in the final cohort, without exclusions. A retrospective chart review was performed to identify patient demographics, operative details, and complications. Outcomes assessed included early complications (<30 days from NSM), late complications (>30 days), rates of prosthetic failure, unplanned reoperations, and reconstructive failures, as well as oncologic safety. Student t , χ 2 , and Fisher exact tests were used to analyze outcomes of paired (BCT vs non-BCT) breasts within each patient., Results: A total of 17 patients undergoing 34 NSMs were included. Each had a history of BCT and either ipsilateral breast recurrence (64.7%), risk-reducing NSM (23.5%), or a new contralateral primary cancer (11.8%). The cohort had a mean age of 51.1 years. With regard to acute complications (ischemia, infection, nipple-areolar complex or flap ischemia or necrosis, and wound dehiscence), there was no significant difference noted between breasts with prior BCT versus no prior BCT overall (41.2% vs 35.3%, respectively; P = 0.724). Complications occurring after 30 days postoperatively (capsular contracture, contour abnormality, animation deformity, bottoming out, rotation, and rippling) in prior BCT breasts versus no prior BCT had no significant differences overall (58.8% vs 41.2% respectively; P = 0.303). The mean follow-up was 5.5 years, during which no patients had a reported locoregional or distant recurrence in either breast., Conclusions: No significant differences in early or late complications were identified between breasts in patients undergoing bilateral NSM with a history of unilateral BCT and XRT. In the 5.5 years of follow-up, there were no recurrences, lending support to NSM for management of recurrent disease in addition to National Comprehensive Cancer Network-recommended total mastectomy. We propose that NSM should not be contraindicated in patients exposed to radiation with BCT., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Both direct-to-implant (DTI) and immediate free flap (FF) breast reconstruction following nipple-sparing mastectomy (NSM) have been described in the literature. However, there is a paucity of comparative studies between these two techniques. Furthermore, existing studies do not control for factors influencing ischemic complications., Methods: A retrospective review of all NSMs performed at a single institution between January of 2014 and January of 2020 was performed. Immediate FF reconstructions were propensity score matched using probit regression to identify a comparable DTI cohort based on mastectomy weight, smoking, age, and history of radiotherapy. Primary outcomes of interest were 30-day ischemic complications., Results: One hundred eight NSMs performed in 79 patients were included. Average age was 45.7 ± 10.5 years and mean body mass index was 27.1 ± 4.8 kg/m 2 . There were 54 breasts in both the DTI group and the immediate FF group. Median mastectomy weight in the DTI group was 508 g (interquartile range, 264 g) as compared with 473 g (interquartile range, 303 g) in the FF group ( P = 0.792). There was no significant difference in the rate of partial nipple-areola complex necrosis in the DTI and FF groups (5.6% versus 3.7%, respectively; P = 0.500) or mastectomy flap necrosis (5.6% versus 11.1%; P = 0.297). Both the DTI and FF groups had a total nipple-areola complex necrosis rate of 1.9% ( P = 0.752)., Conclusion: Both DTI and immediate FF reconstruction can be safely offered to patients undergoing NSM while providing the benefit of a single reconstructive procedure., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Capsular contracture (CC) is a common long-term complication following prosthetic-based breast reconstruction (PBBR). Seven cases of CC following mRNA vaccination for coronavirus 2019 (COVID-19) are reported in the literature., Objectives: The aim of this study was to determine whether receiving the COVID-19 vaccine was associated with CC development following PBBR., Methods: A retrospective, multicenter nested case-control study was performed from January 2014 to July 2022 of adult female patients who underwent PBBR with acellular dermal matrix placement. Cases of CC were selected if no adjuvant radiation was received and they presented for follow-up between December 2020 and July 2022. Controls included patients who met inclusion criteria but who did not experience CC in either breast. Patient demographics, breast cancer characteristics, reconstructive surgery details, postoperative complications, and COVID-19 exposure details were analyzed and correlated with CC development., Results: Of a total of 230 patients (393 breasts) who received PBBR, 85 patients (135 breasts) met inclusion criteria, of whom 12 patients (19 breasts) developed CC and 73 patients (116 breasts) did not. At the time of median follow-up of 18.1 months (n = 85; interquartile range, 12.2-33.6 months), no statistically significant differences were observed between the short- or long-term complications in cases or controls. There were no significant differences in COVID-19 vaccination status, number of vaccine doses, or vaccination type between cases and controls. Vaccination status was not associated with greater odds of CC development (odds ratio, 1.44; 95% CI, 0.42-5.37; P > .05)., Conclusions: Direct association between CC and COVID-19 vaccination is difficult to prove. Given the known risk of severe COVID-19 infection among immunocompromised patients, those with breast cancer who undergo PBBR should be properly counseled on the benefits and risks of vaccination., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Less than 1% of all breast cancers are diagnosed in males. In females, postmastectomy breast reconstruction is associated with increased patient satisfaction. However, there is a paucity of literature describing reconstructive options for postmastectomy deformity in the male chest. The purpose of this systematic review was to evaluate postmastectomy reconstruction outcomes in males with breast cancer., Methods: A systematic review was performed in accordance with PRISMA guidelines. Ovid MEDLINE, Embase, Cochrane, and Web of Science were queried for records pertaining to the study question using medical subject heading (MeSH) terms such as "male breast cancer," "mastectomy," and "reconstruction." No limitations were placed on the year of publication, country of origin, or study size. Study characteristics and patient demographics were collected. Primary outcomes of interest included postoperative complications, recurrence rate, and mortality rate., Results: A total of 11 articles examining 29 male patients with breast cancer who underwent postmastectomy reconstruction were included for analysis. Literature was most commonly available in the form of case reports. The average age was 59.6 +/-11.4 years. Reconstruction methods included fat grafting ( n  = 1, 3.4%), silicone implants ( n  = 1, 3.4%), and autologous chest wall reconstruction with local flaps ( n  = 26, 89.7%). Postoperative complications occurred in two patients (6.8%), including partial nipple necrosis ( n  = 1) and hypertrophic scarring ( n  = 1). Of the studies reporting patient satisfaction, all patients were pleased with the aesthetic appearance of their chest., Conclusion: This systematic review revealed the limited availability of research regarding postmastectomy chest reconstruction in males with breast cancer. Nevertheless, the evidence available suggests that reconstruction can restore a patient's body image and, thus, should be regularly considered and discussed with male patients. Larger studies are warranted to further shed light on this population., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Romina Deldar et al.)

