Scientific Abstract Presentations: Breast Session 2 Thursday, September 26 Thu, Sep 26 1:00-2:30 p.m. PDT

Background: The inflammatory milieu of the implant capsule has been well-characterized. However, no studies have examined whether this inflammatory process extends beyond capsule into the breast. We hypothesized the breast implant foreign body response alters the expression of immune cells in the breast parenchyma.

Methods: Healthy women presenting with breast-related cosmetic complaints were recruited from the plastic surgery clinic between 2018-2022. Reverse transcription polymerase chain reaction (RT-PCR) was performed on breast tissue samples to quantify immune-related gene expression levels between IN and IE. Bulk RNA sequencing was performed to identify differentially expressed genes and altered signaling pathways in the breasts of IN versus IE. Gene expression levels of the implant-exposed breast tissue were expressed as fold change relative to the implant-naïve cohort, after normalizing to GAPDH expression, using the ΔΔCt method. Mann Whitney tests were used to compare ΔCt values. Statistical analysis was performed with GraphPad Prism version 9.3.0 (Graphpad, San Diego, CA) and significance set at P<0.05.

Results: Breast tissue samples were collected from 65 patients (35 IN versus 30 IE). Compared to IN patients, RT-PCR showed IE breast tissue had elevated expression of genes characteristic of plasma cells and Th17-cells. Fold change in IE relative to IN for SDC1, the gene encoding CD138 (a plasma cell-associated cell surface proteoglycan) was 1.90x (p=0.01), while expression of PAX5 (a transcription factor down regulated in the conversion of B-cells to plasma cells) was 0.53x (p=0.031). Fold change for expression of Th17-related genes was 2.16x for IL17A (p=0.004), 1.66x for RORC (p=0.024), 2.36x for BATF (p<0.001), and 1.72 for IL22 (p=0.064). We performed a pilot bulk RNA-seq analysis on a subset of 20 patients (10 IE versus 10 IN). Plasma cell related genes that were significantly upregulated in IE samples included XBP1 (2.22x, p<0.002, a transcription factor uniquely required for plasma cell differentiation), and FAS (1.89x, p<0.001). Th17-cell-related genes that were significantly upregulated in IE samples included C1QL1 (2.68x, p<0.01), BATF (2.44x, p<0.01), and IL17RB (2.26x, p<0.05). Other upregulated pathways identified in IE compared to IN breast tissue included B-cell activation, Th2 related genes, T-cell activation, chemotactic factors, and responses to estrogen.

Conclusion: This is the first study to demonstrate that peri-implant inflammation extends beyond the implant capsule to breast parenchyma. We propose a potential biologic pathway, mediated by the implant foreign body response, that culminates in elevated antibody production against common breast proteins. Immediately after breast implant placement, the silicone surface gets coated with self-protein, which signals an influx of inflammatory cells. Antigen-presenting cells in the capsule that abut the implant surface phagocytose the coated self-protein and present these antigens to other lymphoid cells in the capsule. Activated Th17-cells, in conjunction with self-antigen presentation, migrate into the breast tissue and activate B-cells into antibody-secreting plasma cells.

Background: Oncoplastic breast reduction, which involves removing breast cancer while reshaping and reducing the size of the breast, has been proven effective for women undergoing breast conservation surgery. This technique has been shown to improve symptomatic macromastia and enhance aesthetic outcomes when compared to standard breast conservation therapy alone. The purpose of this study was to examine the comparative outcomes between oncoplastic breast reduction and reduction mammaplasty in respect to clinical safety profile, patient-reported outcome, and aesthetic results.

Methods: A single-surgeon (senior author), single-institution retrospective chart review was performed on patients who underwent either oncoplastic breast reduction or bilateral breast reduction (BBR) from April 2022 to December 2023. Patients who underwent unilateral breast reduction, implant-based or autologous-based breast reduction were excluded from the study. Patient demographics and post-operative clinical data was collected from the electronic medical record. BREAST-Q survey was utilized to assess Quality of Life (QoL) outcomes. Post-operative breast aesthetics were assessed on a Likert scale of 1-5 with ten matched patients in six domains: shape, size, symmetry, nipple areolar complex (NAC), postoperative scarring, and overall postoperative aesthetic.

