Scientific Abstract Presentations: Breast Session 6 Friday, September 27 Fri, Sep 27 10:30 a.m.-12:30 p.m. PDT

Introduction: Literature details that nearly 1 in 5 women who undergo mastectomy in the United States receive autologous breast reconstruction1. These procedures are associated with higher levels of blood loss, although few data examine a temporal role on this phenomenon and the association with intraoperative fluid balance. The goal of this study is to evaluate intraoperative blood loss, fluid resuscitation, and urine output in immediate versus delayed autologous breast reconstruction.

Patients and Methods: A total of 264 patients who underwent autologous breast reconstruction at the University of Virginia between July 2017 – June 2022 were retrospectively extracted from our breast database. Included patients were stratified into unilateral vs. bilateral and immediate vs. delayed reconstruction. Pre- and postoperative hemoglobin and intraoperative fluid status were examined. Mean variables were compared using paired t-tests.

Results: Average preoperative hemoglobin was similar among all included groups (12.66 g/dl, sd = 0.073). Immediate bilateral reconstruction had greater postoperative hemoglobin reduction (-3.26 g/dl vs. -1.98 g/dl, p = 0.0015) and transfusion rates (14.3% vs. 2.00%, p = 0.0206) when compared to delayed bilateral reconstruction. Similar findings were seen in the unilateral group with greater hemoglobin reduction (-2.60 g/dl vs. -1.41 g/dl, p = 0.0001) and transfusion rates (12.1% vs. 0%, p = 0.0246) seen in the immediate cohort when compared to the delayed cohort. Greater intraoperative fluid resuscitation (+ 3199 cc vs. + 2586 cc, p = 0.002) with greater resulting intraoperative net volume status (+ 2308 cc vs. +1866 cc, p = 0.019) was observed in the bilateral immediate group when compared to the bilateral delayed group. This finding was not seen in the unilateral groups. Furthermore, no statistically significant differences were seen in intra-operative urine output when comparing immediate versus delayed bilateral and unilateral reconstructions.

Conclusions: Staging autologous breast reconstruction in both unilateral and bilateral cohorts was associated with reduced blood loss and need for postoperative blood transfusion. Greater intraoperative volume resuscitation was additionally observed in immediate bilateral autologous reconstruction, although no significant differences were seen for the bilateral or unilateral cohorts for intraoperative urine output. Surgical timing impacts intraoperative blood loss and fluid resuscitation and is therefore a critical consideration for preoperative surgical planning and optimizing postoperative outcomes in both unilateral and bilateral autologous breast reconstruction.

Citations 1. Saldanha IJ, Broyles JM, Adam GP, et al. Autologous breast reconstruction after mastectomy for breast cancer: a systematic review. Plast Reconstr Surg Global Open. 2022;10:e4181.

Purpose Mastopexy and breast augmentation are common surgical procedures performed to reshape the breasts, providing improved aesthetic outcomes for patients. These procedures can be done individually or in conjunction with each other depending on the patient's specific needs and aesthetic preferences. However, there is a scarcity of data about the risk factors, complication rates, and clinical outcomes when evaluating the procedures done in isolation versus in combination, which is the ultimate purpose of this study.

Methods The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2008–2021 to identify female patients having undergone mastopexy and/or breast augmentation. Pre-, peri-, and post-operative variables of interest were extracted and analyzed including the incidence of medical and surgical complications at 30 days, reoperations, and readmissions. To establish risk factors, confounder-adjusted multivariable analyses were performed.

Results In total, 8,108 patients were identified from the NSQIP database with 6,059 patients (mean age: 35 ± 10; mean body mass index [BMI]: 23 ± 3.9) having undergone isolated breast augmentation, 1,017 patients (age: 44 ±12; BMI: 27 ± 5.6) undergone isolated mastopexy, and 1,032 patients (age: 40 ± 11; BMI: 25 ± 4.0) undergone combined breast augmentation and mastopexy. 111 (1.8%) patients experienced postoperative complications following isolated breast augmentation, 32 (3.1%) patients following isolated mastopexy, and 33 (3.2%) patients following combined mastopexy and breast augmentation. Patients undergoing isolated mastopexy had a significantly higher rate of surgical complications, predominantly superficial incisional infections, relative to patients who underwent combined mastopexy and breast augmentation (2.2% vs. 0.4%, p<0.001). However, patients who underwent combined mastopexy and breast augmentation had a significantly higher rate of readmission compared to isolated breast augmentation cases (1.1% vs. 0.3%, p=0.004). Most notably, the multivariate analyses revealed that increased BMI (OR: 1.084; p=0.044) and inpatient setting (OR: 6.343; p=0.005) were identified as risk factors of any complication occurrence in patients who received combined breast augmentation and mastopexy, while lower PTT lab values and WBC count were identified as risk factors for complication occurrence in patients receiving isolated breast augmentation (OR: 1.220; p=0.019) and isolate mastopexy (OR:1.117; p=0.034), respectively.

Conclusion Through this national, multi-institutional data spanning over a decade, we were able to provide a comprehensive interrogation of the related clinical variables that dictate complication rates and outcomes between isolated vs combined breast augmentation/mastopexy. In particular, we identified significantly higher rates of surgical complications with isolated mastopexy procedures but higher rates of readmission when combined with breast augmentation. Higher BMI and inpatient setting were also identified as independent risk factors for complications in the combined procedures patient cohort. Ultimately this study serves as a framework through which breast surgeons may integrate these nuanced findings into their perioperative workflow to optimize patient counseling regarding the safest and clinically most efficacious option for their patients considering mastopexy and/or breast augmentation.

Intro: Red Breast Syndrome (RBS) has been noted in past literature as a possible complication of implant-based breast reconstruction (IBBR) with the use of acellular dermal matrices (ADM). Since 2009, RBS has drawn medical attention with reported incidence ranging from 7%-9% among retrospective studies. However, in the past decade, there has been a noted decrease in the emergence of RBS despite its inclusion among analyzed complications in a number of studies. This systematic review aims to evaluate the trend in reported RBS incidence over time and determine an accurate incidence of RBS from reported literature.

Methods: A systematic literature review was performed in July 2023 that analyzed the incidence of RBS among retrospective cohort studies on complication rates of IBBR with ADM. Patient demographics, RBS incidence rates, and all-cause complications were captured. The review was performed according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines and methodological index for nonrandomized studies (MINORS) criteria assessed study quality.