Background: Nipple-sparing mastectomy (NSM) offers improved aesthetics without compromising oncologic safety. Subpectoral breast reconstruction has long been standard practice, although prepectoral reconstruction has recently resurged in popularity. Due to this recent paradigm shift, studies comparing long-term outcomes by reconstructive plane are lacking., Methods: A retrospective review was conducted on consecutive NSMs with implant-based reconstruction in either the prepectoral or subpectoral plane from 2014 to 2018. Patient demographics, implant specifications, and operative details were collected to evaluate primary outcomes of prosthetic failure and unplanned reoperations by reconstructive plane. Secondary outcomes included animation deformity, capsular contracture, rippling, plane change, and minor revisions, including fat grafting. Bivariate and multivariate analyses were performed to assess outcomes., Results: Overall, 405 NSMs were performed on 228 women (subpectoral = 202, prepectoral = 203), with a mean follow-up of 2.1 years (standard deviation 1.1). During the study period (2014-2018), a shift from subpectoral to predominantly prepectoral mastectomies occurred in 2017. Prepectoral reconstructions were more often direct-to-implant (DTI) compared with subpectoral (73.9% vs. 33.2%, p < 0.001). Prepectoral reconstruction demonstrated significantly reduced prosthetic failure (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.14-0.65) and unplanned reoperations (OR 0.43, 95% CI 0.24-0.77) compared with subpectoral reconstruction after controlling for implant characteristics and other possible confounders. Prepectoral patients experienced decreased animation deformity overall (19.7% vs. 0.0%, p < 0.001), with plane changes seen in 10.6% of subpectoral reconstructions for animation deformity correction. Prepectoral patients experienced an increase in rippling (15.3% vs. 6.1%, p = 0.003) without a significant increase in fat grafting (subpectoral = 11.6% vs. prepectoral = 12.3%, p = 0.829)., Conclusions: This single-institution experience compares late complications of prepectoral and subpectoral implant-based reconstruction following NSM. Prepectoral reconstruction can be safely performed with improved understanding of mastectomy planes, readily affords DTI reconstruction, and reduces animation deformity at the expense of rippling., (© 2021. Society of Surgical Oncology.)

