Scientific Abstract Presentations: Breast Session 9 Saturday, September 28 Sat, Sep 28 10:30 a.m.-12:30 p.m. PDT

Introduction

The treatment of breast cancer has evolved from radical mastectomy to nipple sparing mastectomy (NSM) with direct-to-implant (DTI) breast reconstruction. However, postoperative complications are not uncommon and can significantly impact reconstructive outcomes and patient quality of life. NSM with DTI breast reconstruction involves the removal of breast tissue with preservation of the nipple-areola complex (NAC) and skin envelope, creating a pocket for implant placement. When the mastectomy weight is greater than the chosen implant, a volumetric mismatch occurs creating a potential dead space. Dead spaces have shown to predispose to seromas and infections in other reconstructive procedures. The role of volumetric mismatch on the development of complications in breast reconstruction is unknown. Therefore, this study aimed to determine whether volumetric mismatches in NSM with DTI breast reconstruction predispose patients to postoperative complications.

Methods

A multicenter retrospective study was conducted of patients who underwent NSM with DTI breast reconstruction between 1990 and 2023. Data included patient demographics, comorbidities, reconstructive history, surgical technique, mastectomy weight, implant size, volumetric mismatch (mastectomy weight minus implant size) as well as postoperative complications. Complications included explant, infection (requiring antibiotics or reoperation), seroma (requiring aspiration), hematoma (requiring reoperation), skin necrosis (requiring revision) and wound dehiscence (requiring revision). A receiver operating characteristic (ROC) analysis was conducted to identify the volumetric mismatch cut-off with the highest sensitivity and specificity in predicting complications. Bivariate, univariable and multivariable logistic regression analyses were performed.

Results

A total of 1004 patients who underwent 1460 NSM with DTI breast reconstructions were included. The average mastectomy weight was 457.7 g (±219.1 g), implant size 406.9 cc (±154 cc) and volumetric mismatch 50.0 (±110.2). The mean follow-up duration was 19.7 months. Overall complication rate was 9.2% and included explant (3.2%), seroma (4.0%), infection (2.2%), hematoma (1.7%), skin necrosis (2.2%) and wound dehiscence (1.0%). A volumetric mismatch of ≥95 was associated with significantly higher rates of overall complications (10.1% versus 5.9%, p<0.05), seroma (6.9% versus 2.4%, p<0.05), infection (4.5% versus 1.6%, p<0.05), explant due to infection (3.2% versus 0.6%, p<0.05), and wound dehiscence (3.1% versus 0.2%, p<0.05). Upon multivariable logistic regression for any complication, significance was maintained for volumetric mismatch as a significant risk factor (OR 2.7, 95% CI 1.3-5.7, p=0.01).

Conclusions

For patients undergoing NSM and DTI reconstruction, a volumetric mismatch may increase the risk of seroma, infection, explant, and wound dehiscence. Knowing this, plastic surgeons may choose to match their implants more evenly to the mastectomy weight or opt for skin sparing mastectomies when a mismatch would otherwise be unavoidable.

Introduction: Breast cancer-related lymphedema (BCRL) is a chronic and incurable disease impacting approximately 20% of breast cancer patients. Accurate prediction of BCRL is critical for patient education and potential implementation of preventative modalities, such as immediate lymphatic reconstruction following axillary lymph node dissection. Previous studies have identified risk factors associated with the development of BCRL, primarily using logistic regression models. Machine learning (ML) can outperform traditional statistical methods by discovering nonparametric interaction between risk factors and weighing different features to describe their importance to the predictive model. The goal of this study was to apply different ML approaches for prediction of BCRL and compare their performance.

Methods and materials: A retrospective cohort study was conducted involving women with breast cancer who underwent mastectomy at a single institution from January 2015 to June 2022. BCRL diagnosis was confirmed by a certified lymphedema therapist. All patients had a minimum follow-up period of 1.5 years post-mastectomy. The authors compared 4 ML algorithms (logistic regression, random forest, support vector machine, and Naïve Bayes) to predict development of BCRL. Accuracy, recall, precision and F1 score were calculated for each algorithm and compared using t-test. Additionally, Shapley Additive Explanation Analysis (SHAP) was performed to characterize the magnitude and directionality of the identified risk factors.

Results: A total of 365 patients were included in the study. The mean age was 56 years, and the mean body mass index (BMI) was 29. Eighty-one patients (22%) developed BCRL. All machine learning models performed comparably well, with the random forest having the best overall performance (accuracy: 88.5 ± 3.8%, recall: 79.0 ± 14.0%, precision: 51.8 ± 10.1%, and F1 score: 61.3 ± 10.0%). Further analysis demonstrated that the random forest model prioritizes lymph node stage, number of lymph nodes removed, radiation therapy, surgery type, axillary dissection, age at diagnosis, BMI, chemotherapy, tumor stage, and breast cancer histological type as top features to predict BCRL.

Conclusions: This study shows that ML methods can be utilized for individualized prediction of BCRL and outperform traditional descriptive statistical models. Continued training of the ML algorithms with more data will allow for development of more robust predictive models that could be applied in clinical practice.

Background: Bioabsorbable scaffolds have been utilized in breast reconstructive surgery for many years, but more recently, materials like Poly-4-Hydroxybutyrate (P4HB, GalaFLEX & GalaFLEX LITE; BD, Franklin Lakes, NJ) have become more readily accessible to surgeons and patients in the aesthetic realm. Previous reports have demonstrated low complication rates but with smaller sample sizes, a shorter duration of follow-up and multiple surgeons in their series.

Objectives: We determine to demonstrate both the safety and low complication rates over time when utilizing P4HB in varying elective (off-label) breast procedures, including: primary breast augmentation (submuscular and subfascial); revision breast augmentation / implant exchange; and complex pocket control cases (i.e. inferior implant displacement or "bottoming out," lateral displacement, symmastia correction, recurrent capsular contracture). Additionally, we demonstrate its safety and utility in reconstructive cases, including: implant based breast reconstruction; reduction mammaplasty; tuberous breast deformity; and Poland's Syndrome.