Results: From 2009 to 2023 a total of 48 studies (n=6251) met inclusion criteria of which 35 studies from 2017 to 2023 were not already included in a prior systematic review (n=5246). The mean incidence of RBS in the unreported studies was 2.88% with a weighted mean of 3.22%. Analysis of the trend in RBS over time shows an increasing reported incidence rate from 2009 with a peak incidence between 2016 and 2017 followed by a steady decline through 2022.

Conclusion: The incidence of RBS among prior studies and systematic reviews has fluctuated significantly since its initial emergence in 2009. Reported incidence rates have been on the decline since 2018 with a true weighted incidence of 3.22% from analysis of recent reported studies. Potential causes for the decline in incidence include practice changes in ADM preparation, changes in the ADM brand used for IBBR, and improved categorization of RBS compared to cellulitis/infection. Despite more robust criteria for diagnosis, no consensus for management has yet been established.

Intro: ERAS protocols optimize perioperative care to reduce hospital stay and improve patient outcomes in various surgical domains.1 Yet, its role in tissue expander-based breast reconstruction (TEBR) remains less well explored. This study evaluates an ERAS protocol's effectiveness in the context of post-mastectomy TEBR at a high-volume center.

Methods: All patients undergoing immediate TEBR from April 2019 to June 2023, following the adoption of the ERAS protocol, were classified as the ERAS cohort. Patients treated prior to the introduction of ERAS served as retrospective controls. We collected data on patient age, BMI, surgical laterality, expander placement, acellular dermal matrix (ADM) use, operative time, postoperative length of stay (LOS), inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation therapy presence, and complications within 90 days post-surgery. Statistical analyses to compare the cohorts utilized chi-square or Fisher's exact and t-tests or Wilcoxon rank-sum tests, as appropriate. During the study period, our institution experienced an alteration in TEBR placement preferences. Subpectoral placement, the norm until 2018, has been associated with increased postoperative pain, increased narcotic use, and lower seroma rates compared to prepectoral placement.2 To account for this, multivariable linear regression models were constructed to evaluate the independent effects of the ERAS protocol on inpatient milligram morphine equivalents (MME), inpatient LOS, and postoperative complications, while controlling for expander placement.

Results: There were 201 patients in each cohort, with statistically similar demographics. Prepectoral procedures were performed at a higher rate in the ERAS cohort (83.1% vs. 4.5%, p<0.001). Patients on the ERAS protocol were more frequently discharged by day 1 (96.5% vs. 70.2%, p<0.001) and had a lower inpatient MME median (79.8 vs. 151.8, p<0.001). Patients on ERAS had higher seroma rates (17.4% vs. 3.5%, p<0.001), hematoma incidence (4.5% vs 0%, p=0.004), and lower pain levels on POD 0 (2.8 vs 3.6; p<0.001) and POD1 (2.9 vs 3.5; p=0.003). At discharge, the ERAS group was prescribed a median of 225.0 less MME (150.0 vs 375.0; p=0.003). Non-ERAS had more "other" complications (5% vs. 1%, p=0.036) such as emesis, ileus, uncontrolled pain and migraine. Adjusting for implant location, the ERAS protocol was associated with a 60.7 MME reduction (β=-60.7, p<0.001) and a shorter inpatient duration (β=-0.4, p<0.001). Prepectoral placement was also a predictor of decreased MME (β=-30.9, p=0.015). Additionally, prepectoral placement was the sole predictor of seroma development (β=0.2, p=0.003), and decreased postoperative pain (POD0: β=-1.4, p<0.001; POD1: β=-0.7, p=0.035).

Conclusion: Our study reinforces the beneficial role of ERAS in TEBR, markedly decreasing opioid consumption and hospital stay durations. Integrating ERAS into prosthetic breast reconstruction practices can optimize patient recovery while maintaining an acceptable complication profile.

References: 1. Muetterties CE, Taylor JM, Kaeding DE, et al. Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction. Plast Reconstr Surg - Glob Open. 2023;11(12):e5444. doi:10.1097/GOX.0000000000005444 2. Nelson JA, Shamsunder MG, Vorstenbosch J, et al. Prepectoral and Subpectoral Tissue Expander–Based Breast Reconstruction: A Propensity-Matched Analysis of 90-Day Clinical and Health-Related Quality-of-Life Outcomes. Plast Reconstr Surg. 2022;149(4):607e-616e. doi:10.1097/PRS.0000000000008892

Objective Reduction mammoplasty is commonly cited to aid weight loss by facilitating the ability for physical activity. This study aims to analyze preoperative and postoperative weight and body mass index (BMI) changes in adolescents who underwent bilateral breast reduction (BBR) with a secondary focus on the impact of formal preoperative nutritional support.

Methods A retrospective analysis was conducted of patients aged 12-19 years who underwent BBR at our institution between 2019 and 2023. Data included patient demographics, preoperative and postoperative weight and BMI, weight of tissue resected, and formal nutrition referral preoperatively. Dependent and independent t-tests were used for data analysis.

Results There were 99 patients included in the study, 12 of whom received formal preoperative nutritional counseling. Overall, patients did not lose a significant amount of weight during the preoperative period or at 3 months and 1 year postoperatively. Patients demonstrated significantly greater weight loss preoperatively than at 3 months postoperatively (M = -2.19kg vs 0.57kg, p < 0.001) When stratified by nutrition group, patients who did not receive nutritional counseling had significantly greater weight loss preoperatively than at 3 months postoperatively (M = -2.10kg vs 0.65kg, p < 0.001), while there was no significant difference in patients utilizing nutritional services. Furthermore, there was no significant difference between weight loss in the preoperative period and at 1 year postoperatively, regardless of nutritional counseling. Although adolescents with nutritional support had greater weight loss compared to those without nutritional services preoperatively and at 3 months and 1 year postoperatively, this was not significant.

Conclusion Adolescents undergoing BBR had significantly greater weight loss preoperatively than at 3 months postoperatively, thus emphasizing the importance of initial consultation where weight is discussed. Patients with formal preoperative nutritional support lost more weight in the postoperative period than those without nutritional services. Although this was not a significant difference, it suggests that preoperative nutritional counseling in conjunction with the facilitation of physical activity following BBR could help adolescents lose weight postoperatively. Our study is limited by a small sample size of patients receiving nutritional counseling. Further studies with data from multiple institutions and more patients receiving nutritional services are warranted to determine true significance.

