Scientific Abstract Presentations: Breast Session 10 Saturday, September 28 Sat, Sep 28 5:00-6:00 p.m. PDT

Background:

Despite advances in technology and techniques of the last 50 years, capsular contracture remains one of the most common complications after the placement of breast implants for both cosmetic and reconstructive surgery.1 Montelukast and other leukotriene receptor antagonists have been suggested as a possible treatment, with improvement in both prevention and treatment of capsular contracture.2,3 However, most in vivo studies concern patients undergoing cosmetic augmentation.4,5 This study sought to explore capsular contracture in high-risk patients, including those with previous breast reconstruction at risk for recurrent capsular contracture.

Methods:

A single institution, IRB-approved, retrospective study was performed. Data were collected on all patients that underwent peri-implant capsulectomy and implant replacement from 2019 to 2023 by a single surgeon. Patients were grouped into two cohorts: those who started montelukast prophylactically, and who did not. All patients underwent a similar surgical technique, including capsulectomy and implantation with or without acellular dermal matrix using a "no-touch" technique. Patients were offered prophylactic montelukast therapy. The patients that received montelukast prophylactically did so during a three-month trial period. Prophylactic montelukast therapy was started within one month of surgery. Demographic data were collected on all patients, and the primary outcome was measured as Baker capsule grade at the preoperative visit, 3 months postoperatively, and at most recent follow up.

Results:

A total of 35 patients met inclusion criteria for the study. The prophylactic montelukast cohort held 13 patients who agreed to therapy. The control cohort consisted of 22 patients. Preoperative and intraoperative characteristics showed no significant differences in demographic data, exposure to risk factors such as chemotherapy or radiation, location of initial implant, implant size, and use of acellular dermal matrices. There was a significant difference in both Baker grade at the three month follow up after capsulectomy and implant exchange for patients taking prophylactic leukotriene (1.54 vs 2.09, p=0.04), as well as the absolute reduction in Baker grade from preoperative grade to final grade (2.45 vs 1.58, p<0.01). Eight patients in the non-prophylactic cohort began taking montelukast therapy as treatment for capsular contracture, starting several months after their surgery. There were no reports of side effects in 21 patients taking montelukast. There was no significant difference in the use of indefinite montelukast therapy.

Conclusion:

The present study indicates possible positive outcomes for montelukast therapy in prevention of capsular contracture for high-risk. The present study is limited by its size and retrospective nature. Larger, prospective studies are imperative to ascertain the efficacy of leukotriene receptor antagonists before advocating their widespread use alongside surgical intervention of severe capsular contracture.

1 Hammond JB, Kosiorek HE, Cronin PA, Rebecca AM, Casey WJ 3rd, Wong WW, Vargas CE, Vern-Gross TZ, McGee LA, Pockaj BA. Capsular contracture in the modern era: A multidisciplinary look at the incidence and risk factors after mastectomy and implant-based breast reconstruction. Am J Surg. 2021 May;221(5):1005-1010. doi: 10.1016/j.amjsurg.2020.09.020. Epub 2020 Sep 21. PMID: 32988607.

2 Bastos EM, Sabino Neto M, Garcia EB, Veiga DF, Han YA, Denadai R, Santos Rde A, Ferreira LM. Effect of zafirlukast on capsular contracture around silicone implants in rats. Acta Cir Bras. 2012 Jan;27(1):1-6. doi: 10.1590/s0102-86502012000100001. PMID: 22159431.

3 Kang SH, Shin KC, Kim WS, Bae TH, Kim HK, Kim MK. The preventive effect of topical zafirlukast instillation for peri-implant capsule formation in rabbits. Arch Plast Surg. 2015 Mar;42(2):179-85. doi: 10.5999/aps.2015.42.2.179. Epub 2015 Mar 16. PMID: 25798389; PMCID: PMC4366699.

4 Wang Y, Tian J, Liu J. Suppressive Effect of Leukotriene Antagonists on Capsular Contracture in Patients Who Underwent Breast Surgery with Prosthesis: A Meta-Analysis. Plast Reconstr Surg. 2020 Apr;145(4):901-911. doi: 10.1097/PRS.0000000000006629. PMID: 32221199.