Methods: Between October 2019 and October 2023, a single surgeon conducted a total of 677 consecutive cases utilizing P4HB (total 1354 pieces of GalaFLEX and GalaFLEX LITE). Our preliminary findings from a randomized retrospective chart analysis sample reveal promising outcomes. All patients were female. Age range was 21 to 66 years, with the average age of 35. BMI range was 18 – 36, with an average BMI of 25.3. Mean follow-up was 6 months with longest follow-up of 4 years. There were 5 cases performed in 2019, 116 in 2020, 169 in 2021, 207 in 2022, and 180 in 2023. We randomly sampled 250 patients from our in-depth chart review across the four-year period to analyze major (5%) and minor (10%) complication rates. The most common minor complication (i.e., no return to operating room) was palpability with the original P4HB (GalaFLEX). Additionally, occasional sharp pain along the P4HB (GalaFLEX and GalaFLEX LITE) was another complaint but all resolved without intervention by 180-days post- surgery. Major complications were few but required surgical intervention for waterfall deformity, implant malposition, and breast asymmetry. This occurred in 5% of the 250 sampled patients and primarily in the years of 2020 – 2022. No cases of P4HB infection or hematoma were reported in this case series. Furthermore, our preliminary findings suggest a positive trend toward decreasing major and minor complication rates when there is continued use over time by the surgeon of P4HB. This underscores the importance of consistent use and technical expertise with P4HB.

Conclusion: Our consecutive case series of P4HB utilization in 677 patients from a single surgeon over a four-year period is the largest to date in the world. Our findings highlight the enduring success and satisfaction achieved through P4HB utilization in elective aesthetic and reconstructive breast surgery. The material's contribution to increased soft tissue integrity is a key factor in its long-term success, reinforcing its position as a reliable and effective choice in plastic and reconstructive surgeries.

Background: Despite a variety of excision patterns, pedicles and implement of supporting techniques, recurrent ptosis and bottoming out with lower pole overstretch remain unsolved problems after mastopexy(1). It is indeed unrealistic to entrust the same compromised native soft tissue to maintain the shape of the rejuvenated breast in the long term, especially in the setting of concurrent implant positioning(2). Following the authors' encouraging experience(3), internal support with P4HB scaffold was extended to all patients undergoing augmentation mastopexy with smooth implants in a subfascial plane.

Objectives: The authors sought to evaluate lower pole stability after augmentation mastopexy with the adjunct of P4HB scaffold (GalaFLEX) by analyzing lower pole curvature and breast volume redistribution at different time point. Further analysis included correlation between implant size or type of surgery (primary versus revisional) and lower pole stretch.

Methods: 72 consecutive patients undergoing augmentation mastopexy with round smooth implants in a subfascial plane from March 2020 to December 2023 and a 1 year minimum follow up were included in the study. Arbrea Breast Software, an artificial intelligence-based 3D simulator was used to measure the curvilinear distance between nipple to inframammary fold (lower pole arch) and breast volume. Lower pole stretch was determined as the percentage increase from 6 weeks to each post operative time. The ratio between lower pole and total breast volume (lower pole ratio=LPR) was used to assess volume redistribution.

Results: Mean follow up was 24,8 months with the longest being of 45 months. No recurrent ptosis, bottoming out, implant displacement or capsular contracture were reported. Mean lower pole stretch was 5.39% and 8.04% at 6 and 12 months respectively, with substantial stability at 3 years (9,4%). Overall breast volume decreased by 10%, redistributing towards the lower pole in the first year (LPR=0.45 at 6 weeks vs 0.49 at 12 months), showing satisfactory volume distribution in the longer term (LPR= 0.52 at 2 and 3 years). Larger implants showed a trend towards longer LPA's elongations, although not significantly so (p>0.05). Secondary cases (26 patients) showed smaller LPA's elongation at 1 year (8.73%vs6.83%), not reaching statistical significance (p>0.05).

Conclusions

Our datas support GalaFLEX's protective role against lower pole stretch in the first year and beyond, even in the setting of concurrent subfascial breast augmentation with smooth implants, this being the largest published series reporting such long-term results.

References: 1. de Vita R, Zoccali G, Buccheri EM. The Balcony Technique of Breast Augmentation and Inverted-T Mastopexy With an Inferior Dermoglandular Flap. Aesthet Surg J. 2017;37(10):1114-1123. doi:10.1093/asj/sjx142 2. Adams WP, Baxter R, Glicksman C, Mast BA, Tantillo M, Van Natta BW. The Use of Poly-4-Hydroxybutyrate (P4HB) Scaffold in the Ptotic Breast: A Multicenter Clinical Study. Aesthet Surg J. 2018;38(5):502-518. doi:10.1093/asj/sjy022 3. Mallucci P, Bistoni G. Experience and Indications for the Use of the P4HB Scaffold (GalaFLEX) in Aesthetic Breast Surgery: A 100-Case Experience. Aesthet Surg J. 2022;42(12):1394-1405. doi:10.1093/asj/sjac198

Squamous cell carcinoma can originate either primarily from the breast parenchyma (PSCCB) or from the periprosthetic capsule in individuals with breast implants (BIA-SCC). A comprehensive literature review aimed to identify all cases of PSCCB and BIA-SCC, assessing prevalence, incidence rate (IR), and risk. Using specific keywords, studies published up to November 2023 were searched across PubMed, Web of Science, Google Scholar, and the Cochrane Library. The cases retrieved from the literature served as the numerator for PSCCB and BIA-SCC, while the denominator for PSCCB comprised the female population aged 18 to 99 and for BIA-SCC the population with breast implants. A total of 219 papers were included, featuring 2,250 PSCCB cases and 30 BIA-SCC cases. The prevalence of PSCCB was 2.0 per 100,000 individuals (95%CI 0.2:100,000 to 7.2:100,000) with a lifetime risk of 1:49,509 (95%CI 0.2:10,000 to 5.6:10,000). BIA-SCC prevalence was 0.61 per 100,000 (95%CI 0.2:100,000 to 1.3:100,000), with a lifetime risk of 1:164,884 (95%CI 0.2:100,000 to 5.6:100,000). Comparatively, BIA-SCC prevalence was 3.33 times lower than PSCCB, while BIA-ALCL prevalence was 3.84 times higher than Primary Breast ALCL. In assessing BIA-SCC risk against BIA-ALCL, the prevalence of 1:164,910 for individuals with breast implants (regardless of texture) was found to be 180 times lower than the BIA-ALCL prevalence of 1:914 for patients with textured implants. BIA-SCC occurs less frequently than PSCCB and considerably less than BIA-ALCL. The association between textured implants and BIA-SCC cases underscores the importance of patient education regarding uncommon and rare risks associated with breast implants. Ongoing vigilance, research, and strengthened reporting systems are imperative.