Background: Opioids, while effective in managing pain, can pose life-threatening risks to patients and communities. This is especially true when used in isolation for pain control. One of the main contributors to opioid over-prescription are surgeons, particularly in elective surgeries. For plastic surgeons, one of the most common outpatient procedures is breast reduction. Therefore, this study evaluates postoperative opioid prescriptions following breast reduction in order to evaluate for potential multimodal pain management incorporation including perioperative nerve blocks, gabapentinoids, muscle relaxants, and nonsteroidal anti-inflammatory drugs.

Methods: A retrospective chart review captured patients who underwent breast reduction between January 2016 and September 2023 at a single center. Demographics, opioid prescription data, other pain medication prescriptions, and post-operative pain-related medical visits and phone calls were recorded. 

Results: A total of 762 patient records were analyzed. Post operative opioid prescriptions were written for 89% of patients, and only 5% of patients received a non-opioid pain prescription. Use of perioperative nerve blocks increased annually. Average prescribed morphine milligram equivalents (MME) decreased over time, with a significant decrease after NC STOP (Strengthen Opioid Misuse Prevention) Act enactment in January 2020 (259.8±149.8 MME vs 129.8±81.88).  

Conclusions: While prescribed post-operative MME is continuing to decrease, multimodal pain therapies are underutilized . Patients rarely request refills for opioid medications indicating further reduction in total treatment MME would be reasonable, especially if this reduction is concomitant with emphasizing multimodal perioperative pain management such as the increasing trend of perioperative nerve blocks. Translation of these findings to clinical impact may best be done through implementation of a breast reduction specific pain protocol. Reduction in total MME prescription is beneficial for both patient and community health during the ongoing opioid epidemic.

Background Exclusive fat grafting is an alternative method to implant- or flap- based reconstruction techniques following mastectomies or breast conservation therapies. Its efficacy has been explored before but new data has come to light, resulting in previous results becoming outdated. Concerns have also been raised about the oncological safety of this procedure which must be evaluated alongside the efficacy to gain a comprehensive understanding of the merits of this alternative technique. Methods We queried the PubMed electronic database from its inception until August 2023 for studies evaluating the efficacy and oncological safety of exclusive fat grafting breast reconstruction following cancer-related mastectomy or breast conservation therapy. Results of the analysis were pooled and presented as means or valid proportions. Results of the analysis were pooled using a random-effects model and presented with 95% confidence intervals (95% CIs) where appropriate. Results 41 studies were included in our analysis. Pooled results show that on average, 1.7 sessions of exclusive fat grafting were required to complete reconstruction in Breast Conservation Therapy (BCT) patients, with an average volume of 114.2 ml being injected. For mastectomy patients with irradiated breasts, 4.7 sessions were needed on average with 556.8 ml being required to complete reconstruction, compared to their non-irradiated Counterparts requiring only 2.6 sessions and 207.2 ml to complete reconstruction. Oncological recurrence events were found in 29/583 non-irradiated mastectomy patients (p=0.014) and in 41/517 BCT patients (p=0.301)

Conclusion Exclusive fat grafting is an oncologically safe and reasonably efficacious alternative to more common methods of breast reconstruction. More data is needed to fully characterize the oncological safety of this procedure in irradiated and non-irradiated mastectomy patients.

Purpose: Reduction mammaplasty is consistently shown to be associated with high patient satisfaction. Several variables play a role in overall satisfaction, including relief of physical pain and psychological suffering, postoperative aesthetic results, and sensation changes following the procedure (1). We aimed to analyze the role that sensation return plays in overall patient-reported satisfaction following reduction mammaplasty by analyzing studies that utilized two different groups that underwent reduction and measured and compared their postoperative sensation and satisfaction.

Methods: A systematic review was conducted to analyze studies that assessed outcomes following reduction mammaplasty that included both sensation changes and overall patient-reported satisfaction, and compared these between at least two groups, differing by either technique or size of reduction. Six databases were searched using the OVID engine including Scopus, Embase, and MEDLINE following PRISMA methodology. All studies were screened by two independent reviewers.

Results: 1,294 articles populated in the search, eight of which met inclusion criteria. One study compared outcomes with patients who underwent large versus small reductions, and found no difference in postoperative sensation, but significantly higher postoperative satisfaction in the large reduction group. Another study compared patients who underwent reduction mammaplasty with patients with eutrophic breasts and patients with hypertrophic breasts that did not undergo reduction, and found that patients who underwent a reduction had significantly lower sensation than patients in the other two groups, but also had significantly higher postoperative satisfaction. The authors also found an association between satisfaction with aesthetic and functional outcomes and increased sexual function. One study compared superomedial and inferior pedicle techniques and found no difference in sensation, but significantly higher satisfaction and aesthetic outcomes in the superomedial pedicle technique. Similarly, when comparing the extended pedicle technique with free nipple grafts, no difference was found in sensation, but the extended pedicle group reported significantly higher satisfaction and aesthetic outcomes. One study compared the Orlando and Robbins methods and found significantly reduced sensation with the Robbins technique; however, there was no difference in satisfaction or aesthetic outcomes. Three studies compared vertical and Wise pattern incisions and found no difference in sensation or satisfaction postoperatively.

Conclusion: These results suggest that sensation preservation following reduction mammaplasty does not trend with overall satisfaction, and when there is a difference in satisfaction between groups, it preferentially correlates with aesthetic outcomes. In the study that compared large and small volume reductions, aesthetic outcomes were not compared; however, the patients who underwent larger reductions may have had increased satisfaction due to the greater degree of change in appearance and symptomatic relief following surgery. These results suggest that although sensation preservation is important, it may not play as significant of a role as aesthetic outcomes in patient satisfaction following reduction. Our results suggest that when choosing which technique to perform for reduction mammaplasty, the technique that will result in the greatest aesthetic appearance postoperatively should be prioritized.

