Scientific Abstract Presentations: Breast Session 5 Friday, September 27 Fri, Sep 27 8:00-9:30 a.m. PDT

Purpose: Although access to post-breast cancer reconstructive surgeries continues to improve, inequities in its delivery and utilization still remain. Post-mastectomy reconstruction remains a crucial component of the physical and psychosocial domain of breast cancer care. Previous studies have demonstrated a breast reconstruction care gap, in part fueled by racial and socioeconomic disparities. The purpose of this study is to use Area Deprivation Index (ADI) to assess the full impact of other sociodemographic factors on access and utilization of breast reconstruction.

Methods: This was a retrospective cohort of patients who underwent breast cancer surgery from 2014-2019. Patients were stratified by race, age, ADI, median household income, and geography. Population and socioeconomic data were obtained from the United States Census Bureau. ADI was calculated and stratified by the top 25% (most disadvantaged neighborhoods). Charts were abstracted, summary statistics were computed, and a binomial regression was used to calculate relative risks (RR). Significance was assessed at alpha=0.05.

Results: 5619 patients underwent breast cancer surgery. The average age at diagnosis was 60.2 ± 12.5 years. 37 patients (0.7%) were not female, 568 (10.1%) were a minority race, 523 (9.3%) lived in rural locations, and 460 (8.2%) had a median annual household income < $43,000. 2238 patients (39.8%) lived in neighborhoods with the top 25% ADI. Compared to Caucasians, African American patients had a 34% reduced likelihood of breast reconstruction, while Asian patients had a 60% reduced likelihood of reconstruction (RR 0.66, CI 0.49-0.91, p=0.009; RR 0.40, CI 0.16-0.98, p=0.04, respectively). Compared to urban patients, rural patients were more likely to have breast reconstruction (RR 1.51, CI 1.23-1.85, p<0.001). Compared to lower-income patients, patients with income > $71,000 were more likely to have reconstruction (RR 1.19, CI 1.08-1.31, p<0.001). Compared to younger patients, patients > 60 years old had a 55% reduced likelihood of breast reconstruction (RR 0.45, CI 0.39-0.51, p<0.001). Compared to patients from lower ADI neighborhoods, patients from the top 25% ADI neighborhoods had a reduced likelihood of breast reconstruction (RR 0.76, CI 0.68-0.85, p<0.001).

Conclusions: The use of ADI in numerous recent studies has provided a more inclusive and concrete method to assess the true impact of sociodemographic factors on health care across neighborhoods. We have demonstrated that there are more drivers of this complex gap than household income and race alone; the disparity exists due to a sum of system-wide issues putting individual neighborhoods at the highest risk.

Purpose:

The integrity and longevity of silicone breast implants are critical in plastic surgery, affecting patient outcomes and the success of breast augmentation and reconstruction. Given reported rupture rates ranging from 5.4% to 34.2% within ten years of implantation, examining irrigating solutions' interaction with silicone implant shells is vitally important (1). The study's purpose is to determine the impact of various solutions on breast implants' shell integrity based on typical immersion times during operative procedures.

Methods and Materials:

Silicone implants were divided into 80 equal pieces, each measuring 2.5 cm x 2.5 cm. Each of the 80 implants were divided into 4 equal groups and soaked in a specific solution. These groups were saline solution, an antibiotic solution, a dilute chlorhexidine gluconate solution (Irrisept ®), SAF-Clens® AF Dermal Wound Cleanser, and betadine solution. Saline solution served as a baseline control. A three-antibiotic (clindamycin-cefazolin-gentamicin) solution served as a gold standard control. The soaks lasted for 60 seconds, after which the implants were calibrated to a commercial tensiometer (Mxmoonfree 500N Digital Force Gauge). Tension was measured in Newtons over a displacement of 1.0 cm.

Results:

Our results are summarized in Table 1, and our statistical analyses are summarized in Table 2.

The average tensile strengths were as follows: saline at 8.25 N, triple antibiotic at 8.94 N, chlorhexidine gluconate at 8.84 N, SAF-Clens® AF at 7.41 N, and betadine at 8.01 N. Using a two-tailed T-test, a statistically significance difference was observed between the groups of triple antibiotic solution vs betadine (P=0.0394) and the triple antibiotic solution vs. SAF-Clens ® AF (P= 0.0032).

Conclusion:

This study elucidates the subtle yet significant effects of irrigation solutions on silicone breast implant tensile strength. Although most solutions showed no significant difference from saline, the notable variance between antibiotic, SAF-Clens ® AF, and betadine solutions underscores the importance of choosing irrigation agents that avoid compromising silicone implant material. While we know that antibiotic solutions designed specifically for surgical implant procedures offer a safe method of targeting bacterial infections, solutions like chlorhexidine gluconate offer a promising alternative in sterilization for intraoperative use. These findings guide clinicians in optimizing intraoperative practices to protect implant durability and patient well-being. Further research is advised to examine long-term impacts of solution exposure on implant integrity and establish best-use guidelines for these agents, thereby improving plastic surgery care quality. Surgeons should exercise caution and consider alternative options when selecting irrigation solutions for breast implant surgeries to ensure the best possible outcomes for patients.