Results: Of the 66 patients included in the study, 44 (66.7%) underwent BBR for benign macromastia and 22 (33.3%) underwent oncoplastic breast reduction. Macromastia patients were younger (mean age, 37.3 vs 53.6; P = <0.001), had lower ASA class (P = 0.012), and greater resection weight (mean, 820.6 vs 581.7 g; P < 0.001) compared to patients receiving oncoplastic reduction. Wise pattern resection was used in 100% of BBR patients versus 90.9% of oncoplastic reduction patients (P = 0.002). Complication rates were not significantly different between the two cohorts. Both cohorts experienced significant improvements in sexual well-being and satisfaction with breasts (P < 0.05), but only the BBR cohort experienced significant increases in the scales for psychosocial and physical well-being (P < 0.001). In all domains, BBR patients experienced a greater increase in postoperative BREAST-Q scores (P < 0.01), which can be explained by the fact that oncoplastic patients had higher preoperative BREAST-Q scores than BBR patients on all scales (P < 0.01). Among the six aesthetic domains, patients in the oncoplastic aesthetic cohort experienced lower scar ratings (P = 0.039) and trended toward lower overall ratings (P = 0.025) compared to the BBR aesthetic cohort. Although scores for shape, size, symmetry, and NAC appearance aesthetic were also lower for the oncoplastic aesthetic cohort, the differences were not statistically significant.

Conclusions: These results suggest oncoplastic breast reconstruction demonstrates a safety profile comparable to standard BBR. Although the BBR group reported a more pronounced quality of life improvement post operatively, the oncoplastic reconstruction patients also displayed a significant improvement. These findings suggest that oncoplastic breast reconstruction be more readily discussed with breast cancer patients as a favorable surgical option when a lumpectomy is indicated.

Purpose: Infection rates are as high as 35% in patients with implant-based breast reconstruction following mastectomy. Systemic oral prophylactic antibiotics are often prescribed in the post-operative period but have not shown significant evidence-based benefit. Absorbable antibiotic beads provide local therapy and have limited studies on their use in breast reconstruction. The aim of this study was to evaluate the efficacy of prophylactic absorbable beads in the immediate post-operative period following tissue expander (TE) breast reconstruction.

Methods: This is a prospective study of patients undergoing mastectomy and pre-pectoral, drainless, TE reconstruction. The peri-prosthetic fluid was collected through the TE drainage port in the operating room immediately after closure, 1 week post-operatively, and a third timepoint at 2 or 3 weeks postoperatively. The fluid was studied for microorganisms through traditional culture. Groups were divided into those who received antibiotic beads and those who did not. Antibiotic beads were placed in the breast pocket following TE placement and made using vancomycin and gentamicin. Outcome measures include positive postoperative cultures and clinical signs of infection such as fever, erythema, or edema at the breast. Each patient had at least 30 days of follow-up postoperatively.

Results: The study included a total of 31 patients and 54 breasts. There were 22 patients (36 breasts) in the no beads group and 9 patients (18 breasts) in the beads group. In the no beads group, the average age was 50 years old and average BMI was 23.8. In the beads group, the average age was 49 and average BMI was 24.4. In the no beads group, 4 breasts tested positive with fluid culture (11%) while only 1 breast tested positive in the no beads group (5.5%). In the no beads group, the cultures were positive for Cutibacterium acnes in 1 breast, Staph epidermidis in 2 breasts, and Enterobacter cloacae in 1 breast. The 1 breast in the beads group was positive for Cutibacterium acnes. In patients without beads, only 3 breasts had clinical signs of infection that concurred with positive cultures (8.3%) while no patients with beads had clinical signs of infection. Of note, no patients had adverse reactions to antibiotic beads.

Conclusions: Although this is a pilot study, we have shown that overall, prophylactic antibiotic beads can reduce the rate of post-operative infections in the immediate post-operative period. We also show that antibiotic beads can be administered safely in this patient population. More follow-up time and larger sample sizes are needed to further analyze antibiotic beads in patients undergoing TE breast reconstruction.

Background: Managing postoperative pain control is crucial in reducing postoperative opioid use, decreasing hospital length of stay (LOS), and improving outcomes in abdominally based, autologous breast reconstruction (Ab-ABR). Exparel (Pacira Pharmaceuticals, Inc., Parsippany, NJ) and Marcaine (Pfizer, New York, NY) are forms bupivacaine with differing durations of action that are used to treat postoperative pain in Ab-ABR. As Exparel is formulated to have a longer duration of action than Marcaine, the purpose of this study is to determine if differences in postoperative pain control truly exist following administration of Exparel versus Marcaine for patients undergoing Ab-ABR.

Methods: A retrospective analysis of patients undergoing Ab-ABR between 2017 and 2022 was performed. Patients were administered Exparel or Marcaine at the time of Ab-ABR within the pectoralis fascia and immediately deep to the anterior rectus sheath just medial to the semilunaris. Demographics, comorbidities, and opioid utilization were collected. Postoperative pain was assessed using the Numeric Rating Scale from 0 to 10 (10 being worst pain) and categorized by site of pain (chest or abdomen). Primary outcomes included postoperative pain scores and opioid utilization.