Nipple-sparing mastectomy (NSM) offers superior esthetic outcomes without sacrificing oncologic safety for select patients requiring mastectomy. While disparities in oncologic care are well established, no study to date has investigated equitable delivery of the various mastectomy types. The objective of this study is to examine multilevel factors related to the distribution of NSM. Patients undergoing mastectomy between 2014 and 2018 across eight hospitals in a single healthcare system were retrospectively reviewed. Patients were categorized by mastectomy type-NSM or other mastectomy (OM). Patient information such as age, race, comorbidities, and median income by ZIP code was collected. Disease characteristics, such as mastectomy weight, breast cancer stage, and treatment history, were identified. Provider and system-level variables, such as specific provider, hospital of operation, and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A cohort of 1202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, P < .001). 39.8% of white patients (n = 242) and 20.0% of African American patients (n = 88) received NSM (P < .001). Average mastectomy weight was 384.3 (SD 195.7) in the NSM group, compared to 839.4 (SD 521.1) in the OM group (P < .001). 41.4% (n = 359) of patients treated at academic centers, and 6.9% (n = 21) of patients treated at community centers received NSM (P < .001). In the multivariate model, the factor with the largest impact on NSM was specific provider. Odds of NSM decreased by 76%-88% for certain surgeons, while odds increased by 63 times for one surgeon. This study utilizes a large multi-institutional database to highlight disparities in NSM delivery. Expectedly, younger, relatively healthy patients, with smaller breast size were more likely to undergo NSM, in accordance with surgical guidelines. However, when all other factors were controlled, provider preferences played the most significant role in NSM delivery rates. These findings demonstrate the need for practice reexamination to ensure equitable access to NSM., (© 2020 Wiley Periodicals LLC.)

