Scientific Abstract Presentations: Breast Session 3 Thursday, September 26 Thu, Sep 26 3:00-4:00 p.m. PDT

Purpose Breast cancer related lymphedema (BCRL) is the most common cause of secondary lymphedema in developed countries. Previous studies have shown that cardiovascular co-morbidities such as hypertension increase the risk of developing BCRL (1). However, more recent studies have also shown that socioeconomic factors significantly influence the development of disease (2). Given the correlation between cardiovascular diseases and socioeconomic factors, the purpose of this study was to analyze the independent effects of these variables on the risk of BCRL development. Methods We identified patients treated at Memorial Sloan Kettering Cancer Center for breast cancer with either axillary lymph node dissection (ALND) or SLNB (sentinel lymph node biopsy) procedures from January 2000 to November 2023. Results were limited to those who had a minimum of 18 months follow up. Variables of interest included diabetes, hyperlipidemia and hypertension status at time of ALND or SLNB, time to BCRL diagnosis, and socioeconomic risk factors, including race, ethnicity, insurance status, and social deprivation index (SDI) using patients' zip codes. Univariable analysis was performed using either Chi-squared test or Mann Whitney U test. Multivariable analysis was performed using a multiple logistic regression model. Results The database search yielded a total of 28,863 patients who underwent SLNB or ALND procedures with a minimum of 18 months follow up. Within this group, 2,306 (median age 53) were diagnosed with BCRL. On univariable analysis, BCRL rate was higher among Black patients (14% vs. 8.5%, p<0.0001), Hispanic or Latino patients (8.6% vs. 6.6%, p<0.0001), those with Medicaid (4.9% vs. 3.8%, p<0.0006) or Medicare insurance (41.5% vs. 39.1%, p<0.0006) and in those with diabetes (9.3% vs 6.6%, p<0.0001) and hypertension (31.4% vs. 27.7%, p<0.0001), while Asian race was protective (5.6% vs. 8.6%, p<0.0001). On multivariable analysis, several notable socioeconomic risk factors were independently associated with BCRL development. These included Black race (OR 1.22, 95% CI 1.0-1.4, p=0.0110), Medicare insurance coverage (OR 1.20, 95% CI 1.1-1.3, p=0.0004), and SDI score (OR 1.002, 95% CI 1-1.004, p=0.0065) with Asian race identified as a protective factor (OR 0.62, 95% CI 0.5-0.8, p<0.0001).
Conclusion Our large retrospective study highlights the role of socioeconomic factors in BCRL development and suggests that the increased risk of disease in patients with vascular co-morbidities may be related to socioeconomic factors or complex treatment effects rather than independent effects of these co-morbidities. These findings are important as they raise crucial questions relating to patient care and suggest that access to care is a significant risk factor for BCRL.

1. Yusof KM, Avery-Kiejda KA, Ahmad Suhaimi S, et al. Assessment of Potential Risk Factors and Skin Ultrasound Presentation Associated with Breast Cancer-Related Lymphedema in Long-Term Breast Cancer Survivors. Diagnostics (Basel). 2021;11(8):1303. Published 2021 Jul 21. doi:10.3390/diagnostics11081303
2. Montagna G, Zhang J, Sevilimedu V, et al. Risk Factors and Racial and Ethnic Disparities in Patients With Breast Cancer-Related Lymphedema. JAMA Oncol. 2022;8(8):1195-1200. doi:10.1001/jamaoncol.2022.1628

Background: Post-mastectomy flat closure is an increasingly common reconstruction option, but comprehensive research on patient-reported outcomes remains limited.(1) Understanding the psychosocial impact of mastectomy is crucial for guiding patient decisions on breast reconstruction, and the BREAST-Q survey has been instrumental in assessing postoperative outcomes.(2) By combining quantitative analysis and qualitative document analysis, we seek to explore the post-mastectomy flat closure experience. This study analyzes clinical outcomes, evaluates patient satisfaction and quality of life metrics via the BREAST-Q, and explores the applicability of the BREAST-Q survey for this patient population.