References

1) Hillard C, Fowler JD, Barta R, Cunningham B. Silicone breast implant rupture: a review. Gland Surg. 2017;6(2):163-168. doi:10.21037/gs.2016.09.12

Introduction: Breast reconstruction after mastectomy is an important step in the management and treatment of breast cancer. Though reconstruction has been deemed beneficial for postmastectomy patients, the literature on racial disparities in breast reconstruction outcomes is mixed. One study found that IBR surgical complication rates did not differ by race/ethnicity (1) whereas another reported that Black patients were significantly more likely to experience all-cause complications compared to White patients (2). To date, no study has examined potential mediators of the racial/ethnic differences in immediate breast reconstruction complication rates (IBR). The authors sought to examine mediators of the racial differences (Black vs White) in IBR complication rates using the American College of Surgeons–National Surgery Quality Improvement Program (ACS-NSQIP) data sets.

Methods: A cross-sectional study design was used to assess racial differences in IBR complication rates and explore to what extent these differences are explained by the following covariates: age, menopausal status, BMI, diabetes status, smoking status, and socioeconomic status (SES). Self-identified Black or White women, ages 45 years and above from the NSQIP during the years 2012 to 2022. Women were excluded if they have no values available for the covariates IBR is defined as two different outcomes: implant-based (E/I) reconstruction (mastectomy only vs E/I reconstruction) and autologous reconstruction (mastectomy only vs autologous reconstruction). A logistic regress was used to estimate differences in IBR outcomes for Black versus White women. A mediation analyses was used to determine the extent to which the covariates mediate the association between race and our outcome.

Results: Overall, 60,003 post-mastectomy patients were included; of these, 20,001 (33%) underwent IBR. Of these patients undergoing reconstruction, the vast majority received implant-based reconstruction (76%) compared with autologous (24%). Overall, 24,789 Black women and 35,214 White women were included in our analysis. Black women were 12% more likely to have IBR complications (95% CI: 1.12 [1.02, 1.30]), adjusted for age, menopausal status, BMI, diabetes status, smoking and SES. Mediation analyses suggested that 43% of the treatment delay among Black women could be removed if an intervention equalized their age, menopausal status, BMI, diabetes status, smoking status, and socioeconomic status (SES) to that of White patients. The largest mediating factor was BMI, accounting for 48% of the racial disparity in IBR complication rates.

Conclusion: Black women are 12% more likely to experience IBR complications. Equalization of the mediators used in this study could reduce the disparities by 48% for Black women. Future research should identify other causes of racial disparities in complication rates and intervene accordingly.

1. Butler PD, Nelson JA, Fischer JP, et al. Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality Improvement Program data sets. Am J Surg. 2016;212(1):96-101. doi:10.1016/j.amjsurg.2015.08.025
2. Johnstone T, Thawanyarat K, Rowley M, et al. Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis. J Racial Ethn Health Disparities. Published online April 19, 2023. doi:10.1007/s40615-023-01599-1

Background: Women with high-risk breast cancer frequently undergo therapeutic mastectomy followed by postmastectomy radiation therapy (PMRT) prior to definitive delayed autologous breast reconstruction (DBR). The alternative is a one-staged immediate autologous breast reconstruction (IBR) approach followed by irradiation of the reconstructed breast tissue. While DBR is more common, data in the literature is still unclear as to the superiority of DBR versus IBR in the context of PMRT. Our study aims to compare complication rates and the need for revision surgeries between the DBR group and the IBR group as well as the difficulty of microsurgical breast reconstruction in a radiated versus nonradiated field.

Methods: We conducted an IRB-approved retrospective study of all patients who received a mastectomy followed by deep inferior epigastric perforator (DIEP) reconstruction at our institution in the setting of PMRT. Exclusion criteria included history of prior radiation and history of permanent implant-based reconstruction. Wilcoxon-Mann-Whitney test was used to analyze the minor complication rates (not requiring return to the operating room), major complication rates (requiring return to the operative room), and revisional surgery rates ranging from the date of mastectomy to the final follow-up date at our institution. Intraoperative notes were closely investigated for flap loss or other intraoperative complications including arterial thrombosis, venous thrombosis, and technical difficulty (artery or vein requiring reanastomosis).

Results: 164 patients were identified from 2016 to 2022 at our institution who underwent deep inferior epigastric perforator (DIEP) breast reconstruction and PMRT of one breast. Of the 164 patients, 147 underwent DBR while 17 underwent IBR. Age at reconstructive surgery, smoking status, and diabetes mellitus status between the two groups did not differ. The DBR group had 2 complete flap losses and 3 partial flap losses while the IBR group had no flap losses or partial flap losses (p=0.712, p=0.798). There were 3 incidences of intraoperative flap failure in the DBR group and zero incidences of flap failure in the IBR group (2.1% versus 0%, p=0.798). Rates of intraoperative arterial thrombosis, venous thrombosis, or required reanastomosis did not significantly differ between the two groups. There were no significant differences in major complication rates (z=1.273, p=0.203), minor complication rates (z=-0.025, p=.980), or revisional surgery rates (z=1.128, p=1.128). Of note, there were no significant differences in fat necrosis excisions after DIEP breast reconstruction in DBR versus IBR (6.9% versus 1.3%, p=0.413). The DBR group did average 0.43 pre-DIEP major complications which required a return to the OR while the IBR group averaged 0 due to the timeline of their surgery (z=2.53, p=0.011).