Background: This study aims to use the National Surgical Quality Improvement Program database to identify factors associated with extended postoperative length of stay after breast reconstruction with free tissue transfer., Methods: Consecutive cases of breast reconstruction with free tissue transfer were retrieved from the National Surgical Quality Improvement Program (2005 to 2017) database using CPT code 19364. Extended length of stay (dependent variable) was defined as greater than 5 days., Results: Nine thousand six hundred eighty-six cases were analyzed; extended length of stay was noted in 34 percent. On regression, patient factors independently associated with extended length of stay were body mass index (OR, 1.5; 95 percent CI, 1.2 to 1.9; p < 0.001), diabetes (OR, 1.3; 95 percent CI, 1.1 to 1.6; p = 0.003), and malignancy history (OR, 1.9; 95 percent CI, 1.22 to 3.02; p = 0.005). Operation time greater than 500 minutes (OR, 3; 95 percent CI, 2.73 to 3.28; p < 0.001) and immediate postmastectomy reconstruction (OR, 1.7; 95 percent CI, 1.16 to 2.48; p < 0.001) conferred risk for extended length of stay. Bilateral free tissue transfer was not significant. Operations performed in 2017 were at lower risk (OR, 0.2; 95 percent CI, 0.06 to 0.81; p = 0.02) for extended length of stay. Reoperation is more likely following operative transfusion and bilateral free tissue transfers, but less likely following concurrent alloplasty. Given a known operation time (minutes), postoperative length of stay (days) can be calculated using the following equation: length of stay = 2.559 + 0.003 × operation time., Conclusions: This study characterizes the risks for extended length of stay after free tissue transfer breast reconstruction using a prospective multicenter national database. The result of this study can be used to risk-stratify patients during surgical planning to optimize perioperative decision-making., Clinical Question/level of Evidence: Risk, III., Competing Interests: Disclosure:Dr. Song receives royalties from Elsevier for Plastic Surgery, 3rd and 4th editions, and from Biomet Microfixation for Sternalock. The other authors have no financial disclosures, commercial associations, or any other conditions posing a conflict of interest to report., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background/objective: Volume replacement with the latissimus dorsi (LD) is an option for patients after partial mastectomy. Although potential benefits of using the endoscopic technique have been previously described, previous studies have not assessed long term volume and aesthetic outcomes compared to traditional methods. In this study, we aim to compare the endoscopic, latissimus only harvest to the traditional latissimus with skin paddle method., Methods: Eleven patients underwent breast reconstruction with the traditional LD flap harvesting method; 9 underwent endoscopically assisted LD flap reconstruction. The difference between preoperative and >1 year postoperative volumes were recorded. Patient satisfaction and surgeon-based observer assessment of the breast aesthetic and donor site scar were compared between the two techniques., Results: Compared to the traditional group, there was a significant mean volume reduction in the endoscopic group (70.3 vs 21.7 cc, p = 0.0023). Operative time was also longer in the endoscopic group than in the traditional group (368 vs 257 min, p < 0.001). In observer assessment criteria, the result of the donor site scar assessment was superior in the endoscopic group in terms of vascularity (p = 0.0038), relief (p = 0.0023), and pliability (p = 0.053)., Conclusion: Patients' attitudes and feelings about the scar were better in the endoscopic group than in the traditional group. However, compared to the endoscopic group, the traditional group achieved a better breast cosmetic result and better retention of volume postoperatively, possibly due to incorporation of the skin flap and adipo-fascial tissue., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020. Published by Elsevier Taiwan LLC.)

The American Society of Breast Surgeons (ASBrS) outlined definitive guidelines for contralateral prophylactic mastectomy (CPM) in 2016. Despite this, rates of CPM have remained steady. The objective of this study was to identify factors contributing to persistent over-delivery of CPM. Breast cancer patients across 8 hospitals in a single healthcare system from 2014 to 2018 were retrospectively reviewed. The patients were divided according to whether they received nonindicated CPMs versus other mastectomy types. Nonindicated CPM were those procedures not meeting ASBrS consensus guidelines for recommended patients. CPM rate was calculated for each year in the study period. Patient, disease, provider, and system level factors were obtained. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A total of 1,051 patients were analyzed. Nonindicated CPM rates by year remained steady throughout the time period (P = .391). In multivariable regression, patient, disease, and provider level factors were associated with odds of undergoing CPM. Every unit increase in age was associated with a 4% reduction in odds of undergoing CPM (CI 0.941-0.986). Stage 3 breast cancer compared to stage 1 had 53% lower odds of CPM (CI 0.288-0.757). Implant-based breast reconstruction had 2.9-fold higher odds of CPM compared to no reconstruction (CI 1.476-5.551). No system level factors were statistically significant. CPM rates have not notably decreased since the ASBrS consensus statement with certain patient and provider factors impacting persistent overuse of CPM. These results inform oncologic and reconstructive providers of factors contributing to continued use of a nonindicated procedure., (© 2020 Wiley Periodicals LLC.)

Background: Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making., Methods: A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures., Results: Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05)., Conclusions: Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons., Clinical Question/level of Evidence: Therapeutic, III.