Results: A total of 239 patients underwent Ab-ABR. Two hundred (83.7%) received Exparel and 39 (16.3%) received Marcaine at the time of operation. At the time of reconstruction, 125 (52.4%) were delayed and 133 (55.7%) were bilateral Ab-ABR. Ab-ABR types included 156 (65.3%) DIEP, 59 (24.7%) ms-TRAM, and 10% both. Six (2.5%) patients had a history of opioid use. Exparel was associated with a longer median duration of postoperative opioid use (3.0 vs. 2.5 days, p=0.045). There were no significant differences among daily or total opioid usage for the entirety of the hospital stay. Exparel and Marcaine had the same overall pain scores pre-opioid administration across all time points. There were no significant differences between groups after opioid administration across all time points. For pain scores in the abdomen, Exparel had a significantly higher pain score at 48 hours (5 vs 2, p = 0.0398). There were no significant differences in pain scores in the chest at any time point . Marcaine administration was associated with a significantly shorter LOS (2 vs. 3 days, p <0.001). This remained significant on multivariate analysis (CI: -2.384, 00.187, p = 0.022).

Conclusion: Our preliminary data shows that Exparel has comparable efficacy to Marcaine in reducing postoperative pain and opioid use despite Exparel's long-acting formulation. Exparel is significantly more costly than Marcaine, and therefore, our findings may encourage the use of Marcaine instead of Exparel for local anesthesia in Ab-ABR, potentially reducing financial burden for patients and hospitals.

Background: The choice of pedicle technique in breast reduction (BR) surgery is crucial for optimizing postoperative outcomes. The superomedial pedicle (SMP) is commonly used but is limited in cases where the nipple-areolar complex (NAC) is positioned too medially, restricting its mobility. In such instances, plastic surgeons often resort to the inferior pedicle (IP) technique, despite its technical challenges and suboptimal outcomes regarding breast shape and nipple sensation. The superolateral pedicle (SLP) remains an alternative to the IP method. However, it has been previously suggested that it may not be suitable for larger breasts due to concerns over vascular supply and positioning. This study demonstrates the efficacy and safety of the SLP in BR for various resection weights.

Methods: A single-institution retrospective review of all patients undergoing BR using the SMP or SLP Wise-pattern technique from September 2022 to January 2024 was conducted. Demographic data, comorbidities, operative details, and postoperative complications were collected. Postoperative complications were categorized into minor and major (i.e., reoperation).

Results: A total of 146 breasts (n=90 patients) underwent BR: 30 (20.5%) breasts used the SLP technique and 116 (79.5%) used the SMP technique. Mean age was 45.3±14.5 years. Mean body mass index (BMI) for SLP and SMP groups were 34.6±4.7 and 33.4±5.9 kg/m2, respectively. Mean nipple-to-inframammary fold (N-IMF) distances were 12.5±3.3 and 16.3±4.0 cm, respectively (p=0.010). Mean sternal notch-to-nipple (SN-N) distances were 34.0±2.9 and 35.0±4.9 cm, respectively (p=0.562). Median weight of breast tissue resected was 782 (interquartile range [IQR]: 580.5-1,042) g. Mean follow-up duration was 1.7±1.3 months. In the SLP group, 4 (13.3%) breasts experienced at least one complication, including seroma requiring aspiration (n=3, 10.0%) and abscess formation requiring antibiotics (n=2, 6.7%). In the SMP group, 8 (10.1%) breasts experienced at least one complication, including seroma (n=2, 1.7%), hematoma (n=7, 1.7%), abscess formation (n=4, 3.4%), dehiscence (n=2, 1.7%), partial nipple necrosis (n=1, 0.8%), and fat necrosis (n=1, 0.8%). Collectively, there were 5 (3.4%) cases of reoperation, all in the SMP group. The incidence any complications was comparable between SLP and SMP groups (p=0.253). In a propensity score matching analysis, the incidence of any complications was comparable between SLP (n=30 breasts) and SMP (n=23 breasts) groups (average treatment effect on the treated (ATT)=0.067; p=0.713).

Conclusion: The SLP Wise-pattern technique for BR is efficacious and safe, showing comparable complication rates to the SMP technique, with no need for reoperations across a wide range of breast sizes. These findings support its viability as an alternative to traditional pedicle techniques in BR surgery.