5 Pașca A, Bonci EA, Chiuzan C, Jiboc NM, Gâta VA, Muntean MV, Matei IR, Achimaș-Cadariu PA. Treatment and Prevention of Periprosthetic Capsular Contracture in Breast Surgery With Prosthesis Using Leukotriene Receptor Antagonists: A Meta-Analysis. Aesthet Surg J. 2022 Apr 12;42(5):483-494. doi: 10.1093/asj/sjab355. PMID: 34618886.

Background Post-mastectomy lymphedema syndrome (PMLS) is a chronic condition characterized by extremity and torso swelling, impacting many who undergo mastectomy. Autologous breast reconstruction (ABR) has been shown to reduce the incidence and severity of PMLS, although it is still highly prevalent and burdensome. The management of PMLS can be very costly to patients long-term. We aimed to compare PMLS complications and costs among patients who underwent immediate, delayed-immediate, and delayed ABR to determine whether timing of reconstruction impacts burden of care in PMLS.

Methods MerativeTM MarketScan® Research Databases were queried for women aged 18 years and older with a history of mastectomy and subsequent PMLS diagnosis from 2007 to 2019. Patients were stratified by the timing of their ABR relative to mastectomy. They were then evaluated for the severity of disease, as shown by complications secondary to PMLS and the rates of non-operative and operative management. The cost of care associated with these complications, procedures, and visits were also examined. Differences between groups were determined using one-way ANOVA and associations were determined via multivariate logistic regression models.

Results A total of 11,491 subjects were included in the study. Most subjects with PMLS had undergone mastectomy without subsequent breast reconstruction (93.1%). Of those who pursued ABR, most underwent immediate reconstruction (5.2%), followed by delayed-immediate (1.3%), and delayed (0.3%) ABR. Immediate ABR patients had the highest rates of diabetes (p = 0.003) and obesity (p = 0.051). Among complications secondary to PMLS, those who underwent immediate ABR most often developed lymphangitis (p = 0.016). Other PMLS complications, including cellulitis, lymphadenitis, deep vein thrombosis, and superficial infection, were observed at similar rates among the three groups. Delayed-immediate ABR patients required the least non-operative management for PMLS (p = 0.012) and had decreased odds of undergoing non-operative management (OR = 0.57, 95% CI: 0.39-0.85). In contrast, delayed ABR patients required the most operative management for PMLS (p = 0.046), particularly for suction-assisted lipectomy (p < 0.001). Across all three groups, there were no significant associations between the timing of ABR and the likelihood of undergoing vascularized lymph node transfer (VLNT) or lymphovenous bypass (LVB) for operative management of PMLS. The overall cost of care for both operative and non-operative management of PMLS did not significantly differ based on the timing of ABR.

Conclusion Our study concludes that the timing of ABR relative to mastectomy does not significantly impact the severity and cost of PMLS. However, slight variations in the rate of complications secondary to PMLS are evident between the three groups, as are variations in the need for non-operative and operative management. Further characterization of the patient population may provide context towards any socioeconomic imbalances that drive these outcomes. Importantly, our findings revealed that the bulk of expenses related to PMLS are attributed to the cost of undergoing conservative management, including occupational therapy visits, diagnostic imaging, and bandaging supplies or compression garments. In summary, we recommend prioritizing early diagnosis and management of PMLS to prevent exorbitant health and financial burdens, irrespective of ABR timing.

PURPOSE. New surgical techniques are giving patients and physicians more procedural options for post-mastectomy breast reconstruction (BR). There are two major categories for BR type: implant based & autologous flaps. The rate of post-mastectomy BR has also slowly increased over the past decade, resulting in improved cosmetic outcomes, increased psychological well-being, and increased quality of life. However, the rate of BR and medical comorbidities continues to differ significantly among White, Black, Latina, and Asian patients. There exists limited research on the intersection of BR Patient Reported Outcomes (PROs) and the following four factors: 1) Social Determinants of Health (SDH) 2) Race 3) BR Type 4) Complications.