Background: Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site., Methods: A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications., Results: Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5)., Conclusions: In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Surgeons often seek to perfect their technical dexterity, and hand dominance of the surgeon is an important factor given the constraints of operative field laterality. However, experience often dictates how surgeons are able to compensate. While surgeons have experienced preference for the ipsilateral breast, the impact of surgeon handedness, experience, and volume has not been directly examined in a single study. A retrospective chart review of five breast surgeons (2 LHD) at a single institution identified 365 mastectomy patients, totaling 594 breasts, between January 2015 and June 2018. The breasts were identified as ipsilateral or contralateral based on the surgeons' handedness. Surgeons were grouped based on length of surgical experience, three with ≥15 years and two with <15 years. Surgeons with greater experience were the highest volume surgeons in this series. Data included patient demographics, breast and oncologic history, surgical techniques, and surgical outcomes including complications. A total of 270 nonprophylactic and 324 prophylactic mastectomies were identified, of which 529 were performed by surgeons with greater than 15 years of experience and 65 by surgeons with less than 15 years. The overall complication rate was 33.5% (n = 199), of which 18.0% (n = 107) were on the ipsilateral breast and 15.5% (n = 92) were on the contralateral breast. 9.1% of complications required re-operation (n = 54). The odds of any complication on the ipsilateral breast were 2.9 times higher than complications on the contralateral breast when looking exclusively at surgeons with <15 years of experience (P = .0353, OR = 2.92, 1.06-8.03). Surgeons with <15 years of experience have a 2.71 (P = .05, OR 2.71, 1.361-5.373) increase in any ischemic complication and a 16 times (P < .0001, OR = 16.01, 5.038-50.933) increase in major operative ischemic complications. Our study finds that surgeons with less than 15 years of surgical experience have a 2.9 times higher rate of overall complication when operating on the ipsilateral breast. However, years of experience and surgeon volume have a much greater impact on any and ischemic complications after mastectomy., (© 2019 Wiley Periodicals, Inc.)

Background: Poor health literacy is an epidemic in the United States, associated with higher mortality rates and poor postoperative care. Autologous breast reconstruction is highly complex, and the identification of complications is difficult even for non-plastic surgeon practitioners. The authors sought to explore the problem of health literacy in this context and identify the ideal postoperative patient education materials., Methods: Available online postoperative patient education materials for autologous breast reconstruction and corresponding readability scores were assessed. To derive the ideal formula for materials, the authors crowd-sourced quizzes with A/B testing, a method to examine the outcome of two versions of a single variable. The authors implemented their findings and compared performance on postoperative quizzes with and without oral reinforcement., Results: Of the 12 postoperative flap complication patient education materials found through an Internet search, the average grade level readability level was 9.9. Only one of 12 (8.3 percent) mentioned symptoms and signs of flap compromise. The A/B tests result revealed that text approximately 400 to 800 words written on a sixth-grade level led to the highest quiz scores. Patients scored significantly higher on the postoperative day-2 quiz when patient education materials, modeled after these findings, were reinforced with oral presentation (p = 0.0059). Retention of high quiz scores remained at postoperative day 10., Conclusions: Currently available patient education materials are at a high reading level and lack specific information on the identification of flap compromise. The authors propose the most effective postoperative instructions to be approximately 400 to 800 words written on a grade-six level with images and oral reinforcement.

Background: The latissimus dorsi (LD) myocutaneous flap is a widely used local option in oncoplastic surgery for avoiding breast deformities; however, concerns exist regarding its influence in monitoring recurrence. In this study, we evaluated the impact of this flap on postoperative cancer surveillance., Methods: Each patient receiving oncoplastic surgery with LD flap after partial mastectomy were matched in age, cancer stage, and body mass index with patients receiving partial mastectomy alone. Twenty-nine patients with the oncoplastic LD flap received 99 mammograms and 139 ultrasonograms, while 29 patients with partial mastectomy alone underwent 92 mammograms and 129 ultrasonograms. Mammographic and ultrasonographic findings were classified by Breast Imaging Reporting and Data System (BI-RADS) category and reviewed. Any recommendations for additional evaluation and recurrence were documented., Results: During an average follow-up period of 44 months, although the oncoplastic group demonstrated more newly developed benign calcifications (control 14% vs. oncoplastic 41%; p = 0.019) on mammography, the percentage of recall for additional imaging in category 0, and the short-interval follow-up in category 3, was not different between the control and oncoplastic group. Regarding ultrasonography, BI-RADS category was also not different between the two groups; however, the control group showed more fluid collections than the oncoplastic group (control 21% vs. oncoplastic 0%; p = 0.023). One case of local recurrence was observed in the control group., Conclusion: Although there was an increase in benign calcifications in the oncoplastic group, there were no additional abnormal findings requiring further intervention. We concluded that the LD flap for oncoplastic surgery does not interfere with cancer surveillance, and even decreases the rate of fluid collection.