Background: We believe that one or two abnormalities are presented in hypoplastic tuberous breast: a. Herniation of breast tissue through the nipple – areola complex and/or skin shortening at the level of Inframammary Fold (IMF). We describe a new technique which combines the Northwood index and the muscle- splitting dual plane (MUST technique) breast augmentation technique Materials and Methods: We used the Northwood Index (NI) as described by Dr Pacifico in 2005. The NI is the ratio derived between the areola herniation to areola diameter, in the true lateral view photo of the breast. The herniation is measured in cm and it is the maximum anteroposterior distance between the base of the nipple and the edge of the areola. The diameter is measured in cm at the maximum diameter of the areola. When the index was above 0.3, we performed peri-areola tightening with CV-3 stitch and relaxing incisions at the lower pole of the constricted lower pole of the breast. When the Index was below 0,3 we did only the relaxing incisions. In all patients we use round silicone implants to restore the volume and the muscle-splitting dual plane technique (MUST) for the pocket dissection. The MUST technique includes subfascial pocket at the lower part of the breast and division of the pectoralis muscle in 3 different levels depending on the volume of the implant. Level 1: for implants >350cc we divide the pectoralis muscle at the projected level of the lower border of the nipple areola complex in the surface of the pectoralis major muscle. Level 2: for implants between 350-200cc we divide the pectoralis muscle at the projected level of the nipple in the surface of the pectoralis major muscle and Level 3: for implant <200cc we divide the pectoralis muscle at the level of the upper border of the areola complex. Moreover, we classified the tuberous breast very simply in to two types. Type A when the NI is more than 0.3 and Type B when the NI is less than 0.3. From March 2007 to October 2022, we have performed the aforementioned technique in 121 tuberous breasts. Mean age of patient was 27.5 years old. Mean follow-up was 7 years. Results: All patients reported high levels of satisfaction. 5 patients had scar revision. 8 patients had suture exposure in the nipple. Slight recurrence of the deformity was observed in 7 patients. One patient developed infection and we removed the implant.
Conclusions: We advocate a one-stage surgical correction of tuberous breast. Based on the Northwood index we describe two types of hypoplastic tuberous breast. According to this classification we can decide easily whether we will perform peri-areola correction or not and with the MUST technique we can achieve the best expansion of the lower pole of the tuberous breast having the upper pole of the implant covering by the muscle.

Background: The acellular dermal matrix (ADM) has become popular in various reconstructive surgeries of different regions. There are different needs depending on the clinical applications including breast, abdominal wall, and any other soft tissue reconstruction. Removal of the basement membrane (BM), which consists of collagen fibers, may help achieve natural and soft breast reconstruction that require highly elastic ADMs. Given the lack of knowledge of the effectiveness of the ADM without the BM, we compared the clinical outcomes of ADMs with and without BM in breast reconstruction. Methods: We conducted a prospective, single-blinded, randomized controlled trial to evaluate differences in clinical outcomes. The patients were randomized into ADM with BM and without BM groups. Both groups underwent immediate prepectoral direct-to-implant breast reconstruction. Demographics, surgical outcome, and breast shape change using nipple position were compared between the two groups. Results: A total of 56 patients were divided into two groups: ADM with BM (n=30, 53.6%) and ADM without BM (n=26, 46.4%). Clinical and surgical demographics were similar between the two groups. The authors detected no statistically significant differences in the overall rate of complications and breast shape change between the two groups. However, the rate of seromas was higher in the ADM with BM group than that in the ADM without BM group (10% vs. 0%, P=0.09). Conclusion: The two groups showed similar surgical outcomes. The use of ADM without BM in implant-based breast reconstruction was safe with its mechanical properties of lower tensile strength and higher elasticity.

References 1. Mazari FAK, Wattoo GM, Kazzazi NH, et al. The comparison of strattice and surgimend in acellular dermal matrix-assisted, implant-based immediate breast reconstruction. Plast Reconstr Surg 2018;141(2):283-293. 2. Polotto S, Bergamini ML, Pedrazzi G, et al. One-step prepectoral breast reconstruction with porcine dermal matrix-covered implant: a protective technique improving the outcome in post-mastectomy radiation therapy setting. Gland Surg 2020;9(2):219-228. 3. Hagarty SE, Yen LL, Luo J, et al. Decreased length of postoperative drain use, parental opioids, length of stay and complication rates in patients receiving meshed versus unmeshed acellular dermal matrix in 194 submuscular tissue expander-based breast reconstructions: A single-surgeon cohort study. Plast Reconstr Surg 2020;145(4):889-897. 4. Viezel-Mathieu A, Alnaif N, Aljerian A, et al.Acellualr dermal matrix-sparing direct-to-implant prepectoral breast reconstruction: A comparative study including cost analysis. Ann Plast Surg 2020;84(2):139-143. 5. Nam SY, Youn D, Kim GH, et al. In vitro characterization of a novel human acellular dermal matrix(BellaCell HD) for breast reconstruction. Bioengineering(Basel) 2020;7(2):39.

Background: Reported rates of infection following implant-based breast reconstruction (IBBR) range from 1-35% (1). Despite this relatively high rate, there is no consensus regarding optimal practices for IBBR such as the type or duration of antibiotic prophylaxis, which has led to a wide variety of adopted protocols in plastic surgery practice. Quality improvement (QI) projects have long-standing evidence of efficacy in surgery, however, only a handful of previous QI projects have been documented that specifically target the reduction of complications after breast reconstruction. The purpose of this study is to present the outcomes from the MIAMI protocol (Minimizing Infection After Mastectomy with Implants), a self-manufactured QI project to standardize preoperative, intraoperative, and postoperative breast reconstruction protocol at our institution.

Methods: The MIAMI protocol was instituted in December 2022, at both the University of Miami and Jackson Memorial Hospital Systems. Incidence of infection, wounds, hematoma, seroma, flap necrosis, reoperation rates for a complication, and implant loss following IBBR were evaluated for six faculty members and compared between a period before the start of the protocol (December 2021 to November 2022) and after the implementation of the protocol (December 2022 to November 2023). The protocol included standardization in the preoperative area, during surgery, and postoperative. Standardization did not include post-discharge antibiotic type or duration.