This study aims to assess the impact of SDH, race, and type of BR on complication profiles and on PROs. Phase 1 of this study specifically explores the impact of SDH and race on PROs.

METHODS. Patients who underwent a breast reconstruction post-mastectomy from January 2011 to February 2024 and present to the Northwestern Plastic Surgery Clinic are recruited prospectively to fill out two validated BREAST-Q Reconstruction Module Pre- and Postoperative Scales: Psychosocial Well-Being and Satisfaction with Breasts. Additional survey responses include race/ethnicity, income, insurance, housing status, transportation and food access, safety, address, & health literacy. The correlation between these factors with PROs is assessed. Participant addresses are converted to 2022 National Social Vulnerability Index (SVI) and domicile-to-clinic distance is calculated. SVI scores range from 1 to 1,000 with higher scores indicating greater socioeconomic disadvantage. A total of 31 patients were recruited for phase 1.

RESULTS. Respondents identified as African American (AA)/Black (5), Hispanic/Latino (2), White (23), and Asian (2). Thirty participants reported addresses within 140 miles of the clinic, with one respondent reporting an address 987 miles away. No significant correlations were found for the group at large between distance traveled, SVIs, and BREAST-Q subscale scores. However, the SVI comparisons indicate that AA/Black respondents were twice as likely to come from disadvantaged neighborhoods compared to other respondents. The data show, for AA/Black individuals, there may be a correlation between distance travelled versus SVI, Well-Being, and Satisfaction with Breasts, indicating that those respondents further away were more likely to be from disadvantaged neighborhoods yet more satisfied with the results of the surveys than non-AA/Black respondents. Similarly, there was a positive influence between SVI versus Psychosocial Well-Being and versus Satisfaction with Breasts noted for AA/Black respondents while non-AA/Black participants had the opposite experience.

CONCLUSION. Despite no significant correlations between distance traveled, SVI, or BREAST-Q scores for the group at large, this study confirms further investigation into SDH influence will be beneficial. While previous studies have focused on the impact of race, Phase 1 analysis indicates that research should consider domicile socioeconomic factors as perhaps a greater influence for identifying driving factors of BR satisfaction. Phase 1 was intended to identify key factors for consideration in subsequent research. We hope to eventually provide insight into unique challenges of racial minorities navigating the BR pathway, which may inform interventions for improving surgical outcomes of women of color.

Background: Direct-to-implant prepectoral breast reconstruction is becoming increasingly favored (Safran et al., 2019). The reliability and safety of variables such as timing and device placement in this setting continue to evolve in the literature. These considerations are even more controversial in the setting of obesity and breast ptosis due to a concern for increased perioperative morbidity (Bonomi et al., 2019). The goal of this study was to review surgical outcomes after direct to implant, prepectoral breast reconstruction in a patient population with a wide range of body mass indices (BMI).

Methods: A retrospective review of patients who underwent prepectoral, direct-to-implant breast reconstruction from May 2019 – July 2022 by a single surgeon was conducted. Patient demographics, medical history, operative course, and postoperative complications were reviewed. Major complications were defined as instances necessitating a return to the operating room. Patients were categorized by BMI, with subgroups of less than or greater than 30 kg/m2. An additional analysis of patients who underwent skin reducing mastectomy was performed.

Results: Thirty-one patients (54 breasts) were included, with an average BMI of 30 kg/m2. Mastectomy types comprised wise pattern skin reducing including elevation of an inferiorly based adipodermal flap (55%), skin sparing (33%), and nipple sparing (9%). Immediate reconstruction was performed in 58% of cases, while 42% required a vascular delay (greater than 2 weeks, but less than 30 days). Sixteen patients had a BMI less than 30 kg/m2, while 15 patients had a BMI greater than 30 kg/m2. Major complication rates were comparable in the lower BMI and higher BMI groups at 32% and 20%, respectively. In the skin reducing mastectomy analysis, major complication rates of the lower and higher BMI groups were 38% and 13%, respectively.