Purpose: Neurotized deep inferior epigastric perforator (DIEP) flaps are increasingly utilized to improve and restore breast sensation in breast reconstruction patients. Most commonly, neurotization is performed by coapting a sensory branch of the tenth (T10), eleventh (T11), or twelfth (T12) intercostal nerve within the DIEP flap to the anterior cutaneous branch of the third intercostal nerve (T3) in the chest, as described by Spiegel et al. No previous study has investigated the effect of donor nerve selection on sensation of the autologous flap. In this study, we aim to compare the regional pattern of sensation return over time in DIEP flaps innervated with T11 and T12 to guide donor nerve selection.

Methods: Forty-two patients (65 breasts) underwent neurotized DIEP flap breast reconstruction. Of these, 35 flaps used T11 as the donor nerve, and 30 flaps used T12 as the donor nerve. All nerve coaptation was performed with a nerve allograft to T3. Pre- and postoperative sensation was evaluated using the AcroVal pressure-specified sensory device (AxoGen, Alachua, FL) in four quadrants (superior, medial, inferior, lateral) and the nipple-areolar complex of the native or reconstructed breast at specified time points. Higher values correlate to a higher threshold of pressure needed to elicit sensation, indicating worse sensation return.

Results: Baseline characteristics, treatment details, and postoperative complications were similar between the two groups, except the T12 group experienced higher rates of skin necrosis (26.7% vs. 5.7%, p = 0.047). Preoperative sensitivity measurements were comparable between the two groups across all breast areas (Figure 1). In the first six months after reconstruction, the T12 cohort experienced greater sensitivity in the medial quadrant of the breast compared to the T11 cohort (p = 0.019). At 6 to 12 months after reconstruction, the T12 cohort had greater sensitivity in the superior, inferior, and lateral quadrants, and the nipple-areolar complex (p < 0.05). After 12 months, a significant difference persisted in the inferior and lateral quadrants (p < 0.05).

Conclusions: We found a statistically significant improvement in cutaneous sensation of DIEP flaps innervated with a T12 donor nerve compared to T11, despite higher rates of mastectomy skin flap necrosis. To our knowledge, this is the first reported difference in sensation based on donor nerve selection; these results may guide future surgical decision-making to optimize sensory recovery.

Introduction Breast cancer's global burden prompts a comprehensive understanding of patient experiences surrounding surgical interventions to improve the physician-patient relationship. Social media serves as a new potential avenue to further plastic surgery research and posts made by patients themselves may offer insight into care outcomes (1). This study's objective is to further understand patient perceptions regarding breast cancer, mastectomies, and reconstructions via social media to better understand patients' coping mechanisms and support-seeking behaviors as well as guide physician-patient dialogue.

Methods A cross-sectional analysis was conducted of Instagram and TikTok social media posts between May 2015 and November 2023 related to breast cancer surgeries using procedure-related hashtags such as "#Mastectomy," "#DoubleMastectomy," "#DIEPFlap," "#TRAMFlap," and "#LATFlap. Other autologous and alloplastic reconstructions were limited in searchable post volume. Three reviewers analyzed, confirmed, and categorized patient social media post content to prevalent themes related to Breast-Q foci, examining variations between platforms, treatment phases, and procedure types.

Results Data from 1,028 individuals undergoing breast cancer surgeries were analyzed. Posts encompassed various procedures: double mastectomy (39.11%), single mastectomy (22.28%), deep inferior epigastric perforator flap (31.81%), latissimus dorsi flap (3.60%), and transverse rectus abdominis muscle flap (3.70%). The top ten themes identified were 'Raising Awareness' (893, 86.9%), 'Spreading Positivity' (546, 53.1%), 'Resiliency' (319, 31.0%), 'Online Support' (253, 24.6%), 'Update of Appearance' (214, 20.8%), "Uses Music" (210, 20.43%), "Recovery/Rehab" (205, 19.94%), "Scientific Explanation" (203, 19.65%), "Relief with Results" (155, 15.08%), and "Treatment Process" (150, 14.59%). Other notable themes included 'Use of Humor' (144, 14.0%), 'Decision-Making (120, 11.7%), 'Fear of Surgery' (118, 11.5%), and 'Mental Health' (114, 11.1%).

Instagram posts were more likely to discuss spreading positivity (p<0.001), resiliency (p=0.001), and mental health (p=0.011), while TikTok posts were more likely (p=0.001) to discuss a scientific explanation, decision-making, and symptoms (p<0.001). Preoperative posts were more likely (p<0.001) to discuss a scientific explanation, decision-making, and fear of surgery, while postoperative posts were more likely (p<0.001) to discuss updates of appearance, recovery/rehab, and spreading positivity (p=0.012). Differences existed between those who posted after single mastectomies, double mastectomies, and autologous reconstruction: raising awareness (p<0.001), update of appearance (p=0.013), recovery/rehab (p<0.001), scientific explanation (p=0.015), treatment process (p=0.003), range of motion (p<0.001), self-esteem (p=0.017), and wound management (p=0.008).