Conclusion: While the total complication and revision rates did not differ between patients receiving IBR with PMRT and DBR with PMRT, pre-DIEP complication rates are inherently absent in the IBR group and may be a significant factor in patients receiving DBR.

Background: Acellular dermal matrices (ADMs) are commonly used in tissue expander-based breast reconstruction (BR) despite incomplete FDA clearance [1]. Comparative studies on BR with and without ADM are limited to retrospective, single institution reviews with small sample sizes [2]. Current literature largely demonstrates no difference in complication rates between cases with and without ADM. Yet, the limited number of direct comparative analyses serves as a major barrier to FDA approval, and the implant-based breast reconstruction literature largely consists of low strength of evidence studies [3]. Further, there is a significant correlation between ADM-related publications and industry funding [4]. In this study, we leverage a national database to better assess the complication profile among female patients undergoing expander-based BR with and without ADM.

Methods: The data used in this study was collected from the TriNetX Network, which provided access to electronic medical records from approximately 114 million patients from 80 healthcare organizations. Female patients who underwent bilateral or unilateral tissue expander-based BR were included utilizing International Classification Code 10 and Current Procedural Terminology codes. Patients were divided into two groups based on ADM utilization. Representative subgroups were created based on postoperative radiation treatment. Propensity-score matching was performed to isolate the effect of ADM in all groups. Groups were assessed up to 6-months after initial tissue expander placement for the following outcomes: seroma, surgical site infection (SSI), hematoma, capsular contracture, dehiscence, and explanation. Comparative statistics were performed using the TriNetX analysis tool with a significance threshold set at an alpha value of 0.05, denoted as p<0.05.

Results: Of the 15,661 tissue expander-based BR patients, 10,154 (64.8%) underwent BR alone while 5,507 (35.2%) underwent BR with ADM. Reconstruction with ADM was associated with a significantly increased risk of seroma, SSI, hematoma, capsular contracture, dehiscence, and explantation up to 6-month postoperatively (p<0.05). However, postoperative radiation was found to be greater among the ADM group compared to the no ADM group (15.51% vs 8.26%, p< 0.0001). There were no differences in the risk of all breast-related complications for ADM vs no ADM among patients receiving postoperative radiation (p>0.05). Among patients with no postoperative radiation, reconstruction with ADM was associated with an increased risk of seroma (Risk Ratio(RR): 1.385, 95% CI: 1.109-1.729, P=0.0039), hematoma (RR: 1.357, 95% CI: 1.126-1.636, P=0.0013), dehiscence (RR: 1.374, 95% CI: 1.152-1.639, P=0.0004), and explantation (RR: 1.404, 95% CI: 1.131-1.743, P=0.0020).

Conclusion: This is the largest report, to our knowledge, demonstrating the risk profile of expander-based BR with ADM. There may be a role for ADM among patients undergoing postoperative radiation therapy. The results of this study further warrant critical investigation by way of multicenter randomized controlled trials in order to establish superiority, equivalence, or non-inferiority of ADM in BR in alignment with FDA regulations [5].

References

1 Administration,U.S.F.a.D.AcellularDermalMatrix(ADM)ProductsUsedinImplant-Based BreastReconstructionDifferinComplicationRates:FDASafetyCommunication.(2021). 2 Nolan,I.T.etal.Do we need acellular dermal matrix in prepectoral breast reconstruction? A systematic review and meta-analysis.JPlastReconstrAesthetSurg86,251-260(2023). https://doi.org:10.1016/j.bjps.2023.09.042 3 Saldanha,I.J.etal.Implant-basedBreastReconstructionafterMastectomyforBreastCancer:A Systematic Review and Meta-analysis.PlastReconstrSurgGlobOpen10,e4179 (2022).https://doi.org:10.1097/gox.0000000000004179 4 Hirpara,M.M.,Clark,R.C.,Hogan,E.,Dean,R.&Reid,C.M.RiseofAcellularDermalMatrix:Cost Consciousness,Industry Payment,and PublicationProductivity.JAmCollSurg236, 1189-1197(2023).https://doi.org:10.1097/xcs.0000000000000648 5 Agha,R.A.&Orgill,D.P.Evidence-BasedPlasticSurgery:ItsRise,Importance,and a Practical Guide.AestheticSurgeryJournal36,366-371(2016).https://doi.org:10.1093/asj/sjv204

Purpose: In autologous breast reconstruction (ABR), high post-surgical morbidity is reported in 20-40% of select patients. Unfortunately, multivariate logistic regression models and clinically relevant variables with high odds ratios, such as age, body mass index (BMI), American Society of Anesthesiology (ASA) score, and modified frailty index (MFI), predict morbidity with insufficient accuracy. As machine learning (ML) has shown impressive predictive capabilities in several clinical scenarios, we hypothesize that ML may predict post-surgical morbidity in ABR with higher accuracy than classical statistical logistic regression models.