References 1. Wang AT, Panayi AC, Fischer S, et al. Patient-Reported Outcomes After Reduction Mammoplasty Using BREAST-Q: A Systematic Review and Meta-Analysis. Aesthet Surg J. 2023;43(4):NP231-NP241. doi:10.1093/asj/sjac293

Introduction: Approximately 75% of breast reconstructions in the United States utilize tissue expander-based reconstruction. Risk factors including obesity, smoking, hypertension, increased age, and prior radiation have been shown to predispose patients to tissue expander (TE) loss before successful completion of expansion. Though breast reconstruction is one of the most common procedures in plastic surgery, socioeconomic disparities remain prevalent and are well described in the literature. That said, there is a paucity of data looking at socioeconomic status (SES) in the context of TE loss specifically. This study aims to analyze the association between different demographic factors, in particular SES, and premature TE explantation in patients undergoing expander-based reconstruction following mastectomy.

Methods: A retrospective analysis of patients undergoing expander-based reconstruction following mastectomy between January 1, 2018 and August 1, 2021 at a single institution was performed. The cohort was stratified into two groups based on expansion outcome: premature TE loss vs. successful reconstruction. Primary measures were comprised of demographic and outcome data including TE size, fill volume, time to second stage, removal or exchange prior to second stage, and reason for premature removal/exchange. SES was determined by using the median income for each patient's billing zip code from the Census Bureau income statistics.

Results: A total of 306 patients and 523 breasts were expanded over the course of this study. Overall the cohort had an average age of 51 years; 83% of patients were White, 12% Black, and 5% other. Following stratification, 42 breasts experienced premature loss of TE while 481 breasts were expanded successfully. 45% of premature TE removals were in the context of infection. There was no significant difference in age, race, tobacco use, BMI at TE, final fill volume, or time of expansion between the two groups (p>0.05). That said, those with premature TE loss did have a significantly larger tissue expander placed (p=0.02) and a larger initial fill volume (p=0.04). Significantly more of the successful expansions employed acellular dermal matrix (p<0.001). There was no significant difference in type of mastectomy, chemotherapy before mastectomy or second stage, or radiation before mastectomy or second stage between the two groups. When looking at SES, there was no significant difference in median income between the two groups ($70,297 vs. $68,640, p=0.34). There was also no significant difference in distance from the hospital (70.0mi vs. 77.0mi, p=0.35).

Conclusion: There was no difference found in SES between those with premature TE loss and those who completed a successful expansion. Clinical outcomes and care were similar regardless of SES and distance from the hospital. Premature TE loss was associated with a larger expander placed initially and a larger initial fill volume.

Background Immunotherapy is a fast-growing therapeutic class of breast cancer treatment, as new agents are being discovered. Pertuzumab is a monoclonal antibody for treatment of HER2-positive breast cancer (about 15-30% of breast cancer cases) in conjunction with trastuzumab. Trastuzumab was not associated with postoperative complications but was shown to be associated with wound healing complications when administered with pertuzumab in patients undergoing breast reconstruction (1). Pertuzumab prevents heterodimerization of the HER2 receptor tyrosine kinase, downregulating cell proliferation and growth (2). It is thought to downregulate expression of epidermal growth factor receptor (EGFR, alias HER1, promotes wound healing and fibrosis), raising questions of increased complications after breast reconstruction. An understanding of Pertuzumab's effects on postoperative wound healing in free flap breast reconstruction would help guide timing of these procedures. We examined the relationship between the most-commonly used agents, trastuzumab and pertuzumab and complications after free flap breast reconstruction.

Methods Retrospective, multi-institutional chart review was performed evaluating 434 women who underwent 660 free flap breast reconstructions from January 2017 to December 2022. Demographic, oncologic, and perioperative data including immunotherapy within 1 month of surgery was collected and analyzed. Primary study outcomes included flap complications, donor site complications, and infection. Univariate and multivariate logistic regression analysis was performed to evaluate the association of outcomes with immunotherapy treatment.

Results The mean age of patients was 50.8 years (SD 9.9) while mean BMI was 30.4kg/m2 (SD 5.5). There were 8 total flap losses (1.2%) and 11 partial flap losses (2.5%). No significant association was found between immunotherapy treatment within 1 month of surgery and flap loss, delayed wound healing or infection (p>0.05 for all). In multivariable analysis, higher BMI (odds ratio 1.04; 95% CI 1.01 to 1.08) and smoking history (odds ratio 2.48; 95% CI 1.44 to 8.40) were found to be independent risk factors for delayed wound healing but not flap loss.

Conclusion Our study suggests that immunotherapy with pertuzumab and trastuzumab is not associated with postoperative complications after free flap reconstruction. Further research into outcomes after free flap breast reconstruction patients on newer immunotherapeutic agents on free flap reconstruction is imperative.

1. Shammas RL, Cho EH, Glener AD, et al. Association Between Targeted HER-2 Therapy and Breast Reconstruction Outcomes: A Propensity Score-Matched Analysis. J Am Coll Surg. 2017;225(6):731-739.e1. doi:10.1016/j.jamcollsurg.2017.08.023

2. Harbeck N, Beckmann MW, Rody A, et al. HER2 Dimerization Inhibitor Pertuzumab - Mode of Action and Clinical Data in Breast Cancer. Breast Care (Basel). 2013;8(1):49-55. doi:10.1159/000346837

Purpose: While there is an increasing national trend in patients seeking aesthetic flat closure (AFC) after mastectomy, little is known about patients' perceptions after AFC. This study aims to understand the impact of receiving post-mastectomy AFC versus implant-based reconstruction on patients' satisfaction and health rating.

Method: Patients who had AFC or implant-based reconstruction following unilateral/bilateral mastectomy between 2013 and 2022 were retrospectively reviewed. Demographic and operative characteristics were collected. Patients who were at least 6 months from their final reconstruction were contacted to complete a survey, which included the BREAST-Q, and Likert scale questions on overall happiness and health rating.

Results: 50 (20%) AFC patients and 212 (36%) implant patients completed the surveys. AFC patients were older compared to the implant patients (58 vs 47, P<0.001) and had higher BMI (25 vs 22, P<0.001), while more implant patients had a history of anxiety (29% vs 14%, P=0.029). More AFC patients received radiation therapy (42% vs 20%, P=0.002) and had invasive cancer (86% vs 55%, P<0.001). Time between mastectomy surgery and completion of survey were longer for AFC patients than for Implant patients (48 vs 35 months, P<0.001). BREAST-Q scores and overall happiness were comparable, but more AFC patients rated their overall health lower (34% vs 19%). Multivariate ordered logistic regression identified higher BMI (beta=–0.11, p<0.001), larger pre-surgery bra-size (beta=–0.030, p=0.009), and history of anxiety (beta=–0.72, p=0.019) as independent predictors of lower overall health rating.