Background: The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume., Methods: A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m 2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI., Results: A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019)., Conclusion: These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap., (© 2019 Wiley Periodicals, Inc.)

Background: Implants offer a method for augmenting abdominal flaps in the setting of deficient volume in breast reconstruction. They may be placed immediately at the time of reconstruction or on a delayed basis. The authors seek to compare outcomes from a single surgeon and previously published studies., Methods: A systematic review was performed, querying multiple databases. A retrospective review was conducted for patients who underwent abdominally based flap breast reconstruction and implant placement between July of 2005 and August of 2015 performed by the senior author (M.Y.N.)., Results: A systematic review of the literature yielded four articles, for a total of 96 patients (142 breasts) included for systematic review. Eighty-seven breasts (61 percent) were reconstructed with immediate implant at the time of flap reconstruction and 55 breasts (39 percent) had a staged approach to implant placement. Complications were noted in 28 breasts (32 percent) following immediate placement and in 10 breasts (18 percent) following staged placement. A total of 53 patients (79 breasts) were retrospectively reviewed, all of whom underwent reconstruction in a staged manner. Twelve breasts (15 percent) were found to have a flap- or implant-related complication; 97.5 percent of implants/flap reconstructions were successful, with a 54 percent revision rate. When pooling systematic and retrospective data, there was a significant difference in complication rates between the staged and immediate reconstruction cohorts (p < 0.001) in favor of the staged approach., Conclusions: The literature supports a higher rate of implant-related complications following immediate implantation at the time of flap reconstruction. The authors' experience with implant placement highlights the safety and effectiveness of the staged approach., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Acellular dermal matrix has enjoyed extensive use in primary and secondary alloplastic breast aesthetic and reconstructive surgery. The objective of this study was to examine clinical outcomes between available acellular dermal matrix products: DermACELL (LifeNet Health, Virginia Beach, Va.) and AlloDerm Ready To Use (LifeCell Corp., Branchburg, N.J.)., Methods: A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL (n = 30 patients; 50 breasts) or AlloDerm Ready To Use (n = 28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same plastic surgeon (T.A.P.). Statistical analysis was performed by means of Fisher's exact test., Results: Differences in the average age, body mass index, percentage having neoadjuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups were not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days after immediate reconstruction. When comparing outcomes, patients in the DermACELL group had a significantly lower incidence of "red breast syndrome" (0 percent versus 26 percent; p = 0.0001) and fewer days before drain removal (15.8 days versus 20.6 days; p = 0.017). No significant differences were seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, or explantation., Conclusion: Patients reconstructed with DermACELL as compared with AlloDerm Ready To Use have significantly decreased number of days to drain removal and red breast syndrome and equivalent rates of other complications, including seroma, infection, flap necrosis, and explantation., Clinical Question/level of Evidence: Therapeutic, III.