Methods: The "American College of Surgeons - National Surgical Quality Improvement Program" (ACS-NSQIP) database was retrospectively queried to identify ABR cases from January 2005 to December 2020. The primary outcome was to predict the presence of any 30-day post-operative morbidity. This outcome was a composite of all 18 variables in the ACS-NSQIP that track post-operative morbidity. The secondary outcome was to individually predict the 7 complications with the highest incidence in the cohort: return to operating room, bleeding, readmission, superficial infection, wound dehiscence, deep infection, organ/space infection (listed in descending incidence). Three ML models (Random Forests, XGBoost, and L1-L2-RFE) were compared to one multivariate logistic regression (mLR) model and four univariate logistic regression models (age, ASA score, BMI, mFI-5). Performance was analyzed using the area under the curve (AUC).

Results: Of the 25,163 ABR cases identified, 8,330 (33.1%) experienced 30-day postoperative morbidity. Random Forests, XGBoost, and L1-L2-RFE predicted postoperative morbidity similarly to the mLR model (AUC: 0.645, 0.643, and 0.653 vs. 0.653, respectively). The difference in AUC between ML and mLR models was consistently <0.03. Both mLR and ML predicted post-surgical morbidity with >0.10 higher AUC values than any of the four single-factor models, which all showed AUC<0.6 (Age: AUC=0.501; ASA score: AUC=0.555; BMI: AUC=0.561; MFI-5: AUC=0.5450). Among individual complications, bleeding (L1-L2-RFE: AUC=0.754) and deep infection (XGBoost: AUC=0.722) were predicted with the highest AUC. For each individual complication, the difference in AUC between all models (ML, mLR, and single-factor) was <0.05.

Conclusions: ML and mLR performed comparably, yet sub-optimally in the prediction of post-surgical morbidity in ABR. Single-factor models with commonly clinically utilized variables were even worse predictors of morbidity. As all models achieved low AUC, these models may be limited by current surgical database robustness rather than innate predictive capability. Thoughtful design and granularity of future ABR databases may enhance predictive model performance, but further research is warranted.

BACKGROUND: Implant-based breast reconstruction (IBR) can have varying outcomes depending on implant size and type of procedure, whether performed direct-to-implant (DTI) or in a two-stage (TS) procedure with tissue expanders placed first. While implant size has been examined as a possible factor in patient complication, few studies have attempted to directly determine its relationship with patient outcomes. Our aim was to determine outcomes related to implant size and defining optimal implant size cutoffs for both DTI and TS cohorts.

METHODS: Patients undergoing IBR from 2018-2022 at our institution were included. A breast-level study was conducted of the cohort. Due to differences in clinical consideration between DTI and TS procedures, we conducted two separate but parallel analyses of each cohort. We assessed complications post-reconstruction using implant size as a predictor. Risk-adjusted logistic regression models, considering demographic and comorbidity factors, evaluated the implant size-outcome relationship for both DTI and TS cohorts. The Youden Indices of Receiver Operating Characteristic (ROC) curves identified optimal implant size cutoffs. Area under curve (AUC) was reported to assess model prediction quality.

RESULTS: A total of 1,098 patients who underwent IBR were identified. Of these patients, a total of 1,734 breasts received IBR, of which 1,380 (79.6%) breasts underwent a TS procedure and 354 (20.4%) underwent DTI. The average DTI implant size was 424 cc ± 125 while TS was 489 cc ± 143. Within the DTI cohort, Surgical Site Infections (SSI) were observed in 7.6% of cases, with an AUC of 0.8112 and an implant size threshold of 560 cc. Other complications and their respective AUC values leading to implant size cutoffs in the DTI cohort included: implant loss at 9.3% (AUC: 0.7527, Size: 580 cc), hematoma at 3.7% (AUC: 0.7544, Size: 650 cc), and seroma at 8.8% (AUC: 0.6745, Size: 595 cc). Within the TS cohort, SSI was observed in 6.8% of cases, with an AUC of 0.5452 and implant size threshold of 790 cc. Other outcomes in the TS cohort examined included: implant loss at 2.5% (AUC: 0.5224, Size: 700 cc), hematoma at 4.1% (AUC: 0.5041, Size: 700 cc), and seroma at 16.7% (AUC: 0.4934, Size: 790 cc).

CONCLUSION: Our study highlights the significance of implant in determining post-operative complications after DTI IBR. While TS patients receiving extremely large implants may experience complications, our results suggest that implant size does not predict complications. By contrast, reliable AUC models near or exceeding 0.7 were generated in the DTI cohort and suggest that implant size has predictive power for complications in this cohort. This data offers surgeons implant size thresholds for better patient counseling, surgical planning, and outcome optimization.