Conclusion: Our findings suggest that whether patients undergo AFC or implant reconstruction after mastectomy, quality of life as measured by BREAST-Q, overall happiness and health ratings are comparable, supporting the increasing awareness that patients who did not receive reconstruction after mastectomy are satisfied with their choice.

Background: Breast reduction after prior partial mastectomy and radiotherapy (RT) to the cancer-affected breast can be performed to improve symmetry and relieve symptoms of macromastia. However, RT can induce damage to not only the cancer-affected breast, but also to the contralateral breast, and as such, breast reduction in this clinical scenario is thought to have a higher risk of wound healing complications. To date, the extent to which prior breast RT affects the outcomes after surgery on the contralateral breast has not been adequately studied. Therefore, the purpose of this study was to investigate the association between prior breast RT exposure and surgical complications in patients who underwent unilateral breast reduction.

Methods: An institutional retrospective review was conducted to identify all patients with a history of breast cancer who underwent unilateral breast reduction of the other breast between 2015 and 2023. Patients who had and had not received RT were subsequently propensity score matched in a 1:1 ratio. A match tolerance (caliper) of 0.05 was determined and utilized to ensure comparable matches. Patients were matched based on age, body mass index (BMI kg/m2), present comorbidities (diabetes mellitus, hypertension, and smoking status), and prior chemotherapy. Postoperative complications were recorded, and univariate analyses were performed to analyze the association between prior breast irradiation and postoperative complications. Statistical significance was set at p < 0.05.

Results: A total of 139 patients were identified for inclusion, and propensity score matching resulted in 72 patients for analysis (n=36 patients each). Prior to propensity score matching, differences in the rate of complications were seen in patients with a history of RT (n=69) and patients without a history of RT (n=70): reoperations (80.0% versus 20%), infection (63.6% versus 36.3%) and fat necrosis (55.5% versus 44.4%). However, univariate analyses of the propensity-matched cohorts resulted in no statistically significant associations between prior breast RT and postoperative complications: reoperations (p=0.31), infection (p=0.64), and fat necrosis (p=0.64).

Conclusions: A propensity score-matched analysis indicates that there is no statistically significant association between previous radiotherapy to one breast and complications following breast reduction in the other breast. Therefore, this surgical technique should be strongly considered in patients who are seeking symmetry and relief from unilateral macromastia after prior RT for breast cancer treatment.

Introduction

Breast reduction surgery (BRS) effectively improves or resolves many of the symptoms of macromastia. The inferior and superior-medial pedicles are the most commonly used techniques. However, up to 75% of patients have reported being bothered by impaired sensation following surgery and the occurrence of chronic postoperative breast pain has been poorly described. The influence of pedicle technique on sensory outcomes has been controversial and their impact on postoperative pain is unknown. Therefore, this study aimed to compare the sensory and pain outcomes of the inferior pedicle versus the superior-medial pedicle technique in BRS.

Methods

A total of 40 patients undergoing BRS were included. 20 patients undergoing the inferior pedicle were age- and BMI-matched to 20 patients undergoing the superior-medial pedicle. Patients were evaluated preoperatively and postoperatively at 1, 3, 6 and 12 months. Quantitative sensory testing included Semmes-Weinstein monofilament testing on predefined quadrants of the nipple areola complex (NAC) and surrounding breast skin. Patient-reported outcome measures included nipple and chest sensation (5-point Likert scale) and the presence of pain in the breast area. The Patient Reported Outcome Measurement Information System (PROMIS) Neuropathic Pain Quality scale was used to assess for neuropathic pain. Pain intensity was assessed using the numeric rating scale (0-10).

Results

The mean NAC monofilament values were significantly better in the inferior pedicle versus the superior-medial pedicle at 1 and 3 months postoperatively (p<0.05) and comparable afterwards (p>0.05). The mean monofilament values at the surrounding breast skin were similar between both pedicle techniques throughout follow-up (p>0.05). Patient-reported nipple sensation was significantly better in the inferior pedicle group as compared to the superior-medial group at 1 and 3 months postoperatively (p<0.05) and comparable afterwards (p>0.05). At 12 months postoperatively, complete nipple sensation (5/5) was reported in 85% of patients in the inferior pedicle group as compared to 60% of patients in the superior-medial group (p>0.05). Patient-reported breast sensation was comparable between inferior and superior-medial pedicles throughout follow-up (p>0.05). At 12 months postoperatively, complete breast sensation (5/5) was reported in 90% of patients in the inferior pedicle group as compared to 80% of patients in the superior-medial group (p>0.05). Breast pain was reported in 30% of patients at 1 month postoperatively, 50% at 3 months, 30% at 6 months and 25% at 12 months. Pain had neuropathic qualities in 86% of cases, was intermittent in 95% and the average pain intensity was 6.3 (±1.3). Rates of pain were similar between inferior and superior-medial pedicle techniques throughout follow-up (p>0.05).

Conclusions

In BRS, the inferior pedicle may allow for earlier restoration of quantitative and patient-reported NAC sensation as compared to the superior-medial pedicle. Regardless of pedicle technique, a quarter of patients had persistent breast pain at 12 months postoperatively, which was mostly neuropathic in nature. Therefore, patients undergoing BRS should be counseled about potential differences in sensory outcomes with different pedicle techniques, as well as a risk of persistent neuropathic pain.