Results: 749 IBBR procedures were included; 360 (48%) of which were performed prior to the start of the MIAMI protocol, and the remaining 389 procedures (52%) were performed after the protocol was implemented. The mean patient age throughout the study period was 51.9 years [SD 11.27] and the mean BMI was 26.7 [SD 5.04] kg/m2. The implementation of the MIAMI protocol evidenced a substantive decrement in the total infection rate, with a reduction from 58 cases (16%) pre-protocol to 43 cases (11.1%) post-protocol implementation (p=0.04). Major infections observed a decline from 44 (12.2%) to 36 (9.2%) (p=0.19). Minor infections reduced from 14 (3.9%) to 8 (2.1%) (p=0.14). The incidence of hematoma decreased marginally from 14 (3.9%) to 10 (2.6%) (p=0.31). Seroma formation reduced from 50 (13.9%) to 41 (10.5%) (p=0.16). The occurrence of minor wounds (less than 1 cm) reduced from 60 (16.7%) to 62 (15.9%) (p=0.79). Major wound complications (1 cm or more) declined from 48 (13.3%) to 37 (9.5%) (p=0.09). Rates of flap necrosis, re-operation, and implant loss, which were (3.6%), 53 (14.7%), and 48 (13.3%) pre-protocol, respectively, shifted to 11 (2.8%), 50 (12.8%), and 38 (9.7%) post-protocol indicating that these reductions occured however not statistically significant.

Conclusion: Standardization of preoperative, intraoperative, and postoperative procedures for breast reconstruction had a significant impact on surgical outcomes at our instruction, regardless of no consistent standardization for post-discharge antibiotics. This resulted in a statistically significant decrease in overall infection rates and a downward trend of all other complications as well. This represents an opportunity for a multi-institutional study with a longer follow-up period.

1. Wilkins EG, et al. Complications in Postmastectomy Breast Reconstruction: One-year Outcomes of the Mastectomy Reconstruction Outcomes Consortium (MROC) Study. Ann Surg. 2018 Jan;267(1):164–70.

Introduction: Immediate implant-based breast reconstruction (IIBR) is a common procedure following mastectomy, offering patients expedited restoration of breast aesthetics and function. However, complications such as mastectomy flap necrosis (MFN) pose significant challenges to successful outcomes. Indocyanine green (ICG) angiography has emerged as a promising tool for assessing flap perfusion intraoperatively. Rapid ingress is a characteristic of a normal perfusion of a flap in ICG angiography. This study aimed to determine optimum cut-off value of ingress time in ICG angiography to predict skin flap necrosis in IIBR. Methods: Consecutive patients undergoing IIBR and intraoperative ICG angiography between June 2021 and December 2022 were included. Video recordings captured fluorescence enhancement of mastectomy skin flaps using a near-infrared camera. Ingress time, defined as the duration for ICG to reach the entire incisional margins, was measured. Receiver operating characteristic (ROC) analysis determined the optimal ingress time cut-off for predicting full-thickness necrosis. Results: Out of 203 patients included, 33 (16.3%) developed full-thickness necrosis. The mean ingress time was significantly longer in the necrosis group compared to the no-necrosis group (104.6 vs. 47.6 seconds, respectively; p < 0.001). ROC analysis identified an optimum ingress time cut-off of 58 seconds, with a sensitivity of 93.9% and specificity of 74.1%. Multivariable logistic regression confirmed that patients with ingress time longer than 58 seconds had significantly higher odds of developing full-thickness necrosis (OR 36.82; p < 0.001). Conclusion: Ingress time measured via ICG angiography demonstrates promising potential as a predictive metric for full-thickness necrosis in IIBR. A threshold of 58 seconds or longer was associated with increased odds of necrosis development. This study highlights the importance of intraoperative perfusion assessment in optimizing surgical outcomes and guiding clinical decision-making in immediate breast reconstruction procedures. Further research is warranted to validate these findings and refine the clinical application of ingress time in predicting postoperative complications.

Background: Infection in implant-based breast reconstruction is problematic and occurs in up to 22%. Traditionally, infected implants are removed for several months prior to replacement with either an implant or tissue expander (TE) resulting in delay of breast reconstruction. The purpose of this study is to assess outcomes of a new salvage pathway of infected breast prosthetics with device removal, subsequent placement of negative pressure wound vacuum therapy with instillation and dwell (NPWTi-d), and early-staged replacement of a TE/implant within a few days.

Methods: A single-center retrospective review was performed for breast cancer patients who underwent implant-based reconstruction (2018 to 2023). Patients who had infection or exposure of a TE/implant requiring removal of the device were included in the study. Patients were divided into two groups. Group 1 (NPWTi-d) was managed with implant removal, placement of NPWTi-d in the breast pocket until clinical improvement, followed by repeat washout with replacement of the TE/implant. Group 2 (control) underwent traditional TE/implant removal and no NPWTi-d. Demographic information was recorded. Outcome variables included postoperative infection (leading to TE/implant loss or hospitalization for intravenous antibiotics), skin necrosis, type of breast prosthetic during salvage, reinfection after TE/implant salvage, time interval without a TE/implant following explantation, and time to final implant-based reconstruction.

Results: The study included 47 patients (76 TE/implants). There were 13 patients (16 TE/implants) in Group 1 and 34 patients (60 TE/implants) in Group 2. The average age was 44.2±9.3 years old in Group 1 compared to 50.7±12.1 years-old in Group 2 (p=0.0956). The mean body mass index was 33.5±7.0 kg/m2 in Group 1 compared to 31.6±6.2 kg/m2 in Group 2 (p=0.5022). Neoadjuvant chemotherapy was administered to 38.5% (5/13) of Group 1 patients compared to 26.5% (9/34) of Group 2 (p=0.4816). There were 30.8% (4/13) of Group 1 who received adjuvant radiation compared to 23.5% (8/34) of Group 2 patients (p=0.7129). The average time interval of TE/implant-free days was 2.5 ± 1.2 days in Group 1 compared to 134.6±78.5 days in Group 2 (p=0.0001). Final breast reconstruction using implants occurred in 92.3% (12/13) of Group 1 compared to 32.4% (11/34) of Group 2 patients (p=0.0003). There were no patients (0/13) in Group 1 who declined further reconstruction following TE/implant loss compared to 38.2% (13/34) of Group 2 patients (0.0094). The success rate (no surgical site infection within 90 days) of implant salvage was 81.3% (13/16 implants) in Group 1. The time interval to final implant-based breast reconstruction was 69.0±69.7 days in Group 1 compared to 225.6±93.6 days in Group 2 (p=.0001). The mean follow-up time was 324.5 (range 105-637) days in Group 1 and 486.8 (range 131-931) days in Group 2.