Methods: A retrospective review was conducted for patients who underwent post-mastectomy flat closure at our institution from 2014 to 2022, examining patient demographics, surgical details, and complications. Data was reported as means ± standard deviations. Following consent, patients completed the BREAST-Q survey, rating satisfaction and factors influencing their choice for flat closure. Each domain within the BREAST-Q survey was independently evaluated. The median scores, along with their interquartile ranges (IQR), were calculated for further analysis. Further, qualitative analysis of patient emails, employed an inductive, triangulated approach to extract themes and provide a multi-faceted understanding of the post-surgical experience.

Results: 252 patients underwent post-mastectomy flat closure at a mean age of 61.36 ± 12.28 years. The mean time between mastectomy and the last plastic surgery follow-up was 832.7 ± 797.4 days. The overall postoperative complications rate was 17.5% (n=44), with specific complications including seroma (4.8%), hematoma (7.1%), nipple or skin necrosis (0.4%), surgical site infection requiring oral and/or IV antibiotics (2.0%), and other complications (3.2%)

50 (19.8%) patients completed the BREAST-Q survey, on average 4.6 ± 2.36 years after their mastectomy procedure. Patients reported high satisfaction with their surgeons, moderate satisfaction with their breasts, and high physical well-being. Survey results illuminated reasons for choosing flat closure, such as lower complication rates and avoidance of foreign objects. Furthermore, qualitative feedback from 15 email correspondents revealed some limitations of the survey's relevance and language, highlighting emotional impacts and a desire to improve future surveys. The qualitative analysis identified four main categories: Study Participation, Reasons for Declining Participation, Negative Language and Emotional Impact of Survey, and Desire to Help Improve.

Conclusions: Our study provides a comprehensive insight into the experiences and outcomes of patients who opted for post-mastectomy flat closure. The study reaffirms that flat closure is a viable option with generally low complication rates, aligning well with patient-centric reasons for this choice. However, the study also exposes gaps in patient satisfaction and the limitations of existing survey tools like the BREAST-Q in capturing the nuanced experiences of this specific population. Future research should focus on refining patient-reported outcome measures and fostering clinician-patient dialogues that offer flat closure as a routinely discussed reconstruction option in post-mastectomy care.

References: 1.La J, Jackson S, Shaw R. 'Flat and fabulous': women's breast reconstruction refusals post-mastectomy and the negotiation of normative femininity. 2.Liu LQ, Branford OA, Mehigan S. BREAST-Q Measurement of the Patient Perspective in Oncoplastic Breast Surgery: A Systematic Review. Plast Reconstr Surg Glob Open. 2018;6(8).

Purpose: Nipple-areola complex (NAC) ischemia is a rare but known complication following nipple-sparing mastectomy (NSM) with breast reconstruction. The authors sought to characterize predictors of NAC complications.

Methods: A prospectively maintained database was queried to identify patients who underwent NSM with immediate reconstruction. The effect of patient demographic and surgical characteristics on postoperative NAC ischemic complications was investigated. Multivariate logistic and linear regression were performed.

Results: A total of 444 patients underwent nipple-sparing mastectomies with reconstruction (791 breasts) between 2006 and 2023. Sixty-eight patients (15%) experienced a nipple complication, with 46% having bilateral nipple complications (99 breasts). The mean time from surgery to complication recognition was 12 days. The majority of complications were managed with observation requiring no intervention (n=33; 49%), while 8 (12%) required topical treatments and 28 (41%) required operative intervention. Of those requiring operative intervention, 11 (2.5% of total patients) experienced a complete nipple loss. Demographic factors such as age (OR 1.05; p=0.0017) and active smoking (OR 6.35; p=0.0076) were significantly associated with the development of any nipple complication. Severe cardiac and pulmonary disease were also associated with the development of NAC ischemia, although these were rare comorbidities (0.9% and 0.5%, respectively). Surgical factors, including bilateral surgery were also associated with a significantly increased risk of NAC ischemia (OR 4.33; p=0.029). In multivariate analysis, reconstruction method was significantly associated with the development of nipple necrosis when comparing autologous reconstruction versus direct-to-implant reconstruction (OR 2.75; p=0.0491). Implant location (prepectoral versus subpectoral), incision location, previous breast radiation therapy, and previous breast surgery were not associated with increased risk of NAC ischemia.

Conclusion: Age, active smoking, and bilateral surgery were associated with a significantly increased risk of nipple-areola ischemia. Although the use of implant expander reconstruction is commonly used in patients undergoing post-operative radiation therapy, it was not associated with improved nipple outcomes when compared to direct-to-implant or autologous reconstruction.