Introduction: In the U.S., over 3 million breast cancer patients and survivors (BCPS) are focusing more on quality of life due to improved survival rates. Addressing the gap in postoperative information, AI, especially as a specialized AI virtual assistant (AIVA) for breast cancer care, and advancements in Large Language Models (LLMs) like ChatGPT-4 are aiding healthcare professionals in patient management. This study aims to evaluate the effectiveness of the AIVA tool in addressing post-plastic surgery inquiries from breast cancer patients and survivors, comparing it to the voice-enabled application of OpenAI's ChatGPT-4 through verbal prompts. Methods: We developed an AIVA using IBM Watson Assistant, a platform that enables the creation and training of chatbots. Our AIVA utilizes conversational AI technology to interact in real-time with BCPS, capable of understanding a broad spectrum of user inputs. We compiled 242 frequently asked questions by post-plastic surgery BCPS at Mayo Clinic Florida, encompassing 10 key postoperative care topics. Each question was initially answered by a plastic surgery expert for reference. We then presented these questions to AIVA and the voice-enabled ChatGPT-4 application. Our analysis focused on identifying knowledge gaps and the accuracy of AIVA and ChatGPT-4's responses compared to the expert's answers. Additionally, four medical professionals rated the appropriateness of the answers on a 5-point scale. We evaluated ChatGPT-4's responses for length, complexity, and wordiness using Hemingway and Flesch-Kincaid readability tools online. To analyze the data, we employed the Shapiro-Wilk test to ascertain data normality and the Kruskal-Wallis test for comparisons due to the non-normal distribution of our data. Results: In a comparison of 10 topics, AIVA significantly outperformed ChatGPT-4 in accuracy, with median scores of 0.9 (0.6, 1.0) for AIVA and 0.6 (0.2, 0.8) for GPT (p < 0.001). AIVA's answers also had a substantially lower knowledge gap than GPT's (median 0.1 (0.0, 0.1) vs 0.2 (0.0, 0.6), p 0.028). ChatGPT's accurate answers were generally more complex in language and structure than inaccurate ones (p < 0.001). No knowledge gap was found in the accurate ChatGPT responses, while only 53.3% of inaccurate responses showed no knowledge gap (p < 0.001). In these inaccurate responses, ChatGPT requested additional context or information 35% of the time, misunderstood words 5.8%, misheard questions 4.2%, and redirected to healthcare professionals 1.7%. 42% of responses were rated as incorrect, 46.6% of which showed no knowledge gap. Moreover, AIVA's responses received twice the Likert scores from our four reviewers compared to ChatGPT (median 3.0 (2.7, 3.0) vs 1.6 (1.2, 2.4), p < 0.001). All responses rated as totally correct showed no knowledge gap (p < 0.001). There was a significant correlation between the complexity of answers, their readability, and the received Likert scores, with higher scores indicating greater complexity and lower readability (p < 0.001). Conclusion: AIVA surpassed ChatGPT's audio app in patient query response, demonstrating greater accuracy, depth, and relevance. Our analysis suggests that ChatGPT's detailed answers tend to be more accurate. Statistically significant differences (p < 0.001) across various metrics reinforce these findings.

Purpose: Patients may suffer from persistent postoperative pain following mastectomy, referred to as Persistent Post-Mastectomy pain (PPMP). PPMP is associated with increased use of analgesics, physical disability, and decreased quality of life (QOL), with one proposed mechanism being nerve injury followed by neuroma formation. Neurotization with allograft to the 3rd, 4th, or 5th intercostal nerve has been employed to restore sensation during breast reconstruction. This study aims to characterize neurotization practices performed during autologous breast reconstruction, as well as determine the potential of neurotization to reduce the PPMP and improve QOL, as measured by patient-reported outcome measures (PROMs).

Methods: A single-center retrospective cohort study was conducted including >18 years old females who underwent abdominal-based autologous breast reconstruction (deep inferior epigastric perforator [DIEP], superficial inferior epigastric artery [SIEA], muscle sparing or free transverse rectus abdominus myocutaneous [MS-TRAM, free TRAM] flaps) between August 2007 and October 2022 and were at least one-year post-operation. Patients were included in the study if they completed all of the following four scales from the BREAST-Q Reconstruction Module (Breast Sensation, Sensation: QOL Impact, Psychosocial Well-being and Breast Symptoms), Breast Cancer Pain Questionnaire, Pain Catastrophizing Scale, three PROMIS short forms (Anxiety 7a, Depression 8b and Sleep Disturbance 8b), and the Positive and Negative Affect Schedule Short Form. Sociodemographic and clinical variables, surgical course, postoperative complications, and PROM scores were analyzed. P<0.05 was deemed statistically significant.

Results: 298 patients underwent autologous breast reconstruction, 67 (108 breasts) with neurotization and 231 (361 breasts) without neurotization. The mean age and BMI of the neurotized and non-neurotized cohorts were 52 and 49 years and 28.3 and 29 kg/m2, respectively (p=0.006, p=0.177). The mean time point at which surveys were completed was 4.2 (± 1.3) and 9.7 (± 2.9) years postoperatively in the neurotized and non-neurotized cohorts, respectively (p<0.001). Differences in demographic distributions, comorbidities (obesity, hypertension, Diabetes Mellitus, prior DVT or PE), genetic mutations, chemotherapy, radiation, and postoperative complications of the neurotized and non-neurotized cohorts were not statistically significant (p>0.05). Similarly, history of SLNB or ALND, use of abdominal mesh and flap laterality between the cohorts were not statistically significant (p>0.05). There were significantly more regional blocks performed in the neurotized cohort (p<0.001), more free TRAMs in the non-neurotized cohort (p=0.05) and increased free flap weight in the non-neurotized cohort (p=0.014). Out of 108 neurotized flaps, allografts were used in all cases and the 3rd intercostal nerve (105 flaps, 97.2%) was most commonly used. Neurotization targeting the flap was performed via coaptation to the cutaneous nerve supplying the flap in 104 (96.3%) cases and to the breast skin or nipple in 4 (3.7%) cases.

Conclusion: Further analysis of pain, sensation and QOL, adjusting for cohort differences in a multivariable regression analysis, will be essential to uncover the nuanced differences in patient-reported outcomes between the neurotized and non-neurotized cohorts. Our ongoing patient accrual will facilitate comprehensive data collection, enabling us to finalize and analyze the results in time for presentation at PSTM 2024.

Purpose: Secondary breast reduction is performed for refractory macromastia after previous primary breast reduction. While obtaining information about which dermoglandular pedicle was used during the primary operation is thought to be helpful to determine the optimal approach to maintain nipple-areolar complex (NAC) viability, current literature debates the true clinical benefit of this information. Additionally, data regarding postoperative outcomes following secondary breast reduction where patients underwent single versus combined pedicles is limited. The present study investigates the risk of postoperative complications after secondary breast reduction procedures in patients with unknown primary pedicles.