Background. Deep inferior epigastric artery perforator (DIEP) free flap and pedicled latissimus dorsi musculocutaneous flap (LDMF) are two options for autologous breast reconstruction. In some cases, reconstruction with LDMF is inadequate and DIEP flaps remain an option for salvage reconstruction in those who previously underwent LDMF. Here, we discuss a case series that reviews the operative technique of utilizing a DIEP flap as salvage reconstruction in patients with prior LDMF breast reconstruction.

Methodology. A multi-institutional series of seven patients who underwent a DIEP flap after a previous LDMF breast reconstruction from July 2020 to December 2023 was retrospectively reviewed. Pre-operative, intra-operative, and post-operative outcomes were collected. Three patients were surgically managed at the University of Colorado Hospital and four patients were surgically managed at the University of Kansas Medical Center.

Results. The mean age of the patients was 59 years old with a range of 50-79 years old. The length of follow-up ranged from six months to three years. Complications included delayed wound healing in one patient while another patient experienced wound dehiscence, seroma, and cellulitis. Five patients (71.4%) underwent adjuvant radiation prior to DIEP salvage reconstruction, including the two patients that experienced complications. Retainment of the LDMF at the time of DIEP reconstruction was dependent on the need for volume and its feasibility for coverage. One of the seven patients (14.2%) had her initial LDMF completely excised, whereas another patient (14.2%) had partial excision of her LDMF. In the remaining five patients (71.4%), the LDMF was elevated and deepithelialized to retain for volume augmentation. De-innervation of the latissimus muscle was performed on two patients (28.6%) who had discomfort related to animation deformity. Subsequent reconstructive revisions were completed in six patients (85.7%). Five patients (71.4%) had fat grafting. Two (28.6%) patients that underwent fat grafting also had additional dog-ear revision. One patient (14.2%) underwent abdominal scar revision.

Conclusion. Salvaging a prior LMDF flap with a DIEP flap requires preoperative planning and adjustments in operative approach to use the autologous tissue. Operative considerations should include the patient's preoperative concerns, including animation deformity, inadequate volume, and volume mismatch and how the LDMF can be incorporated with the DIEP at the time of operation. Subsequent revisions may be necessary depending on patient satisfaction. Our multi-institutional approach for management of prior LDMF in the setting of planned DIEP reconstruction includes: 1. Evaluation of volume and native skin paddle to determine if LDMF should be excised or deepithelialized and retained, 2. Preoperative evaluation for pain or animation deformity related to LD with de-innervation of the thoracodorsal nerve at time of operation.

Purpose: Asian American, Native Hawaiian, and Pacific Islander (AANHPI) patient populations continue to be underrepresented in plastic surgery research and are often defined as one monolithic group despite the cultural, socioeconomic, and clinical heterogeneity of this patient population. Whereas the general AANHPI population has been shown to be underrepresented in reception of postmastectomy breast reconstruction, existing literature has not characterized the disaggregation of such rates for AANHPI ethnic subgroups.

Methods: Patients who underwent mastectomy were identified in the 2007-2020 registries within the Surveillance, Epidemiology and End Results (SEER) Database. The SEER database contains granular information about specific AANHPI ethnicity. Patients were stratified by race and ethnicity, and additional demographic, oncologic, and survival variables were collected. Multivariate binary logistic regression was conducted to assess for reception of postmastectomy immediate breast reconstruction (p<0.05).

Results: 227,279 patients who underwent mastectomy were identified. 50,559 of 146,038 (34.6%) non-Hispanic White patients and 5,690 of 17,584 (32.4%) AANHPI patients underwent subsequent breast reconstruction (p<0.001). The difference in rates of reconstruction between the two groups decreased from 6.7% in 2007 to 1.0% in 2020. Patients who identified as Korean (41.7%), Pacific Islander (40.7%), Asian Indian or Pakistani (34.9%), and Japanese (34.6%) were associated with the highest rates of postmastectomy breast reconstruction. Among subgroups with more than 100 recorded patients, Hawaiian (24.1%), Filipino (23.3%), Cambodian (22.9%), and Samoan (11.7%) groups were associated with the lowest rates. After controlling for age, oncologic stage, preoperative radiation and chemotherapy treatment, relative income, and rural-urban density, 18 out of 21 AANHPI ethnic subgroups with sufficient sample size predicted a lower likelihood of breast reconstruction (p<0.05) when compared to non-Hispanic White patients. Odds ratios for reception of reconstruction ranged from 0.09 (95% CI: 0.02-0.43) for Micronesian patients to 0.69 (95% CI: 0.61-0.78) for Japanese patients. Chamorran, Melanesian, and New Guinean ethnicities were non-significant predictor variables. Other negative predictors of reception of breast reconstruction included older age, more advanced oncologic stage, preoperative radiation, neoadjuvant chemotherapy, lower income, and residence in a noncentral metropolitan area (p<0.001). A sensitivity analysis restricted to the years 2019 and 2020 showed that, while the rates of reconstruction for several ethnic subgroups (e.g. Japanese, Korean) increased to non-significant differences when compared to non-Hispanic White patients, the majority of subgroups (e.g. Chinese, Asian Indian or Pakistani, Hawaiian) still conferred a relatively lower likelihood of reconstruction.