Conclusions: Our study demonstrates that prepectoral direct-to-implant breast reconstruction is a viable option for patients with varying body mass indices, including those with a BMI greater than 30 kg/m2. Despite concerns about increased perioperative morbidity in this population, our findings suggest that complication rates are comparable to those reported in the literature (Castagnetti et al., 2022), (Safran et al., 2021). Further research is necessary to validate these findings and provide more robust evidence regarding the outcomes of prepectoral reconstruction in patients with obesity and breast ptosis.

[1] Safran, Tyler M.D.; Al-Halabi, Becher M.D., M.Sc.; Dionisopoulos, Tassos F.R.C.S.C.. Prepectoral Breast Reconstruction: A Growth Story. Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 525e-527e doi: 10.1097/PRS.0000000000005924

[2] Bonomi S, Sala L, Gennaro M, Ricci C, Cortinovis U. Skin-Reducing Mastectomy and Direct-to-Implant Breast Reconstruction With Submuscular-Dermal-Mesh Pocket. Ann Plast Surg. 2019 Jan;82(1):19-27. doi: 10.1097/SAP.0000000000001614. PMID: 30247191.

[3] Castagnetti F, Coiro S, Foroni M, Falco G, Mele S, Cenini E, Begnini E, Borgonovo G, Ferrari G. A Pure Autologous Dermal Graft and Dermal Flap Pocket in Prepectoral Implant Reconstruction After Skin-Reducing Mastectomy: A One-Stage Autologous Reconstruction Alternative to Acellular Dermal Matrices. Aesthetic Plast Surg. 2022 Aug;46(4):1679-1685. doi: 10.1007/s00266-022-02800-2. Epub 2022 Feb 9. PMID: 35138424.

[4] Safran, T. , Al-Halabi, B. , Viezel-Mathieu, A. , Boileau, J. & Dionisopoulos, T. (2021). Skin-Reducing Mastectomy with Immediate Prepectoral Reconstruction: Surgical, Aesthetic, and Patient-Reported Outcomes with and without Dermal Matrices. Plastic and Reconstructive Surgery, 147 (5), 1046-1057. doi: 10.1097/PRS.0000000000007899.

Introduction: Breast reconstruction surgery, particularly implant-based procedures, often involves the use of a triple-antibiotics irrigation solution to reduce the risks of infection and capsular contracture. However, concerns have arisen regarding the continued efficacy of cefazolin, a key component of this solution, due to the emergence of cefazolin-resistant gram-positive bacteria. This study aims to assess the safety and efficacy of excluding cefazolin from the triple-antibiotics irrigation regimen in prepectoral direct-to-implant breast reconstruction.

Method: A retrospective analysis was conducted on patients who underwent immediate prepectoral direct-to-implant breast reconstruction between September 2020 and April 2022 at Samsung Medical Center. Patients were categorized into two groups based on the irrigation solution utilized during surgery: the triple-antibiotics group, consisting of cefazolin, gentamycin, and povidone-iodine, and the dual-antibiotics group, which omitted cefazolin but included gentamycin and povidone-iodine. Data regarding postoperative complications, including infections and capsular contracture, were collected. Statistical analyses were performed to compare complication rates between the two groups and to evaluate the independent associations between irrigation type and adverse outcomes.

Result: A total of 445 cases were included in the analysis, with 126 cases in the triple-antibiotics group and 319 cases in the dual-antibiotics group. The mean follow-up period was 12 months. Overall, complications occurred in 28.3% of cases, including 2.7% infections and 7.2% capsular contracture. However, there was no significant difference in complication rates between the two groups. Multivariable analysis further confirmed that irrigation type was not associated with the development of overall complications, infections, or capsular contracture.

Conclusion: The exclusion of cefazolin from the triple-antibiotics irrigation solution did not appear to increase the risks of infection or capsular contracture in prepectoral direct-to-implant breast reconstruction. These findings suggest that cefazolin may not be indispensable in irrigation solutions for this procedure. However, further long-term studies are warranted to validate the safety and efficacy of omitting cefazolin and to provide more comprehensive insights into the optimal antimicrobial regimen for breast reconstruction surgeries.