Conclusion: A breast implant salvage pathway with removal of the infected device, NPWTi-d placement, and early replacement of the TE/implant was successful in 81%. Patients experienced less implant-free days by 132 days and faster time to final reconstruction by 156 days compared to those managed with traditional device removal. Patients who underwent this salvage pathway were less likely to abandon completing breast reconstruction.

Introduction: Post-mastectomy breast reconstruction often involves a multistage process beginning with tissue expander placement to create adequate skin flap surface area. Despite the benefits, expander infections can occur, posing significant challenges including delay or alteration of adjuvant therapy, prolonged reconstructive timeframes, and increased costs. While medical treatments are often employed to salvage infected expanders, surgical interventions may become necessary. Herein, we aim to identify risk factors indicative of an impending explantation in infected breast expanders.

Methods: This retrospective cohort study examines expander infections occurring at our center between 2017 and 2019. Patients were identified using CPT codes for tissue expander placement and ICD codes for infection and electronic medical records were reviewed, collecting data on patient demographics, cancer characteristics, medical and surgical cancer treatments, reconstructive procedures, relevant history of breast surgeries, treatments administered for the infected expander, and the final outcomes of each expander. We also assessed the impact of the red breast antibiotic protocol, which constitutes an oral regimen (Minocycline/Linezolid, Ciprofloxacin, and Rifampin) and an intravenous regiment (Minocycline/Vancomycin/Daptomycin, Meropenem/Cefepime, and Rifampin)

Results: In the study period, we identified 180 cases of expander infections, among which 29% (n=53) necessitated explantation. There was no significant association between type of antibiotic regimen and explantation (29.9% versus 28.3% explantation rates in red breast protocol and non-red breast protocols, p =0.828, respectively). Prior chemotherapy and radiotherapy were also insignificant in association with expander explantation in this population (p = 0.41 and 0.77, respectively). On the other hand, explantation was significantly associated with higher BMI (median, Interquartile range = 30.4 (27.7-34.0) versus 28.6 (24.6-31.7), p = 0.01, in explanted versus non-explanted expanders, respectively), breast cancer histology (64% versus 42% versus 20% versus 16% explantations in invasive lobular carcinoma, invasive ductal carcinoma, ductal carcinoma in-situ, and no cancer histologies, p <0.001, respectively), and breast cancer stage (p<0.001). Multivariate binary logistic regression analysis revealed that BMI (Odds Ratio = 1.2, p < 0.001), expander volume (Odds Ratio = 0.997, p = 0.003), and breast cancer stage (Odds Ratio = 12.2, p < 0.001 in Stage III) independently predicted explantation, while prior chemotherapy and radiotherapy were insignificant.

Conclusion: Our analysis underscores the significance of prompt and aggressive management in patients with expander infections, particularly those with higher BMI and advanced breast cancer stage. Notable, the latter was the most prominent risk factor for ultimate explantation, where stage III patients had 13-times the odds of explantation compared to those who had a prophylactic mastectomy.

Background Despite a recent marked increase in the use of prepectoral direct-to-implant (DTI) breast reconstruction, concerns persist regarding the potential for elevated complication risks associated with this method. This has led to a cautious approach in adopting the technique; however, the decision-making process has been primarily based on empirical grounds, with lacking solid evidence. Identifying risk factors for adverse outcomes and utilizing them for selection would be ideal; however, previous studies have been prone to selection bias due to their focus on selected populations. This study aimed to construct a nomogram to predict the likelihood of postoperative complications following prepectoral DTI breast reconstruction, employing it in all patients without a selective process.

Methods Prepectoral DTI breast reconstruction was performed on all consecutive patients who were determined to be eligible for immediate implant-based reconstruction between August 2019 and March 2023. To identify significant predictors of complications with an incidence greater than 5%, data was partitioned into training and validation sets in a 7:3 ratios. All candidate predictors were included in the least absolute shrinkage and selection operator-penalized regression model. Using Generalized Linear Models, a predictive model was constructed, and a nomogram was developed. For complications with an incidence of less than 5%, Firth's bias-reduced logistic regression analysis was employed to construct the prediction model. Five-fold cross-validation was applied to all model. For all complications, the area under the curve (AUC) was evaluated.

Results In total, 433 breasts (362 patients) were analyzed. There were 149 cases (34.4%) of complications within 90 days after surgery, including 92 (21.2%) with delayed wound healing, 42 (9.7%) with wound revision, 14 (3.2%) with seromas, 4 (0.9%) with hematomas, and four (0.9%) with infections. Removal of implant due to complications developed in 15 cases (3.5%) in a median follow-up period of 13 months. Using patient demographics including age, body mass index and prior radiation history, and operation-related variables including mastectomy incision pattern and implant profiles, prediction models showing promising accuracy were created for early complications (AUC = 0.724), delayed wound healing (AUC = 0.682), wound revision (AUC = 0.717), seroma (AUC = 0.768) and hematoma (AUC = 0.697). Especially the prediction model for infection showed the highest AUC level of 0.849.

Conclusion The findings of the current cohort study, which included consecutive patients without a selection process, suggests that the prepectoral DTI appears to be quite safe. These nomograms could potentially predict complications following prepectoral DTI breast reconstruction and contribute to evidence-based patient selection, thereby optimizing outcomes.

Purpose: Infectious complications associated with implant-based breast reconstruction (IBBR) can be devastating and may lead to reconstructive failure. While there are known demographic risk factors for reconstructive failure, few studies have identified intraoperative findings that predict failure after attempted salvage.

Methods: Patients undergoing IBBR with acellular dermal matrix (ADM) between January 2017 and July 2023 were included (n=837). Intraoperative records of patients who developed a major infection (that required intravenous antibiotics +/- surgical intervention) were reviewed. Dictated intraoperative findings specifically reviewed included status of ADM incorporation, qualitative descriptors of pocket fluid (e.g., "purulent", "murky", "serous") and other intraoperative findings such as hypergranulation tissue or defined capsular rind. Reconstructive salvage denoted any operative intervention not resulting in device explantation (i.e., washout and device replacement/exchange). Reconstructive failure denoted device explantation at any timepoint (i.e., index washout or later date).