Conclusions: Disparities in reception of immediate breast reconstruction exist within the AANHPI patient population despite an overall trend of improving relative representation for the procedure. This analysis supports the need for disaggregation in plastic surgery research for improved knowledge and targeted interventions.

Purpose: Patient frailty status has previously been validated as a predictor of poor postoperative outcomes. More specifically, the Modified 5-Item Frailty Index (mFI-5) has been demonstrated to be an effective preoperative predictor of postoperative complications in patients undergoing tissue expander (TE) breast reconstruction [1]. There is, however, a paucity of literature evaluating the impact of frailty on patient-reported outcome measures. Thus, the purpose of this study was to examine the importance of mFI-5 in predicting BREAST-Q scores following TE breast reconstruction.

Methods: Female patients above the age of 18 who underwent immediate TE breast reconstruction between January 2017 and April 2023 were eligible for inclusion. Four domains of the BREAST-Q were examined, including Sexual Well-being (SEX), Psychosocial Well-being (PWB), Satisfaction with Breasts (SWB), and Physical Well-being of the Chest (PWBC). Patients were considered to be low frailty if they scored less than two points in the mFI-5 and high frailty with 2 or more points. Patients' frailty scores increased by one point for each of the following comorbidities: congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease or pneumonia diagnosis within 30 days, functional status, and hypertension requiring medication. Statistical significance was set as a p-value less than 0.05, and a minimal clinically important difference (MCID) of 4 was used for BREAST-Q score evaluation.

Results: 3,442 patients were included in this study. The majority of patients (93.3%) were categorized as low frailty while 231 (6.7%) patients met criteria for high frailty. When compared to low frailty patients, high frailty patients were more often older (p<0.001), minority patients (p<0.001), single (p<0.001), underwent adjuvant radiotherapy (p=0.002), and had increased BMI (p<0.001). On nonparametric testing, in the preoperative time period, high frailty patients scored significantly lower in all domains of the BREAST-Q. MCID was met in the domain of SWB, PWBC, and SEX. At the 1-year postoperative time, low frailty patients scored statistically and clinically significant higher scores for SWB, PWBC, and SEX. When all variables of interest were controlled for in multivariable linear mixed effects models, however, patient frailty status was no longer a significant predictor or modifier of any BREAST-Q domain.

Conclusion: When all variables of interest were accounted for, frailty was not significantly associated with any of the evaluated BREAST-Q domains in patients undergoing immediate TE breast reconstruction. This demonstrates that patient-reported outcomes in low frailty and high frailty patients are comparable, suggesting that TE breast reconstruction is safe and efficacious in the frail population. While it is important to be able to identify frail patients due to the proven utility of predicting postoperative outcomes, it may not be the most useful predictor of patient-reported outcomes in TE breast reconstruction. Future research should examine the interaction of time and frailty to determine if a relationship exists between BREAST-Q scores and mFI-5 depending on time point.

1.Moss W, Zhang R, Carter GC, Kwok AC. A Case for the Use of the 5-Item Modified Frailty Index in Preoperative Risk Assessment for Tissue Expander Placement in Breast Reconstruction. Ann Plast Surg. 2022;89(1):23-27. doi:10.1097/SAP.0000000000002771

Introduction: The Enhanced Recovery After Surgery (ERAS) protocol, first introduced in colorectal surgery, is a comprehensive and multidisciplinary protocol. It encompasses various elements including nutritional guidance, optimizing fluid balance, and minimizing post-operative nausea. One of its main components is its use of a single weight-based dose of intraoperative methadone. Previous studies have demonstrated that a single dose of methadone can provide superior analgesia compared to multiple doses of short-acting opioids. Widely adopted across surgical specialties, ERAS has consistently shown benefits including shorter hospital stays and enhanced patient satisfaction. However, its implementation remains relatively limited in plastic surgery. This study seeks to assess the effectiveness of the ERAS protocol on decreasing post-operative pain and narcotic consumption in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods: We performed a retrospective review of all patients who underwent DIEP flap reconstruction from October 2020 to May 2021 to establish a historical control group (n = 36). Following this, the ERAS protocol was implemented in May 2021, and patients were prospectively enrolled in the ERAS cohort from May 2021 to March 2024 (n = 190). Primary outcomes, including length of stay, pain scores, heart rates, blood pressures, and occurrence of tachycardia, were compared between the ERAS and control cohorts using univariate analysis. Post-operative narcotic use was also recorded and converted to morphine milligram equivalents (MME) to enable standardized comparisons. Additionally, as a secondary aim, unpaired Student's t-tests and Spearman correlation analysis were conducted to identify risk factors associated with increased post-operative narcotic use and pain.