Purpose Prepectoral tissue expander (TE) based breast reconstruction is an innovative modality as it may lead to less pain and improved aesthetics than subpectoral TE placement. However, prepectoral TE reconstruction does not have the perfusion benefit of the pectoralis major muscle adjacent to the skin, increasing the risk for mastectomy skin ischemia. Hyperbaric oxygen therapy (HBOT) has been shown to salvage compromised mastectomy skin. We analyzed the reconstructive outcomes of patients undergoing TE placement and HBOT usage at our institution.

Methods We performed a retrospective chart review of patients undergoing immediate TE breast reconstruction from July 2016 through January 2022. Patient demographics, intraoperative data, receipt of HBOT, complications at the 48-hour, 30-day, and 90-day mark, and final breast reconstruction choice were collected. Chi-squared tests determined associations between receipt of HBOT and TE plane (prepectoral vs. subpectoral). Analyses were performed by-patient and by-breast.

Results
We included 357 patients (568 breasts) undergoing immediate TE breast reconstruction. The distribution of TE placement was 83% prepectoral (298 patients, 476 breasts), 13% subpectoral (47 patients, 73 breasts), and 3% unknown (12 patients, 19 breasts). Prepectoral TE placements were associated with larger mean mastectomy weights (650 g vs. 563 g) and TE sizes (479 cc vs. 456 cc) than subpectoral TE placements. More prepectoral (n=19, 33 breasts) compared to subpectoral (n=0) patients received HBOT (p=0.03). For patients who received HBOT, concern for mastectomy skin necrosis was noted on average 7 days after surgery (SD: 4.8 days) and HBOT was started on average 10 days after surgery (SD: 7.7 days). Hyperbaric oxygen therapy significantly salvaged more mastectomy pockets, preventing a return to the operating room for TE explantation in 76% (n=25/33) of breasts, compared to 52% (n=17/33) who had mastectomy skin necrosis but did not receive HBOT (p=0.03). For patients who had successful mastectomy pocket salvage after HBOT, the distribution of reconstructive outcomes was not significantly different than those who did not receive HBOT and did not have TE explantation (p=0.09).

Conclusions
Our study of HBOT in immediate prepectoral TE based breast reconstruction demonstrated that when mastectomy skin necrosis occurs, HBOT is able to significantly salvage more mastectomy pockets. In addition, this data may improve the conversation between patients and surgeons regarding the potential benefits of HBOT for compromised mastectomy skin pockets.

Introduction: The choice of reconstructive approach in implant-based breast reconstruction after mastectomy has fluctuated in the last decade, with prepectoral reconstruction resurging in popularity with the advent of acellular dermal matrices. Infection is a feared complication in all device-based breast reconstruction, but may be particularly devastating in pre-pectoral reconstruction where device involvement necessitates operative intervention and explantation. Trialing conservative management with antibiotic therapy may enable implant salvage in certain cases. While previous studies have characterized overall complication profiles in different planes of reconstruction following mastectomy, no existing studies describe the likelihood of implant salvage with respect to the plane of reconstruction in a large patient cohort.

Methods: Patients who underwent device-based breast reconstruction after mastectomy from January 2013 to December 2023 were identified by CPT code and retrospectively reviewed. Patients with post-operative infections were identified and patient characteristics were collected and analyzed for clinical outcomes. Patients were separated into four groups (total submuscular, dual plane, pre-pectoral with ADM and pre-pectoral without ADM) and outcomes were compared, with device salvage and explantation as the main outcomes of interest. Device salvage was characterized as clinical resolution of infection following conservative management and explantation was characterized as removal of implants. Multivariate logistic regression was used to calculate most contributory predictors of salvage vs. explantation (p<0.05).