Purpose: Implants are the most common method of post-mastectomy breast reconstruction in the United States. The ideal plane and position of tissue expander/implant placement has become a critical consideration in surgical decision-making between the surgeon and patient. While prepectoral implant-based reconstruction (IBR) has recently become popularized to avoid animation deformity (AD) typically associated with subpectoral IBR, there is a paucity of high-quality evidence comparing outcomes and impact specifically on patient satisfaction. This study aims to evaluate the impact of AD on patient-reported outcomes (PRO) by comparing two-stage prepectoral vs. subpectoral reconstruction.

Methods: In this retrospective study, patients who underwent two-stage tissue expander to implant breast reconstruction between August 2019 to December 2022 were divided into prepectoral or subpectoral groups; and demographics, co-morbidities, and complication data were collected. Eligible patients were asked to complete the BREAST-Q Animation Deformity scale and Reconstruction-Postoperative modules. Mean and standard deviation were used to report descriptive statistics. A t-test was used to assess differences in scores between the two groups.

Results: Among 82 patients, 33 and 49 patients underwent two-stage prepectoral and subpectoral IBR, respectively, with comparable complications and revision rates. As expected, the subpectoral cohort had a lower (worse) Animation Deformity Scale score compared to prepectoral (72±19 vs. 83±15, p=0.004), consistent with greater AD. Interestingly, despite the difference in AD PRO between the two groups, there was no statistically significant difference in BREAST-Q scores for Satisfaction with Breasts (p=0.3), Physical Well-Being: Chest (p=0.8), or Satisfaction with Implants (p=0.065). However, Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in the prepectoral cohort (p=0.019 & p=0.009 respectively).

Conclusions: Although animation deformity is associated with subpectoral IBR, it does not appear to impact overall breast reconstruction satisfaction based on PRO. However, prepectoral IBR demonstrated higher psychosocial and sexual well-being scores. While requiring further investigation, this work provides valuable data to enhance informed decision-making regarding the optimal IBR tissue plane and demonstrates the need for thoughtful risk-benefit analysis by incorporating both clinical factors and PRO.

Purpose

The Goldilocks mastectomy (GM) utilizes a Wise-pattern skin excision creating a de-epithelized inferior dermal flap that can act as a replacement for acellular dermal matrix (ADM) products. In this case series, both autologous and implant reconstructive options were included with the aim to present how our modifications have decreased cost without sacrificing surgical outcomes.

Methods

A retrospective review was performed for all patients who underwent a mastectomy from April, 2022 to December, 2023, both traditional and goldilocks procedures. No patients were excluded based on age, co-morbidities, or BMI. Primary outcomes were the raw cost of the procedure and complications rates.

Results

A total of 52 patients (91 breasts) were included in this study, with 36 undergoing a GM. Average age was 48 years and average BMI was 27.6 kg/cm 2. Half the patients (47%) had delayed implant reconstruction, 33% had delayed autologous free-flap reconstruction with the remainder undergoing immediate autologous reconstruction. ADM was required in 33% of patients undergoing traditional mastectomy with an average raw cost of $18,414. The GM cohort utilized ADM in 12% of cases leading to an average cost of $7,462 demonstrating a significant difference (p < 0.001). Only 4 out of the 36 GM (11%) patients experienced clinically significant complications.

Conclusion

The Goldilocks mastectomy using an inferior dermal pedicle is a safe technique that provides an optimal mastectomy pocket for breast reconstruction by using autologous tissue for prosthesis coverage, which significantly decreases the overall price of the procedure without compromising surgical outcomes.

Background: Therapeutic mammoplasty (TM) for breast tumors is a widely practiced and versatile oncoplastic technique. The aim of our review was to analyze oncological and aesthetic outcomes over a 7 year period.