Conclusion Social media posts provide a publicly available dataset that catalogs patient experiences through the breast reconstruction journey. Concerns of patients via social media reflect themes of Breast-Q measures. Understanding nuanced patient discussions across platforms, treatment phases, and surgical types can provide novel insights for providers. Utilizing the knowledge gained from this data may allow for a more individualized approach toward consenting patients for surgery. Postoperatively, physicians may better incorporate expectations surrounding appearance and the healing process. Tailoring interactions based on these insights facilitates improved support, informed discussions, and enhanced patient experiences throughout their treatment journey. The impact of social media on postoperative body image and mental health warrants continued investigations.

References ¹ Timberlake AT, Wu RT, Cabrejo R, Gabrick K, Persing JA. Harnessing Social Media to Advance Research in Plastic Surgery. Plast Reconstr Surg. 2018;142(4):1094-1100. doi:10.1097/PRS.0000000000004811

Introduction

Fat necrosis is a significant problem after deep inferior epigastric perforator (DIEP) flaps. While many factors have been associated with fat necrosis, we aimed to analyze a large database of DIEP flaps with long-term follow-up to better define these risk factors and investigate how the development of fat necrosis may impact other complications.

Methods

We performed a retrospective review of patients who underwent post-mastectomy DIEP flap reconstruction between 2004-2022. Demographics, treatment details, and post-operative outcomes were collected. Patients who developed fat necrosis were compared to those who did not, and a sub-analysis was performed on fat necrosis requiring operative intervention.

Results

We identified 256 patients (407 flaps). Mean follow-up was 24±20 months. Fat necrosis developed in 111 (27%) flaps, of which 66 (60%) required operative intervention. A higher prevalence of neoadjuvant radiation (47% vs 30%, P<0.01) was observed in patients who developed fat necrosis. Fewer flaps in the fat necrosis group used >2 perforators (81% vs 90%, P=0.02). Flaps that developed fat necrosis had higher rates of infection requiring oral (14% vs 6%, P<0.01) or IV antibiotics (8% vs 3%, P=0.04), delayed wound healing (14% vs 5%, P<0.01), operative wound breakdown (13% vs 5%, P=0.01), and partial flap loss (4% vs 1%, P<0.01). 61% (27/44) of infections occurred in the first 30 days post-operatively. While the rate of operative wound breakdown was higher in the operative fat necrosis group (18% vs 4%), this was not significant on regression analysis (P=0.05). More patients with operative fat necrosis required revision fat grafting (47% vs 24%, P=0.02).

Conclusions

Patients should be counseled that a large percentage of those who develop fat necrosis may ultimately require surgical excision and fat grafting to address the resulting contour deformities. Additionally, as fat necrosis may increase the risk of other complications such as infection and wound breakdown, future investigation will focus on whether early intervention may reduce these risks.

Intro: Oral contraceptive pills (OCPs) are commonly utilized by women aged 15-45 for contraception and menstrual cycle regulation. Despite being associated with an increased risk of thromboembolism, their potential impact on surgical outcomes, particularly in the context of reduction mammoplasty, remains an area of inquiry. This retrospective cohort study aimed to explore the association between OCP use and outcomes following reduction mammoplasty, utilizing data from the TriNetX database.

Methods: A retrospective cohort study was conducted using the United States Network in TriNetX. CPT 19318 was used to identify patients who underwent breast reduction surgery. Within this group, two cohorts were created: OCP and Control. OCP was defined by those who were taking oral contraceptive pills at the time of surgery (Norgestimate, Norgestrel, Dienogest, Desogestrel, Drospirenone, Ethynodiol, Ethinyl Estradiol) and Control could not be taking OCPs at the time of surgery. Propensity score matching was carried out for age, race, previous delivery (vaginal and cesarean), and body mass index. Outcomes within six months of surgery were documented, including mastodynia, ptosis, fat necrosis, deformity or disproportion of the breast, postoperative hematoma/hemorrhage, and postoperative embolism/thrombosis. Relative risk within a 95% confidence interval and chi-squares were calculated.

Results: After matching, each cohort was comprised of 8,526 patients with a mean age of 31.7 years (SD: 11.5 years). Controls exhibited a 1.36-fold higher likelihood of postoperative hematoma/hemorrhage, with 195 (2.3%) Controls experiencing the complication compared to 143 (1.7%) individuals taking OCPs (CI:1.10-1.68; p<0.01). However, the OCP group did not demonstrate an increased risk for developing an embolism or thrombosis, with 32 (.38%) experiencing the complication compared to 35 (.41%) Controls (RR=.91; CI:.57-1.48; p=.71). No statistical difference was found between groups in terms of mastodynia (p=.10), ptosis (p=.15), fat necrosis (p=.54), or deformity or disproportion of reconstructed breast (p=.32).