Results: 2,012 reconstructed breasts in 1,206 patients were analyzed. Postoperative infection occurred in 99 (4.9%) cases. The infection rate was highest in dual plane procedures (31/280, 11.1%), followed by prepectoral (20/243, 8.2%) and submuscular (48/1489, 3.2%) placement (p<0.001). Oral antibiotics were provided most frequently in prepectoral cases (90.0%) (p=0.67). Intravenous antibiotics and/or hospital admission occurred most frequently in prepectoral (75.0%), followed by submuscular (58.3%) and dual plane reconstruction (25.8%) (p=0.0012). Rate of explantation was highest in dual plane (80.6%) procedures, followed by submuscular (70.8%) and prepectoral (65.0%) placement (p=0.43). Rate of salvage was comparable in submuscular (31.8%) and prepectoral (31.6%) reconstruction, but less frequently observed in dual plane reconstruction (21.4%) (p=0.60). History of diabetes and neoadjuvant chemotherapy trended toward lower rates of salvage (p<0.2); however, neither were significant predictor variables in multivariate logistic regression.

Conclusion: Submuscular implant placement in device based breast reconstruction is associated with lower rates of implant infection and greater likelihood of salvage in our practice. Dual plane procedures were associated with the highest rate of infection and lowest rates of salvage, although findings were not statistically significant. Our data suggests that while patients theoretically have increased soft tissue coverage with dual plane reconstruction, it may not confer much benefit to prepectoral reconstruction from an infectious standpoint. Overall, our data suggests that conservative management of infection in device-based reconstruction is a reasonable treatment option, with resolution of infection in many cases.

Background: The lateral upper arm pathway represents a collateral route of lymphatic drainage postulated to terminate in the deltopectoral groove distinct from the arm's main lymphatic collectors. The lateral upper arm pathway may prevent or alleviate breast cancer-related lymphedema (BCRL) by draining to higher level lymph nodes spared during axillary lymph node dissection (ALND). However, we previously reported that the lateral upper arm pathway is visualized intraoperatively draining to the axilla with the arm's main collecting channels in 10% (3/29) of immediate lymphatic reconstruction (ILR) patients.1 Our objective was to complete a 5-year follow up to better describe intraoperative visualization of the lateral upper arm pathway draining into the axilla in ILR patients.

Methods: A retrospective review of breast cancer patients undergoing ILR from September 2016 through May 2023 was performed. Intraoperative lymphatic mapping was performed with fluorescein isothiocyanate (FITC) injected at the medial upper arm or hand/wrist, while isosulfan blue was injected over the cephalic vein in the lateral upper arm prior to ALND. Patient demographic and intraoperative lymphatic channel data were analyzed.

Results: 333 consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a median age of 54 years and 99% were female. Divided FITC lymphatics were identified in 97% (323/333) of patients and blue divided lymphatics were identified in 8.1% (27/333) of patients after ALND. A median of 2 divided FITC lymphatics were identified, and a median of 1 divided blue lymphatic was identified. Blue divided lymphatics were significantly closer to the axillary vein (median 1.4 cm) compared to FITC divided lymphatics (median 2.3 cm) (U = 14,815; p = 0.001). Blue divided lymphatic diameters (median 0.40 mm) were comparable to FITC divided lymphatic diameters (median 0.60 mm) (U = 8,690; p = 0.314).

Conclusion: In this 5-year follow up of intraoperative lymphatic channel mapping in ILR cases, we visualized blue divided lymphatics in the axilla in a comparable proportion of patients. For the first time, we describe that lymphatics of the lateral upper arm pathway travel closer to the axillary vein than the arm's main lymphatic collectors when visualized intraoperatively. As the lateral upper arm pathway is visualized intraoperatively in only a small proportion of patients, this may represent an anatomic variation of the pathway's drainage. Further studies are needed to confirm if these patients also demonstrate drainage to the deltopectoral groove, which may confer a lower risk of BCRL after ALND.

References:

1. Johnson AR, Bravo MG, James TA, Suami H, Lee BT, Singhal D. The All but Forgotten Mascagni-Sappey Pathway: Learning from Immediate Lymphatic Reconstruction. J Reconstr Microsurg. 2020 Jan;36(1):28-31. doi: 10.1055/s-0039-1694757. Epub 2019 Aug 9. PMID: 31398762.

Background: Breast cancer is the second leading cause of cancer among women in the United States, necessitating a diverse array of therapeutic interventions1. Radical and modified radical mastectomy remain effective oncologic treatment modalities, however, cause significant deformity requiring autologous and implant-based repair to reconstruct the chest. Longitudinal trends in chest wall reconstruction after modified radical mastectomy remain under described.