Materials and Methods: Retrospective chart review of 552 patients who underwent TM from June 2015 to December 2021 with the author was completed. Data recorded included demographics, surgical techniques, operative time, risk factors, histological findings and details of adjuvant therapy. Wound healing risk factors assessed included smoking, obesity, diabetes, adjuvant therapy. Outcome measures included complication rate (early and late), duration of follow up, recurrence rate, mortality rate, cosmetic results, and patient satisfaction. Primary chemotherapy was used to downsize large tumors. Intra-operative margin assessment was performed in all patients with breast cancer. Cosmetic outcomes were assessed by evaluation of photographs by an independent review panel.

Results: 87% of the patients underwent TM for breast cancer, 13% had benign tumors. 118 (21.4%) of the cancer patients received primary chemotherapy. Intraoperative radiation therapy (IORT) was performed in 111 (20.1%) of patients. Mean tumor size was 15.9 mm. Mean resection weight was 259 g. Mean margin taken was 16 mm. Back to OR rate was 1.6% (9 cases). Contralateral occult disease was identified in 11 cases (2.2%). Early complication rate (<2 months) was 2.9% (16 cases). Late complication rate (> 2 months) was 5.7% (31 cases). Mean follow up was 42 months. Recurrence rate was 3.8%. Mortality rate was 3.1%. Overall survival was 96.4% and disease-free survival 94.2%. Excellent and good aesthetic results were achieved in 93.8%. Patient satisfaction was 92%.

Conclusion: TM is a versatile technique that can safely address tumors in all breast quadrants due to multitude of available pedicles. It is an oncologically appropriate and cosmetically favorable technique. Primary chemotherapy allowed for TM in patients with large tumor-to-breast ratio at presentation. Intraoperative margin assessment was imperative for increasing re-operation rates. TM addresses breast ptosis, asymmetry, and improves breast contour which results in high patient satisfaction due to improved breast appearance.

Purposes: Breast augmentation is one of the most performed surgical procedures in the field of plastic surgery, yet it is associated with a significant re-operation rate of 15% to 20% within three years. This underscores issues with patient education, implant selection, and pre-operative planning (1). Recent advancements in 3D imaging, such as VECTRA 3D, enhance breast augmentation simulations, assisting both patients and surgeons in preoperative planning. This study evaluated the accuracy of VECTRA 3D volume and linear measurements simulations compared to postoperative outcomes and examined how demographics and surgical factors influence accuracy. Validating the tool's precision would significantly enhance the doctor-patient partnership, patient education, and ultimately patient satisfaction (2). Methods: A prospective cohort study was conducted from January 2021 to December 2022, involving 78 patients and 154 breasts whose primary breast augmentation surgeries were simulated using VECTRA 3D's algorithm. A predictive volumetric accuracy analysis was performed, with a precision threshold set at ±10% of the postoperative volume (3). Results: 73% of breasts were accurately predicted within ±10% error, with an absolute difference between methods of 39.44cc or 7.52%. Postoperative breast volume averaged 521.2cc, while forecasted volume was 529.2cc, with a 1.49% relative volume difference (p-value = 0.07), indicating slight overestimation. Precision decreases with larger postoperative breasts (>650cc). Notably, Nipple-IMF measurement had the highest difference (8.7%, p<0.001), while Sternal-Nipple had the lowest (2.4%, p=0.64). BMI and preoperative breast volume influenced accuracy. Conclusion: VECTRA 3D is generally reliable for forecasting postoperative breast volumes. Accuracy declines as the volume of postoperative breast augmentation increases. Surgeons should consider BMI and preoperative breast volume when using this tool. VECTRA remains valuable for patient consultations, improving education, communication, and surgical outcomes.

1. Teitelbaum S. A. (2015). Augmentation mammaplasty: principles, techniques, implant choices and complications. In Grabb and Smith's Plastic Surgery (pp. 565).
2. Adams Jr W. P. (2008). The process of breast augmentation: four sequential steps for optimizing outcomes for patients. Plastic and Reconstructive Surgery, 122(6), 1892-1900.
3. Roostaeian J. (2014). Three-Dimensional Imaging for Breast Augmentation: Is This Technology Providing Accurate Simulations? Aesthetic Surgery Journal, 34(6), 857-875.