Conclusion: The results of this study indicate that discontinuation of OCPs prior to reduction mammoplasty would not offer any discernible advantages in terms of postoperative outcomes. The decision to continue or discontinue OCPs before reduction mammoplasty should be based on patient-specific factors, rather than on reducing the risks associated with the procedure.

Purpose: Inadequate postoperative pain relief places patients at risk for increased morbidity, including surgical complications and chronic postoperative pain. In our previous study, we reported that our methadone-based Enhanced Recovery After Surgery (ERAS) protocol for deep inferior epigastric perforator (DIEP) flap breast reconstruction resulted in lower postoperative opioid requirements, lower pain scores, and decreased incidences of tachycardia. This study aims to establish ERAS pathway patient opioid requirements after hospital discharge.

Methods: This is a prospective study of 387 patients who underwent DIEP flap breast reconstruction by two attending surgeons at a tertiary care institution from March 2017 to December 2023. Of the 378 patients, 186 were managed prior to ERAS implementation, and 193 were seen following implementation. The ERAS pathway includes a single dose of intra-operative weight-based methadone and specific management guidelines, such as patient education, medication optimization, and fluid management. All patients were discharged on either postoperative day 2 or 3. At the time of discharge, all patients were prescribed oxycodone 5 mg for pain as necessary. Patient home opioid pain medication usage was surveyed for 14 days post-discharge. All opioid usage units were converted to morphine milligram equivalents (MME). Paired t-test analysis was used to compare differences in opioid usage between days at home for a subset of patients, as well as compare opioid refill requests for patients prior to vs following ERAS pathway implementation.

Results: When comparing opioid refills request patterns between the 186 non-ERAS patients, and the 193 ERAS pathway patients, there was no significant difference in average number of patients requesting an opioid prescription refill. Of note, patients in the non-ERAS group that requested refills asked for a higher number of refills than those in the ERAS pathway group that requested refills (p < 0.05). Additionally, a subset of 71 ERAS patients reported discharge pain medication usage. Of these patients, 43 patients (60.6%) discontinued opioid medications on home day 3 (postoperative day 5 to 6), 59 patients (83.1%) discontinued opioid medications on home day 7 (postoperative day 9 to 10), and 69 patients (97.2%) discontinued opioid medications on home day 13 (postoperative day 15 to 16). Of the 14 home days surveyed, there was a statistically significant decrease in mean opioid medication usage between home day 1 and 4, with average medication use falling to less than one pill per day (10.75 MME to 6.6 MME, p < 0.05). Further decrease in pill usage was observed between home day 11 and 14 (1.7 MME to 0.5 MME, p < 0.005).

Conclusion: Our preliminary results demonstrate that most patients in our methadone-based ERAS pathway require decreased opioid pain medications at home, with over 60% of patients stopping opioid use by home discharge day 4. Among patients that request opioid medication refills, the number of refills requested by an individual ERAS pathway patient is less than that requested by the non-ERAS pathway patient. This study establishes a baseline opioid requirement for ERAS pathway patients and advocates for minimizing opioids prescribed upon hospital discharge.

Background/Purpose The latissimus dorsi flap (LDF) is a historical workhorse and contemporary salvage mainstay for breast reconstruction. There is still debate regarding the timing and staging of LDF-implant breast reconstruction. We examine the outcomes of a single-surgeon, single-institution experience of LDF breast reconstruction outcomes, with focus on staging of flap and implants.

Methods and Materials We performed a retrospective chart review of patients who underwent LDF breast reconstruction from 2008-2021 by a single surgeon (RS). Charts were reviewed for demographics, comorbidities, indications, number and type of planned stages, and outcomes. Acute and chronic complications and revisions were compared according to indication and staging of reconstruction, as well as use of radiation. Staging groups were 1-stage LDF alone, 1-stage LDF/implant, 2-stage LDF to implant, and 2-stage LDF/tissue expander to implant. The 1-stage LDF/implant cohort was compared versus all other groups. Capsular contracture incidence was compared between the 1-stage LDF/implant cohort and the staged implant groups.