Results: Patients in the ERAS and control cohorts were comparable in age, body mass index (BMI), weight, race, and comorbidities statuses including hypertension, diabetes, hyperlipidemia, and cardiovascular disease. Our study found that patients in the ERAS cohort had significantly lower post-operative pain scores (3.96 vs. 4.99, p=0.01), incidence of tachycardia (6.3% vs. 25%, p=4E-4), as well as heart rates (85.6 vs. 91.7%, p= 7E-4). Patients in the ERAS cohort also had significantly lower post-operative narcotic use at 12 hours post-operatively (13.6 vs. 24.9 MME, p = 0.02), 24 hours post-operatively (41.7 vs. 70.7 MME, p= 0.01), and in total throughout the entire post-operative stay (83.3 vs.132.3 MME, p=0.009). The two groups, however, were comparable in post-operative mean arterial pressures, systolic pressures, and length of stay. Our data also showed that younger age and higher BMI, weight, and flap weight were significantly associated with increased post-operative narcotic use and pain (p<0.05). However, reconstruction laterality (unilateral vs. bilateral) and the timing of reconstruction (delayed vs. immediate) did not show significant associations.

Conclusions: Our study found that implementing the ERAS protocol significantly reduced post-operative opioid use, pain levels, heart rates, and tachycardia incidents. Additionally, we found that certain populations, such as younger patients and those with higher BMIs and flap weights, are at higher risk of increased post-operative pain. Overall, these findings underscore the potential for methadone to effectively manage pain, reduce reliance on opioids and improve overall patient comfort and satisfaction following autologous breast reconstructive surgery.

Introduction: Impaired breast sensation can be a devastating side effect of mastectomy and breast reconstruction. Breast sensitivity is important not only for protective sensation, but also has significant impacts on quality of life. Studies have linked innervated reconstructions to improved patient-rated quality of life, but no previous study has examined objective sensory measurements with patient-reported outcomes (1). In this study, we aim to investigate the relationship between cutaneous breast sensation of different anatomical regions and BREAST-Q scores.

Methods: Patients with alloplastic and autologous breast reconstruction were administered the BREAST-Q and underwent sensory testing of the breasts with a pressure-specified sensory device at specific timepoints after surgery. BREAST-Q scores and sensation measurements were paired at each timepoint; any instances without both outcomes were dropped from the analysis. Univariate linear regression analysis was utilized to assess the relationship between various areas of the breast and corresponding scores on different BREAST-Q scales. Areas found to be significant in the univariate analysis were subsequently included in a multivariate linear regression analysis. A sub-analysis was performed with the subset of patients who'd completed the new Sensation Module of the BREAST-Q.

Results: 185 patients with both BREAST-Q and sensation testing were included in this study, comprising 93 with autologous reconstruction and 92 with implant-based reconstruction. On multivariate analysis, sensitivity of the nipple-areolar complex was identified as being significantly associated with higher scores on the Psychosocial Wellbeing scale (β = -0.15, 95% CI [-0.29, -0.01], p=0.032) and the Sexual Wellbeing scale (β = -0.19, 95% CI [-0.35, -0.02], p = 0.03). However, there was no correlation between breast sensation and Wellbeing of the Chest scores. In the univariate analysis, sensation in all areas of the breast was associated with higher Satisfaction with Breasts scores; however, these associations were not significant in the multivariate analysis. This suggests that overall breast sensation-as opposed to localized regions-plays a significant role in breast satisfaction. In a sub-analysis of breast sensitivity and the Sensation Module of the BREAST-Q, sensitivity of the lateral quadrant of the breast was significantly associated on multivariate analysis with higher scores on the Breast Symptoms scale (β = -0.21, 95% CI [-0.38, -0.05], p=0.02).

Conclusion: In this first study of the effect of sensation of different anatomic regions of the breast on patient-reported quality of life, we found sensitivity of the nipple-areolar complex to be independently associated with Psychosocial and Sexual Wellbeing, underscoring the NAC's role as an erogenous zone. General breast sensitivity, rather than a particular region of the breast, correlates with Satisfaction with Breasts. Heightened sensitivity of the lateral breast was associated with fewer unpleasant breast symptoms. As reinnervation of the breast pocket after mastectomy begins from the lateral edge of the breast, these findings suggest that unpleasant symptoms (burning, tingling, etc.) precede the recovery of or occur in the absence of "normal" touch sensation.

References 1) Temple CLF, Ross DC, Kim S, et al. Sensibility following innervated free TRAM flap for breast reconstruction: Part II. Innervation improves patient-rated quality of life. Plast Reconstr Surg. 2009;124(5):1419-1425.doi:10.1097/PRS.0b013e3181b98963

BACKGROUND: Autologous breast reconstruction (ABR) post nipple-sparing mastectomy (NSM) is recognized for its safety and aesthetic value. However, BMI-based recommendations for free flap reconstruction remain debated due to potential peri-operative risks. This study assesses outcomes concerning BMI, defining optimal BMI cutoffs post NSM.

METHODS: Patients undergoing free flap breast reconstruction from 2005-2018 at our institution were included. We assessed complications post NSM using BMI as a predictor. Risk-adjusted logistic regression models, considering demographic and comorbidity factors, evaluated the BMI-outcome relationship. Receiver Operating Characteristic (ROC) curves defined BMI cutoffs. Outcomes with Area Under the Curve (AUC) > 0.7 were considered. Youden's Index identified optimal BMI cutoffs.