Background: The impact of connective tissue disease (CTD) on outcomes following breast surgery and reconstruction is unknown. The purpose of this study was to evaluate the effect of both CTDs and systemic immunomodulatory therapy on outcomes following breast surgery and reconstruction., Methods: A retrospective review was performed of all patients from 2005 to 2010 with an active CTD who underwent breast surgery with or without reconstruction. Surgical events were assigned to 1 of 4 groups: ablative surgery alone, autologous reconstruction, implant reconstruction, and revision surgery. Logistic regression was utilized to examine the relationship between complications and type of surgery, CTD diagnosis, and immunomodulatory therapy. Four non-CTD control groups were then compiled for outcome comparison. The a priori P-value was set at P < 0.05, and all tests were 2 sided., Results: Thirty-three patients with CTD underwent112 procedures. Diagnoses included psoriasis/psoriatic arthritis (n = 12), rheumatoid arthritis (n = 10), lupus (n = 4), scleroderma (n = 3), Sjogren syndrome (n = 2), mixed CTD (n = 1), and seronegative polyarthritis (n = 1). Nineteen of 33 (58%) patients who received systemic treatment for CTD in the perioperative period were less likely to experience a minor complication compared with those without treatment (odds ratio= 0.69; P = 0.019). There were no differences in postoperative complications in patients with CTD compared with control groups., Conclusions: Ablative breast surgery and reconstruction among patients with CTDs can be performed safely with low perioperative complication rates. Patients receiving systemic therapy, and continuing their regimens perioperatively, experience complication rates similar to those not requiring therapy.

Background: When postmastectomy radiation therapy is anticipated, delaying autologous reconstruction prevents radiation delivery issues and radiation-induced contour irregularities. Delayed-immediate autologous breast reconstruction may allow for maintenance of the breast skin envelope as compared with delayed reconstruction with the temporary insertion of a tissue expander. The authors compared perioperative complications and revision surgery rates of comparative cohorts to determine which method is preferable., Methods: Delayed-immediate reconstruction was defined as placement of a temporary tissue expander in the first stage at the time of mastectomy before flap reconstruction, which occurred following postmastectomy radiation therapy. Delayed reconstruction was categorized as mastectomy with primary closure in the first stage followed by flap reconstruction., Results: One hundred fifty-two patients and 192 breasts met the study criteria for this retrospective review (delayed reconstruction, 118 breasts; delayed-immediate autologous breast reconstruction, 74 breasts). Patient age and body mass index were similar between groups (p>0.05). Perioperative first-stage complication rates were 8.5 percent in the delayed group and 10.8 percent in the delayed-immediate cohort (p=0.81). Total flap loss (2.5 versus 4.1 percent; p=0.68) and arterial (1.7 versus 1.4 percent; p=0.82) and venous (4.3 versus 5.4 percent; p=0.73) anastomotic revision rates were similar between the cohorts, respectively. Reoperative surgery occurred in 11.9 percent versus 9.6 percent in the delayed and delayed-immediate cohorts, respectively (p=0.69)., Conclusions: In comparing two treatment algorithms, flap-related complication rates are comparable. First-stage surgery results in a slightly increased complication rate in the delayed-immediate cohort. Improved overall results with delayed-immediate reconstruction are implied, given significantly decreased rates of revision surgery following flap reconstruction., Clinical Question/level of Evidence: Therapeutic, III.

Background: The inferior pedicle technique remains the most popular approach to breast reduction in the United States. Modifications to this procedure have enhanced versatility, patient safety, and outcome satisfaction in patients with all degrees of macromastia., Methods: A 6-year retrospective review of 241 patients who underwent bilateral inferior pedicle breast reduction was conducted at our institution. Modifications analyzed included methylene blue tattooing to provide preoperative landmarks, preoperative hydrodissection to reduce intraoperative blood loss, incorporation of inframammary darting to reduce tension at the "T-junction," preservation of superomedial volume for enhanced medial fullness, and dermatome blade-guided tissue resection., Results: Inframammary darting reduced the incidence of wound dehiscence. Preoperative hydrodissection reduced intraoperative blood loss by a factor of 2. Dermatome blade use reduced operative times at no increased incidence of postoperative seromas or hematomas., Conclusions: Outcomes resulting from these modifications appear to be at least comparable to, and perhaps better than, those previously reported., (Copyright © 2012. Published by Elsevier Inc.)