Results Our study included 154 patients and 207 LDF flaps. Mean follow-up was 46.89 months (1-164). Comparing indications for reconstruction, there was a non-statistically significant trend toward acute minor complications with primary reconstruction versus salvage indication (28% vs. 12.5%, p=0.065). Radiation after LDF reconstruction was significantly associated with a higher rate of late and total complications compared to before, both before and after, and no radiation (53.3% vs 26.6% vs 0% vs 28.1%, p-value=0.026, 60% vs 32.8% vs 0% vs 38.5%, p-value=0.037). There was a large but not statistically significant difference in capsular contracture for the 1-stage LDF/implant group versus staged implant groups (29.6% vs. 0%, p=0.115). The 1-stage LDF/implant cohort had a significantly greater rate of late complications (32.1% vs 10%, p-value=0.04), total complications (40.6%vs 15%, p-value=0.025), late revisions (35.8% vs 10%, p-value=0.020), and total revisions (40.1% vs 15%, p-value=0.028). After excluding capsular contracture, however, there were no significant differences in complications or revisions on the basis of indication, staging, or radiation status (p >0.05).

Conclusion Our study demonstrates the safety of performing single-staged LDF with implant for breast reconstruction. There was a trend toward increased incidence of capsular contracture which merits analysis in future studies with larger cohorts of staged reconstructions. Capsular contracture remains a common complication, and future research should examine means to reduce the risk of capsular contracture following LDF breast reconstruction.

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ASPS Staff would like to thank and remember Dr. Randy Sherman, who contributed to this abstract before his passing in July 2023. More information is available from Plastic Surgery News at https://www.plasticsurgery.org/for-medical-professionals/publications/psn-extra/news/remembering-randy-sherman-md-1951-2023.

Background:

Deep Inferior Epigastric Perforator (DIEP) flap surgery offers better satisfaction and quality of life (QoL) than other reconstruction options but may involve longer hospital stays and significant post-surgery care (1). Enhanced recovery after surgery (ERAS) protocols have improved quality of care and reduced postoperative length of stay (LOS) in hospitals. Our study aims to investigate the impact of ERAS pathways on DIEP outcomes, evaluating how modern interventions might reduce inpatient hospitalization length without compromising patient safety and postoperative QoL.

Methods:

A computerized search was conducted on September 29th, 2023, using five databases. The search strategy was: "Free Tissue Flaps" OR "Myocutaneous Flap" OR "Surgical Flaps" AND "Patient Discharge". From the results of the computerized search, researchers manually selected studies that described DIEP flap protocols and outcomes with a mean LOS less than 5 days to be included in the review. Study characteristics included original articles, clinical trials and descriptive studies. Studies in languages other than English, conferences articles, editorials, reviews, abstracts, and book chapters were excluded. Studies that occurred in animal models, in-vitro or ex-vivo were excluded. We recorded rates of total flap loss, partial flap loss, hematoma, seroma, infection and reoperation. The studies were separated into five groups based on mean LOS following DIEP flap. Group 1: <1; Group 2: 1.1-2 days; Group 3: 2.1-3; Group 4: 3.1-4 and Group 5: 4.1-5 We used the Kruskal-Wallis test to determine significant differences in complication rates between the 5 groups because of the non-normal distribution of complication rates.

Results:

After screening 703 studies, 27 papers were selected based on our inclusion criteria, encompassing 2,175 patients for analysis. Among these, 68 patients underwent outpatient DIEP flap procedures, and 218 received drain-free DIEP flap surgeries. Infection emerged as the most reported complication, with rates ranging from 1.56% to 5.17%. The highest infection rate occurred in patients with a length of stay (LOS) ranging from 1.1 to 2 days, whereas the lowest rate was noted in those with an LOS of 4.1 to 5 days. There were no reports of total flap loss in studies with LOS less than 2 days, while the rate of total flap loss in studies with LOS between 4 and 5 days was 2.74%. Statistical analysis revealed no significant differences between groups in terms of total flap loss (p=0.315), partial flap loss (p=0.051), hematoma (p=0.459), seroma (p=0.319), infection (p=0.59), or the necessity for reoperation (p=0.346).

Conclusion:

Complication rates are not statistically different across various short LOS groups following DIEP surgery. This suggests that abbreviated LOS following DIEP flap breast reconstruction is feasible without significantly increasing postoperative complications, supporting the incorporation of early discharge protocols in appropriate patients.

References:

Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125(6):1585-1595. doi:10.1097/PRS.0b013e3181cb6351

Introduction Breast cancer related truncal lymphedema can be a difficult post-surgical complication that is not yet well understood. We aim to analyze the effects of radiation on lymphatic structures of the chest and map changes in lymph flow using indocyanine green (ICG) lymphography. Radiation is a known risk factor of lymphedema development but the extent of its damage on truncal lymphatics has never been assessed. Severe lymphatic destruction can be represented as zones of no lymphatic flow seen on ICG imaging. We will explore the incidence of no flow zones in irradiated chests and identify changes in lymphatic drainage pathways.