Methods: A retrospective review was conducted of an institutional database of patients who had undergone breast reduction surgery between 2019 and 2023. Secondary breast reduction procedures were identified and stratified according to whether the pedicle utilized at the index operation was known or unknown. Patient demographics, clinical variables, operative techniques (including pedicle design during secondary breast reduction), and postoperative complications were collected and analyzed.

Results: A total of 15 patients (22 breasts) who had undergone secondary breast reduction was identified. The mean age at time of surgery was 49.7 ± 11.8 years, and body mass index was 29.6 ± 4.4 kg/m2. Common comorbidities included hypertension (26.6%, n=4) and diabetes (13.3%, n=2). No patients were identified as currently smoking. Twelve patients (80%) had previously undergone bilateral breast reduction, and three patients (20%) had previously undergone unilateral breast reduction. Among the 12 patients who had undergone a primary bilateral procedure, a secondary bilateral reduction occurred in 58% (n=7), and 42% (n=5) underwent a unilateral procedure. The primary pedicle was known in 46.7% (n=7) of patients, and unknown in 53.3% (n=8). The rate at which the same pedicle was utilized for the secondary procedure among the known group was superior pedicle (100%, n=2/2), superomedial pedicle (75%, n=3/4), and inferior pedicle (0%, n=0/1). In the unknown group, the inferior pedicle (37.5%, n=3), superior pedicle (25%, n=2), and superomedial pedicle (12.5%, n=1) were utilized. The remaining two patients (25%) underwent secondary reductions that utilized more than one pedicle: one patient underwent a superomedial + central mound pedicle, and the other patient underwent a superomedial + central mound + inferior pedicle. All postoperative complications occurred in the unknown group (n=5), in which the inferior (n=3) and superomedial (n=2) pedicles were utilized for secondary reductions. Complications related to the NAC included loss of sensation (n=1), necrosis (n=2) and reoperation (n=1). However, there were no complications related to the NAC among patients who underwent a combined pedicle technique. Additional complications for the unknown group included seroma (60%, n=3), fat necrosis (40%, n=2), T-junction breakdown (40%, n=2), infection (20%, n=1), and abscess (20%, n=1).

Conclusions: Postoperative complications occurred more frequently after secondary breast reduction in patients with an unknown primary pedicle than in patients with a known pedicle. No complications related to the NAC occurred in patients who underwent a combined pedicle technique. These findings suggest that optimizing the number of pedicles utilized and cautious postoperative care is essential to mitigate risks associated with secondary breast reductions.

INTRODUCTION: This study examines differences in cancer stage and characteristics, treatments received, and reconstruction rates and outcomes among a racially diverse group of women. Existing data largely focuses on the experiences of Caucasian women, thus this study aims to fill in critical knowledge gaps in underrepresented Women of Color (WOC). Exploring these factors and how they relate to breast cancer in a broader demographic can highlight disparities and contribute to a more equitable understanding of healthcare outcomes.

METHODS: This study engaged a voluntary sample of 413 adult females with a history of surgical intervention for breast cancer. A racially and ethnically diverse population was sampled from May 2023 to June 2023, including 250 White, 99 African American, 29 Hispanic, 24 Asian, and 11 American Indian/Alaska Native women. Conducted by Kantar Lightspeed LLC, the computer-based survey combined a 45-item questionnaire, developed with the BRAVE Coalition, the 13-item BREAST-Q Satisfaction with Breasts subscale, and several open response questions. It focused on cancer stage and characteristics, treatments received, and reconstruction rates and outcomes to examine differences among those of diverse racial backgrounds.

RESULTS: A total of 413 breast cancer survivors from a racially diverse background were surveyed. Respondents were asked about breast cancer stage, tumor characteristics, and treatments received. White women were significantly more likely to receive breast-conserving surgery compared to Black women (p<0.001). Black women were significantly more likely than White women to receive bilateral mastectomy (p<0.001). Black women were significantly more likely to undergo chemotherapy compared to white women (p=0.003). Notably, pairwise comparison of breast cancer stage at diagnosis, her2 status, and triple negative status showed no statistically significant difference between race groups (p=0.37, p=0.14, and p=0.15, respectively). Respondents were also asked about any breast reconstruction received and associated complications. Among patients who underwent mastectomy, White women received reconstruction at higher rates compared to Black women, however this difference was not significant. Among those who received reconstruction, Black patients were significantly more likely than White patients to experience complications in the form of flap compromise (p=0.002).

CONCLUSION: Despite no significant differences in breast cancer stage and tumor characteristics, race was found to be significantly associated with the type of breast cancer treatment received. White women were over three times more likely to undergo breast conserving surgery compared to their non-White counterparts. Further, Black women were significantly more likely to receive more aggressive cancer treatment in the form of bilateral mastectomy and chemotherapy compared to their White counterparts. Although there was no significant difference in rates of reconstruction between Black and White women post-mastectomy, Black women were significantly more likely than White women to experience flap compromise post-reconstruction. The present data suggests that Black women are receiving more aggressive treatments independent of cancer stage and characteristics, as well as experiencing greater post-reconstruction complications compared to White women. The results of this study highlight the need for more research into the underlying causes for these disparities in treatment and reconstruction outcomes in WOC.

Introduction: Breast reconstruction post-mastectomy is a critical aspect of the recovery process for patients, offering psychological and aesthetic benefits. However, one previous study found that 32.9% of patients can develop complications (1). Patients with Systemic Lupus Erythematosus (SLE) represent a unique subset due to their altered immune response and potential for increased complications. The interplay between SLE and outcomes after breast surgery is underexplored in medical literature. This study aims to help fill the gap by evaluating the surgical outcomes of breast reconstruction in SLE patients.

Methods: A retrospective review was performed for adult patients who underwent mastectomy with associated breast reconstruction at one of the Mayo Clinic's three main campuses (Arizona, Florida, Rochester) between January 1, 2010, and December 31, 2023. Potential patients were identified through i2b2 using diagnostic (ICD-9, ICD-10) and procedure (CPT) codes. Patient charts were evaluated to assess eligibility. Patients without SLE or those who underwent mastectomy prior to 2010 or at an outside institution were excluded. Patient data and surgical outcomes were collected. Surgical outcomes of interest included mastectomy skin flap necrosis, nipple-areolar complex necrosis, wound dehiscence, hematoma, seroma, infection, tissue expander failure, and breast implant failure.