RESULTS: A total of 3,066 patients who underwent free flap breast reconstruction was identified, of which 204 patients underwent NSM, totaling 295 breasts. The average BMI was 28.3kg/m2 ±5.3. Surgical Site Infections (SSI) were observed in 3.7% of the cases, with an AUC of 0.7718 and a BMI threshold of 40.7. Other complications and their respective AUC values leading to BMI cutoffs included: seroma at 2.0% (AUC: 0.8607, BMI: 35.7), hematoma at 3.7% (AUC: 0.787, BMI: 37.8), fat necrosis at 5.8% (AUC: 0.7757, BMI: 37.6), fascial dehiscence at 0.3% (AUC: 0.9903, BMI: 30.4), and skin necrosis at 12.5% (AUC: 0.7777, BMI: 33.7). Flap loss due to vascular complications was observed in 1% of patients, with an AUC of 0.9834 and a BMI cutoff of 39.5.

CONCLUSION: Our study highlights the significance of BMI in determining post-operative complications after NSM and free flap breast reconstruction. While ABR offers numerous benefits, it's crucial to be cautious when considering patients with BMI near or beyond our identified cutoffs. This data offers surgeons BMI thresholds for better patient counseling, surgical planning, and outcome optimization.

Background: Two-stage prosthetic breast reconstruction is the most common operative approach following mastectomy in the United States. Traditionally, closed-suction drains are placed during the initial surgery to help manage seroma formation, but have been associated with patient discomfort and infection (1). Drainless tissue expansion has been reported possible previously, but lacking is a description of how to implement this approach and the associated demands (2-4). This study aims to describe what to expect in terms of frequency of follow-up, drainage sessions required, drainage volumes expected, and how the experience may differ based on reconstruction timing.

Methods: A retrospective review was performed for all patients who underwent prepectoral dual-port tissue expander placement from February 2023 to December 2023. Patient demographics, past medical history, perioperative chemo and radiation therapy, intraoperative details, and complications were reviewed. Periprosthetic drainage volumes recorded during all post-operative follow-up visits were collected. Descriptive statistics were used to summarize the outcome measures (mean, standard deviation), independent sample t-tests were used to compare means for immediate versus delayed reconstruction, and a descriptive linear mixed effects model was generated to longitudinally assess the change in drainage amount over successive sessions. Statistical significance was defined as p < 0.05.

Results: 28 patients making up 41 breasts were included in the analysis. 9 (32%) patients had nipple-sparing, 7 (25%) had skin-sparing, and 12 (42%) had simple mastectomies. 3 patients had surgical site infections and 3 had mastectomy flap necrosis. Average grand total drainage for an individual breast was 543 mLs (SD =287 mLs). Average drainage per session for an individual breast was 85 mLs (SD = 38 mLs). Average number of follow-up days to reach point of no additional drainage was 36 days (SD = 13 days), with an average of 6.5 sessions within that time (SD = 1.7 sessions). The linear mixed effects model revealed significant decreases in amount drained with each session (-20 mLs; 95% CI -24, -17; t = -11.9) and highly variable individual patient trajectories, as indicated by variation in the baseline drainage amounts (154 mLs, SD = 57 mLs) and variation in the rate of change of drainage amounts across sessions (SD = 7.25 mLs). Finally, independent sample t-tests demonstrated statistically significant differences in total average drainage between immediate and interval-staged reconstruction (708 mLs and 425 mLs, respectively; p < 0.01) and average drainage per session (107 mLs and 69 mLs, respectively; p < 0.001). There were no significant differences between average days of follow-up and average number of drainage sessions required between immediate versus delayed reconstruction.

Conclusion: Drainless breast reconstruction is possible, does not require inordinate clinical demands, and has an equivalent safety profile to the standard approach utilizing drains. This study also provides a better understanding of the expected frequency of drainage sessions and volumes, as well as a description of differences when performed in an immediate versus delayed fashion.

References 1. Saratzis A, Soumian S, Willetts R, Rastall S, Stonelake PS. Use of multiple drains after mastectomy is associated with more patient discomfort and longer postoperative stay. Clin Breast Cancer. 2009;9(4):243-246. doi:10.3816/CBC.2009.n.04 2. Franck P, Chadab T, Poveromo L, Ellison A, Simmons R, Otterburn DM. Prepectoral Dual-Port Tissue Expander Placement: Can This Eliminate Suction Drain Use?. Ann Plast Surg. 2020;85(S1 Suppl 1):S60-S62. doi:10.1097/SAP.0000000000002344 3. Moyer HR, Sisson KM. The Effect of Early Cultures and Dual-port Expanders on Two-stage, Prepectoral Breast Reconstruction: The 25/25 Study. Plast Reconstr Surg Glob Open. 2024;12(1):e5507. Published 2024 Jan 8. doi:10.1097/GOX.0000000000005507 4. Parmeshwar N, Piper M, Viner J, Foster R, Kim EA. Evaluation of Dual-port versus Single-port Tissue Expanders in Postmastectomy Breast Reconstruction. Plast Reconstr Surg Glob Open. 2021;9(7):e3703. Published 2021 Jul 15. doi:10.1097/GOX.0000000000003703