Methods This study is a retrospective review of breast cancer patients with a clinical suspicion of truncal lymphedema who received ICG lymphography of their chest from August 2023 to January 2024. Data was collected on all breast cancer treatment modalities including radiation, chemotherapy, axillary dissection, and mastectomy. Zones of no lymphatic flow were recorded using ICG lymphography. Lymphatic drainage to the ipsilateral axillary nodes, ipsilateral inguinal nodes, and to contralateral lymph node basins were also assessed. Univariate analysis and multivariable logistic regressions were performed to analyze the association between treatment modalities and the presence of no flow zones. Chi-square test of independence was used to test the difference in drainage pathways between patients with and without radiotherapy. All statistical analysis were performed with SPSSv24.0 (p<0.05 considered statistically significant).

Results Our cohort included 32 hemi-trunks (19 patients). 19 sides (59%) had undergone prior radiation and 13 had not. Additionally, 69% underwent mastectomy, 53% had chemotherapy, and 31% had axillary dissection. Zones of no lymphatic flow were seen in 66% of hemi-trunks. Prior radiation was significantly associated with hemi-trunks containing absent lymphatic flow (p=0.027). On multivariate analysis, controlling for confounding chemotherapy, axillary dissection, and mastectomy, radiation was associated with 18.57 times increase in odds of absent lymphatic flow. Overall, lymphatic drainage to the ipsilateral axilla was seen in 41% of hemi-trunks, drainage to the groin was seen in 81%, and contralateral drainage was seen in 28%. Using Chi-square analysis, radiation was significantly associated with less lymphatic drainage to the ipsilateral axilla (p<0.001) and increased contralateral drainage (p=0.003). There was no significant change in drainage to the inguinal nodes in trunks that received radiotherapy (p=0.604).

Discussion We show that prior radiation is significantly associated with zones of no lymphatic flow and increased drainage to contralateral lymph node basins. This represents severe damage to lymphatic vessels resulting in lymph stasis and formation of aberrant drainage pathways. This is the first study to illustrate no flow zones of the irradiated chest using ICG imaging and shows the level of lymphatic damaged caused by radiation therapy.

Purpose Safety concerns have been raised regarding silicone breast implants due to their link with Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and the recently identified BIA Squamous Cell Carcinoma (BIA-SCC). Previous research conducted in our laboratory has documented an unexpected reduction in the growth of BIA-ALCL and primary T cell lines when exposed to textured silicone implant shells. Given this intriguing finding, we expanded our investigation to examine the impact of widely used commercial silicone textured breast implant shells on various cell lines within the peri-implant environment, such as endothelial cells. Interestingly, we observed a similar significant decline in cell count following direct culture with textured implant shells over eight days. These preliminary findings prompted us to explore the possibility of a harmful metabolic or biochemical factor being directly released from the implant shells, by utilizing conditioned media (CM) from media in wells lined with textured implant shells in varying concentrations.
Methods and Materials To simulate a peri-prosthetic microenvironment, Allergan and Mentor textured implant shells were cut, sterilized via steam autoclave, and used to line the wells of 96-well plates. Low serum (2%) media was added to implant shell-lined wells and no-plant wells, and 150 µL of resulting media from each well was collected every 48 hours for use as conditioned media (CM). Human Umbilical Vein Endothelial Cells (HUVECs) were seeded in a separate 96-well plate with ~1,000 cells/150µL (10-15% confluence) and fed with collected CM at varying dilution ratios every 48 hours up to 8 days. Ratios of CM:Fresh Media (FM) 1:0, 2:1, 1:2, 1:5, 1:15 were used for replenishment. Wells with HUVECs receiving fresh media were used as the control. Cell count and morphology were assessed on Days 1, 4, and 8. Results The most significant decrease in cell count was observed for the non-diluted (1:0) textured shell-exposed CM group on Day 8 compared to FM diluted and FM groups. In comparison, when CM was increasingly diluted with FM, cell count increased over time, especially in higher CM:FM ratios 1:2, 1:5, 1:15, which were similar to the FM group cell counts (p<0.05). The presence of hypertrophied HUVECs were observed in the 1:0 textured shell-exposed CM group. Both Allergan and Mentor textured implant shells had similar impacts on cell behavior.
Conclusions The negative impact of textured implant shells on endothelial cell count was observed with direct cell exposure to shells as well indirect exposure through CM. Results of this study strongly suggest the involvement of a factor released by the implant shell into its surroundings, potentially disrupting normal cellular growth and metabolism, in addition to the possible effect of shell surface absorption of nutrients. Further investigation into the interactions between different cell types and implant shells is crucial for a more comprehensive understanding of the potential risks associated with these prostheses.