Results: Of 837 patients, 11.9% developed infection (n=100) and 8% developed a major infection (n=71). The average post-operative day of infection was 31.2 (STDEV = 27.6) History of prior breast radiation, bilateral reconstruction, and postoperative seroma were significantly associated with the development of any infection (OR of 1.72 [p=0.05], 2.81 [p=0.003], and 5.18 [p=0.001]). Bilateral reconstruction and postoperative seroma were significantly associated with development of major infections, with odds ratios of 2.36 and 6.51 (p=0.03, p=0.01). Bilateral reconstruction and postoperative seroma were also significantly associated with implant failure due to infection (OR 2.91 [p=0.02] and 5.51 [p=0.001], respectively).

Overall, the rate of reconstructive failure was 53.5% (n=38) and the rate of implant salvage was 46.5% (n=33). Of these, 8% (n=6) had successful treatment with IV antibiotics alone, 38% (n=27) were salvaged with operative intervention, 28.2% (n=20) failed without salvage attempt, and 25.4% (n=18) underwent salvage attempt but ultimately failed due to subsequent infection. Grossly unincorporated ADM was found intraoperatively in 51% of patients. Unincorporated ADM was significantly associated with reconstructive failure (OR 5.4, p=0.02). Of the available microbial culture data, 78% of were positive, most commonly MSSA, MRSA, Serratia, Enterobacter, or Proteus. Serratia infection, prior hematoma, and gram-negative infection were also associated with reconstructive failure, but these finding did not achieve statistical significance. Subjective description of fluid character (murky, purulent) was not correlated with outcome.

When comparing patients who had success of operative salvage to patients who eventually failed an attempt at salvage, 38% of patients with successful salvage had unincorporated ADM compared to 77% of patients who ultimately failed reconstruction. Unincorporated ADM at the time of index washout was significantly associated with failure of the salvage attempt (p=0.007).

Conclusion: In the setting of infection, the presence of unincorporated ADM within the mastectomy cavity during operative attempt at device salvage was significantly associated with eventual reconstructive failure. Surgeons should be aware that this finding may portend poor outcomes for patients. These results may be useful in informing intraoperative decision making.

Abstract Purpose Failed augmentation necessitates a surgical alternative to achieve aesthetic and functional desires without implants. The purpose of this study is to present 7-year results of an alternative explantation and mastopexy that is not mechanically dependent on skin envelope tightening, without vertical scars nor foreign materials. Method
Thirteen women underwent explantation and mastopexy in 2017 by one surgeon. Imaging was used to determine volume. Implant volume was determined from records or estimated by bra size change. Chest and breast dimensions are measured. These parameters and women's desire are used to design a surgical blueprint determining the almond shaped incision, internal cone and external breast. The almond pattern containing the areola is incised partial thickness then deepithelized. The almond's cephalad border is incised full thickness, the cephalad flap is elevated and the implant is removed. One centimeter cephalad to the almond's caudal border, the deepithelized dermis is incised partial thickness, extending its entire width. The deepithelized dermis is rotated into an oblique cone. Two long and one short straps are elevated from the cone base, leaving deep dermis intact. The long straps transfer weight, transpose, reshape and increase breast projection. The short strap defines cleavage. The cephalad flap is advanced over the cone and the areola is delivered through a hole. Simultaneously fat grafting was injected in the pectoralis major muscle or in the cephalad flap.
Secondary fat grafting was directed outside and inside the cone. Experience and Results A retrospective review from 38% of women was obtained at a mean follow up of 73 months. The mean age at explantation was 54 years and the mean implant volume was 370 cm3. Explantation was performed in 40% for ruptured implants, 40% for cosmetic reasons and 20% for migraines. A hematoma required re-operation in one woman. Minor complications were dog ears, suture erosion, hard spots that resolved and left breast numbness. Two of thirteen women underwent simultaneous fat grafting and one secondary fat grafting. She was initially satisfied but became dissatisfied at 7 years. Results were excellent in 40%, good in 40% and fair in 20%. Quality of life improved in 100% and 100% would do it again. Nipple sensation increased in 60% and unchanged in 40%. Breast position, shape, projection and feel improved in 100%, 80%, 60% and 80% respectively. Breast symmetry was better in 60% and worse in 40%. Appearance in clothing and naked improved in 100% and 60% respectively. Sixty percent appeared thinner and 50% wore clothing they couldn't previously. Eighty percent could go braless. The areola and inframammary scars were acceptable in 100% and 0% requested revisions. Vertical scars prevented 60% from selecting other techniques. Sixty percent reported "being rid of implants" was their best result. Conclusion The almond pattern eliminates vertical scars and T junctions, while concealing scars at the areola-cutaneous junction and near the new inframammary fold. Explantation and auto projecting mastopexy has a high satisfaction rate and long-lasting results. Simultaneous and secondary fat grafting were unable to satisfy explantation volume loss.

Background: Prepectoral plane for immediate implant-based breast reconstruction (IBBR) is gaining popularity. Variable data exists on differences in outcomes of prepectoral and subpectoral IBBR. Through our robust analysis in a large matched single-surgeon cohort, we aim to assess the postoperative and long-term outcomes of prepectoral versus subpectoral IBBR.

Methods: A retrospective review was conducted to identify patients who underwent immediate IBBR between 2013 to 2022 by a single surgeon at our institution. Patients were grouped into two groups, subpectoral versus prepectoral, and propensity score matched to control for comorbidities, and intraoperative variables. Immediate and long-term postoperative outcomes were analyzed.

Results: A total of 423 breast reconstructions were included (284 subpectoral and 139 prepectoral). After propensity score matching for comorbidities, adjuvant radiation, mastectomy (prophylactic vs therapeutic), and tissue expander use, 103 subpectoral and 103 prepectoral were analyzed for differences. The average follow-up time was 377.8 days (range, 31 to 1680 days). The subpectoral group had a significantly longer length of stay than the prepectoral group (1.48 days versus 0.4 days; p<0.001). In the matched cohorts, the prepectoral group had a higher rate of seromas (9.7% versus 21.8%; p=0.02). However, there was no significant difference in rates of explantation (12.6% versus 11.9%; p=0.87), hematoma (4.9% versus 3.0%, p=0.72), skin or nipple necrosis (9.7% versus 11.0%; p=0.76), or major (10.7% versus 9.1%; p=0.71) and minor (3.9% versus 5.9%; p=0.54) infections. For long-term outcomes in the matched cohort, there was no significant difference in the rate of capsular contracture (5.8% versus 1.0%; p=0.12), fat necrosis (1.95% versus 3.0%, p=0.68), and overall breast revision surgeries (43.7% versus 36.1%, p=0.27). In the matched cohorts, fat grafting rates were significantly higher in the subpectoral group (24.3% versus 12.9%; p=0.04). Subgroup analysis of radiated breasts showed no significant differences between reconstruction planes in long-term complications, breast revision surgeries (41.9% versus 35.5%; p=0.58) and fat graft rates (12.5% versus 6.1%; p=0.48).