Results: The i2b2 search identified 103 patients, of which, 31 met inclusion criteria for analysis. The average age at time of mastectomy was 48.8±12.6 (range 26-75), and the average BMI was 28.9±7.2 (range 20.3-50.4). Twenty-four (77.4%) patients had a breast cancer diagnosis at the time of mastectomy. Seven (22.6%) included patients had a history of tobacco use. Thirteen (41.9%) patients were taking Hydroxychloroquine. Eight (25.8%) patients had undergone chemotherapy, and only three (9.7%) patients had a history of radiation. Twenty-seven (87.1%) patients underwent immediate reconstruction compared to four (12.9%) who underwent delayed. Twenty-two (71.0%) patients underwent implant-based reconstruction, with 19 patients receiving silicone implants and three receiving saline. Fifteen (48.4%) patients experienced at least one complication, with four (12.9%) patients experiencing more than one. There was only one case (3.4%) of full-thickness mastectomy skin flap necrosis, with this patient undergoing surgical debridement and replacement of tissue expander. Two (9.5%) patients experienced tissue expander failure, and three (12.5%) patients had breast implant rupture. There were no cases of nipple-areolar complex necrosis in patients who underwent nipple-sparing mastectomy. Three (10.3%) patients developed wound dehiscence. There were seven (22.6%) cases of infection, three of which were treated with IV antibiotics. Two (6.7%) patients developed hematoma requiring evacuation. There were four (12.9%) cases of seroma.

Conclusion: This study provides insights into the surgical outcomes of SLE patients following post-mastectomy breast reconstruction, highlighting significant complication rates. With nearly half of the patients encountering at least one complication, further research to better elucidate the heightened risk profile in this demographic is warranted.

Background: Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel node biopsy (SLNB) or targeted axillary excision.  In those scenarios, ALND can be performed 1) immediately if frozen sections are positive or 2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision making and operative planning.

Methods: A single-center retrospective review was performed (2019-2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into 2 groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographical information and operative time were recorded.  

Results: There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1±63.2 minutes in Group 1 compared to 222.6±52.2 minutes in Group 2 (p=0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3±71.6 minutes compared to 171.3±43.2 minutes in Group 2 (p=0.001). 

 Conclusions: Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.

Background: Breast reconstruction with abdominally-based free flaps provides a durable reconstruction with established psychosocial benefits.1 A common challenge of autologous reconstruction is a mismatch in available tissue volume at the donor site for reconstruction relative to the volume of the mastectomy specimen. In most cases at least one, and sometimes multiple, revision surgeries are undertaken for address these aesthetic concerns.2,3,4 However, these additional surgeries translate to added costs and impose additional challenges for patients and physicians.5 The present study introduces a unique classification system based on the relative volume of the free flap to mastectomy specimen, aiming to guide decision-making and discussions with patients regarding aesthetic reconstruction.

Methods: A retrospective review was conducted on all patients who underwent mastectomy with immediate breast reconstruction with deep inferior epigastric (DIEP) flap reconstruction between 2018 and 2021 at a single institution. Data on breast flaps and mastectomy weights were also collected, and cohorts were classified into one of three reconstruction classes based on the weight of the flap relative to the mastectomy specimen weight. Patients with a "Class 1" had a flap weight that was greater than or equal to 115% of the mastectomy weight. "Class 2" was between 85% and 115%, and "Class 3" held the remainder with flap weight less than 85%. Data on revision procedures during a minimum of two years follow-up were included.

Results: The analysis encompassed 320 patients meeting inclusion criteria, with a total of 610 reconstructed breasts. Revision surgery was undertaken by 243 patients, totaling 471 individual procedures. Data were organized by breast to allow for preoperative asymmetry (Table 1). The most common procedures involved in the patients' revision surgeries were mastopexy/lift, nipple reconstruction, and fat grafting, respectively. Across the breast reconstruction classes, a trend from Class 1 to Class 3 was observed with increasing mastectomy weights and decreasing flap weights. Class 2 breasts were less likely to undergo revision surgeries. Class 1 breasts were more likely to undergo reduction, while Class 3 breasts were more likely to undergo mastopexy, fat grafting, and hybrid reconstruction.

Conclusion: The Northwell Classification System offers a straightforward, data-driven approach for surgeons to conceptualize breast reconstruction utilizing autologous tissue. It aids surgeons in planning and discussing a patient's DIEP flap reconstruction and identifies when a stacked or hybrid approach may be beneficial. Most patients undergo at least one revision procedure to achieve an aesthetic result after DIEP flap reconstruction, and this system helps anticipate the type of necessary revisions to optimize the result. Moreover, it provides patients with a clearer framework to understand the nuances of their reconstructive approach compared to that of other patients.

1. Saldanha IJ, Cao W, Broyles JM, et al. Breast Reconstruction After Mastectomy: A Systematic Review and Meta-Analysis. Agency for Healthcare Research and Quality (AHRQ); 2021. doi:10.23970/AHRQEPCCER245

2. Alves AS, Tan V, Scampa M, Kalbermatten DF, Oranges CM. Complications of Immediate versus Delayed DIEP Reconstruction: A Meta-Analysis of Comparative Studies. Cancers. 2022;14(17):4272. doi:10.3390/cancers14174272

3. Nelson JA, Voineskos SH, Qi J, et al. Elective Revisions after Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium. Plast Reconstr Surg. 2019;144(6):1280-1290. doi:10.1097/PRS.0000000000006225

4. Smith JM, Boukovalas S, Chang EI, et al. Analysis of Breast Aesthetic Revision Procedures after Unilateral Abdominal-based Free-flap Breast Reconstruction: A Single-center Experience with 1251 Patients. Plast Reconstr Surg - Glob Open. 2023;11(3):e4861. doi:10.1097/GOX.0000000000004861

5. Kroll SS, Reece GP, Miller MJ, et al. Comparison of Cost for DIEP and Free TRAM Flap Breast Reconstructions: Plast Reconstr Surg. 2001;107(6):1413-1416. doi:10.1097/00006534-200105000-00014