Conclusion: Despite higher rates of seroma formation in the prepectoral group, the rate of major postoperative complications like explant, major infections, and long-term outcomes are similar for prepectoral and subpectoral IBBR, including patients receiving adjuvant radiation therapy. Additionally, prepectoral IBBR is associated with a shorter duration of hospital stay and secondary fat grafting. With appropriate patient selection, prepectoral IBBR may provide comparable results.

Introduction: Bottoming out is a well described phenomenon in both reconstructed and augmented breasts using implants. Over time, the soft tissue of the breast loses its structural integrity under the weight of a breast implant and the force of gravity. This causes preferential expansion of the breast's lower poles and can lead to implant malposition, nipple malposition, patient discomfort, and need for revision. This phenomenon happens with both saline and silicone breast implants, but many plastic surgeons anecdotally believe the frequency of bottoming out is greater with the use of saline implants. No comparative mechanical studies have been done to investigate this experience, however. Our hypothesis is that saline implants have a higher rate of bottoming out, as they impart more force on their surroundings compared to silicone implants. This study aims to develop a model of bottoming out, by examining the vertical force of silicone and saline breast implants dropped on to a force plate at varying heights.

Methods: Three silicone implants (Mentor MemoryGel Smooth Round High Profile Memory Gel: 250cc, 450cc, 650cc) and three saline implants (Mentor Smooth Round High Profile Slaine: 250cc-300cc, 420cc – 500c, 630cc-750cc) were chosen to act as matched comparisons. Silicone implants were weighed, and each corresponding saline implant was filled with saline solution to match the weight of the silicone implant. Implants were dropped from varying heights onto a force plate, and the vertical force of impact (Fz) in Newtons was recorded. Each implant was dropped five times from the varying heights and the force averaged. Implants were dropped from 5cm, 10cm, 15cm, 20cm, 25cm, and 30cm to simulate the spectrum of vertical variation that a breast implants feels through normal day to day activities (i.e, walking, running, jumping). Repeated measure ANOVA was utilized to analyze the 3 main factors (material, implant weight, and drop height) and their interactions.

Results: Saline implants at all three weights, and from all five drops heights, imparted more vertical force on the force plate when compared to their matched silicone implant. The difference in force (Fz) was found to be statistically significant at each implant weight and from all drop heights.

Conclusion: Saline implants, when dropped from varying heights impart more vertical force compared to weight matched silicone implants. The inherent properties of silicone in a breast implant act as a shock absorber and translate less force onto its surroundings, particularly in the vertical dimension. This serves as an explanation for why bottoming out is anecdotally reported more with saline implants compared to silicone implants. These findings have significant implications when selecting the appropriate breast implant for a patient. Further studies are needed for clinical correlation.

Purpose: There has been notable interest in understanding changes in sensory recovery following reduction mammoplasty given its significance in post-operative patient satisfaction (1). Several techniques are used to assess changes in sensation including Semmes-Weinstein monofilament testing, transcutaneous mechanical stimulation, and pressure-specified sensory testing. Given this array of techniques, there is currently no universally accepted method for reporting post-operative sensation in reduction mammoplasty, underscoring the absence of a standardized approach. In this study, we aimed to elucidate the differences in objective and subjective measurements of sensory recovery after reduction mammoplasty and how those measurements relate to patient-reported satisfaction.

Methods: A systematic review was conducted using PRISMA methodology to identify all studies that report preoperative and postoperative sensation and patient satisfaction following reduction mammoplasty. Six databases including Scopus, Embase, and MEDLINE were searched using the OVID engine to identify all relevant articles published through October 2023. Each article that populated was screened by two independent reviewers. Patients who had reported either preserved or increased sensation of the breast and nipple areolar complex (NAC) as well as those who reported excellent, good, acceptable, or fair satisfaction were recorded from each article identified.

Results: Of the 1,294 articles reviewed, 39 articles met inclusion criteria. A total of 33 articles provided the data required to perform a quantitative analysis, three of which used objective measures of sensation (9.09%) and 30 of which used subjective measures (90.91%). Of the studies that used subjective measures of reporting sensory outcomes, an average of 75.96% (SD=7.07) of patients had preserved or increased sensation following reduction mammoplasty, which was significantly lower than the percentage of patients that were satisfied with the overall procedure (mean=86.49%, SD=13.82) (p=0.032). Studies that used objective measures of reporting sensory outcomes, reported similar levels of sensation (mean=92.42%, SD=7.07) and satisfaction (mean=94.33%, SD=9.81) following reduction mammoplasty (p=0.80).

Conclusion: Our analysis demonstrated that higher sensation scores were recorded following reduction mammoplasty when using objective measurements as opposed to subjective measurements. In the present literature, we identified few studies that use an objective means of recording sensation outcomes after mammoplasty reduction. This highlights the current paucity in objective sensation data and emphasizes the need for incorporation of objective sensation measurements in future studies. These data suggest that subjective patient-reported or physician-reported measures of sensation may be an underrepresentation of the true degree of sensory recovery and highlights the importance of standardizing sensation measurements. Objective measures should be utilized as the gold standard, so that sensation data can be most accurately reported and disseminated in the literature.

References: 1. Schulz S, Zeiderman MR, Gunn JS, et al. Safe Plastic Surgery of the Breast II: Saving Nipple Sensation. Eplasty. 2017;17:e33. Published 2017 Nov 21.

Introduction: Previous literature suggests that nipple-areolar complex (NAC) reconstruction improves patient satisfaction following breast reconstruction.1,2 While current literature highlights the positive impact of NAC reconstruction on patients' quality of life, there has yet to be a study that includes the pre-NAC reconstruction score and directly compares patients who underwent NAC reconstruction and those who did not opt for the procedure. This study aims to compare long-term patient-reported outcomes between patients who opt for NAC reconstruction and those who do not using the BREAST-Q.

Methods: A single-center, retrospective analysis of patients who underwent skin-sparing postmastectomy breast reconstruction between 2018 and 2021 was performed. NAC reconstruction included local skin flaps, grafts, and tattoos. The following BREAST-Q domains were reviewed: Physical Well-being of the Chest, Satisfaction with Breasts, Psychosocial Well-Being, and Sexual Well-Being. Scores at the following time points were collected: T0 (preoperative, before mastectomy) and T1. T1 was defined as 1 year after breast reconstruction for those without NAC reconstruction and 1 year after NAC reconstruction for the intervention cohort. A score difference of 4 was considered to be the minimally clinically important difference (MCID).

Results: 2,858 skin-sparing breast reconstruction patients were included, of which 1796 (63%) patients did not undergo NAC reconstruction, and 1,062 (37%) did elect for NAC reconstruction.

At T1, patients who underwent NAC reconstruction reported statistically and clinically higher BREAST-Q scores. This included higher scores for Physical Well-being of the Chest (65 [IQR: 55, 78] vs. 59 [49, 71], p<0.001]; Satisfaction with Breasts (71 [59, 93] vs. 66 [53, 83], p<0.001); Psychosocial Well-Being (80 [68, 92] vs. 76 [60, 92], p<0.001); and Sexual Well-Being (56 [43, 66] vs. 50 [39, 66], p=0.002).

Differences in BREAST-Q scores between preoperative and 1-year postoperative time points were measured (ΔT1-T0). The change in scores was significantly different between the NAC reconstruction cohort and control cohort, favoring the NAC reconstruction cohort in all 4 BREAST-Q domains: Physical Well-being of the Chest (0 [IQR: -12, 13] vs. -7 [-20,8], p<0.001]; Satisfaction with Breasts [0 [-16, 14] vs. -4 [-20, 9], p=0.023]; Psychosocial Well-Being (4 [-3,18] vs. 1 [-13, 13], p=0.008); and Sexual Well-Being (7 [-8, 21] vs. 0 [-15, 16], p=0.004).

Conclusion: After skin-sparing mastectomy breast reconstruction, patients opting for NAC reconstruction reported statistically and clinically higher satisfaction in all four BREAST-Q domains. Patients may benefit from more in-depth conversations with their providers about NAC reconstruction's positive impact on their overall quality of life.

References: 1. Egan KG, Cullom M, Nazir N, Butterworth JA. Patient Satisfaction Increases with Nipple Reconstruction following Autologous Breast Reconstruction. Plast Reconstr Surg. 2021 Aug 1;148(2):177e-184e. doi: 10.1097/PRS.0000000000008180. PMID: 34133405. 2. Bykowski MR, Emelife PI, Emelife NN, Chen W, Panetta NJ, de la Cruz C. Nipple-areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer. J Plast Reconstr Aesthet Surg. 2017 Feb;70(2):209-214. doi: 10.1016/j.bjps.2016.10.009. Epub 2016 Nov 9. PMID: 27988150.

Background: Lymphedema is characterized by progressive limb enlargement and affects around 5 million individuals in the United States. The most common etiology is breast cancer related lymphedema, which occurs in 30% of patients following axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) can be performed at the time of ALND to decrease the risk of lymphedema by microsurgically anastomosing disrupted, afferent lymphatics to veins in the axilla. However, a dead space with soft tissue deficiency still exists, which can result in axillary tightness. This pilot study presents a novel method of comprehensive axillary lymphatic reconstruction following ALND using a buried dermal flap to eliminate axillary dead space and provide vascularized tissue with intact subdermal lymphatics.

Methods: A single-center retrospective review was performed to assess patients with breast cancer who underwent unilateral mastectomy and ALND without immediate reconstruction from January 2018 to December 2023. Patients were included if they had ILR attempted and were divided into two groups: Group 1 had ILR alone and Group 2 had ILR with the buried dermal flap. ILR was completed using standard techniques previously described to perform lymphovenous anastomosis for disrupted lymphatics in the axilla. The technique of our buried dermal flap involves harvesting a "random pattern" pedicled flap with a length-to-width ratio of approximately 2:1 from the inferolateral edge of the mastectomy incision. The flap is de-epithelialized and transposed over the ILR and axillary dissection dead space. Indocyanine green (ICG) lymphangiography is used to confirm intact subdermal flap lymphatics. Two sample t-tests and chi-squared tests were performed for statistical analysis.

Results: There were 28 patients included in this study: 18 patients in Group 1 and 10 patients in Group 2. Patient demographics (p = 0.53), comorbidities (p = 0.83), and breast cancer type (p = 0.66) were similar between the two groups. The primary indication for mastectomy with ALND was inflammatory breast carcinoma. There was no statistically significant difference in the mean number of lymphovenous anastomoses performed (1.6 vs. 1.7, p = 0.75). Mean operative time of 224.4 ± 51.9 minutes in Group 1 was similar to 223.9 ± 32.9 minutes in Group 2 (p = 0.97). None of the patients in Group 2 have developed any signs of lymphedema at 3-month follow up.

Conclusion: This study introduces a novel method of comprehensive axillary reconstruction following ALND using a buried dermal flap that is inset into the axilla over the ILR. The flap adds minimal operative time, which was not statistically significant. We propose that it is an efficient accessory procedure to augment ILR by providing supplementary intact lymphatic channels to the area of lymphatic injury, while obliterating the axillary dead space. Lymphangiogenesis to the flap may theoretically provide another outlet for lymphatic drainage, and the soft tissue can minimize axillary tightness. Future study includes analyzing outcome data in this patient population at follow up visits.

Introduction: It is essential to examine predictors of ideal outcomes in surgery. "Textbook outcomes" are optimal surgical results based on multiple quality measures. It is also important patients have access to trusted centers that consistently produce high quality surgical outcomes.

Methods: A retrospective review of all bilateral DIEP flap breast reconstructions at our institution from 2017 to 2022 was performed. Criteria for "textbook outcome" were OR time within one standard deviation of institutional average or less, length of stay

Results: Textbook outcomes occurred at a significantly higher rate in the co-surgeon cohort compared to the single surgeon cohort (79% vs. 57%, p = 0.025). The average OR time was significantly shorter in the co-surgeon cohort compared to the single surgeon cohort (403 minutes vs. 572 minutes, p <0.0001), and elevated OR time was the most common reason for not achieving a textbook outcome. There were no differences in the other criteria for a "textbook outcome".

Conclusion: Textbook outcomes in bilateral DIEP flap breast reconstruction are achieved at significantly higher rates with a co-surgeon. This is primarily due significantly shorter OR times. Further research into factors affecting textbook outcomes is needed.