Purpose: This retrospective study utilizes the Surveillance, Epidemiology, and End Results (SEER) database to investigate trends in breast reconstruction over two decades (2000-2020) following unilateral modified radical and radical mastectomy. The primary objectives are to assess whether there is a decline in autologous reconstruction (AR) in favor of implant-based reconstruction (IBR), to analyze demographic shifts in patients undergoing these procedures, and to examine differences in oncologic management.

Methods: We analyzed data from the SEER 17 registry, encompassing seventeen geographic regions in the United States. Female patients undergoing radical mastectomy between 2000 and 2020 were included. Detailed demographic and oncologic variables were collected, and reconstruction types were categorized as IBR, AR, or a combination. Subgroup analyses compared IBR and AR patients, and demographic changes between the 2000-2010 and 2010-2020 cohorts were examined.

Results: Of the 25,649 patients included, 51.8% underwent IBR, and 48.2% underwent AR. AR patients tended to be younger, more frequently Black, with higher incomes, and less rural residence compared to IBR patients. Longitudinal analysis revealed a shift from AR to IBR dominance, with AR decreasing from 41.8% of all reconstructions in 2000 to 24.5% in 2020. Significant demographic changes in AR patients between 2000-2009 and 2010-2020 included increased average age, higher proportions of Black and Asian patients, lower income, and increased non-marital status. Oncologic management also differed, with AR patients less likely to undergo chemotherapy and radiation, and experience longer times to reconstruction than IBR patients.

Conclusions: This study highlights a shifting landscape in post-modified-radical mastectomy breast reconstruction, with a notable decline in AR in favor of increasing IBR popularity. Demographic changes reveal evolving trends in patient characteristics, emphasizing the importance of understanding these shifts for equitable access and informed decision-making in breast cancer reconstructive care.

Purpose: The incidence of obesity in the United States continues to rise with subsequent increases in the incidence of bariatric surgery for massive weight loss (MWL). Prior bariatric surgery with massive weight loss demonstrates an increased complication rate in abdominal procedures. In terms of plastic surgery, this broadly includes deep inferior epigastric perforator (DIEP) free flap breast reconstruction and abdominal body contouring (traditional abdominoplasty, fleur-de-lis/vertical, and circumferential body lift). Obesity is a known risk factor for breast cancer, so many patients will have MWL surgery and breast cancer. These patients most frequently undergo body contouring surgery (BCS) for excess skin following MWL. Bariatric surgery followed by mastectomy with breast reconstruction gives these patients the unique opportunity to utilize their redundant tissue similar to abdominal BCS. Due to the known increase in complication rates for abdominal procedures following MWL, many patients may be hesitant to consider DIEP for their breast reconstruction. In this study, patients who underwent DIEP breast reconstruction surgery following MWL were compared to those who received abdominal BCS following MWL to assess relative complication rates and potentially provide patients considering DIEP with reassurance that their complication rate is similar to commonly performed abdominal BCS.

Methods: A retrospective cohort study was performed including patients treated at either a National Cancer Institute designated cancer center or a tertiary referral hospital who underwent either DIEP or abdominal BCS following MWL between October 2011 and February 2022. Patients met inclusion criteria if they lost more than 50% of excess body weight, were at a stable weight for the six months prior to surgery, and had a complete chart for analysis. Statistical analysis included independent samples t test and Fisher's exact test for univariate analyses along with multivariate analysis for predictive variables of postoperative complication.

Results: A total of 24 DIEP flaps (in 14 patients) and 188 abdominal body contouring procedures (in 188 patients) met inclusion criteria. The average age was 55 ± 10 years in the DIEP group compared to 49 ± 12 years in the abdominal BCS group. Average BMI in the DIEP group was 32.2 ± 4.8 kg/m2 compared to 34.0 ± 8.8 kg/m2 for the abdominal BCS patients. The postoperative complication rate did not differ between the two groups (50% with DIEP vs. 34% with BCS, p=0.17). Multivariate analysis further demonstrated that procedure type was not a predictor of postoperative complication (p=0.34).

Conclusion: Patients with DIEP procedures were found to have similar complication rates to those who received standard abdominal BCS. It should be noted that the complications after DIEP were frequently Clavein-Dindo IIIb (66%) and required surgical intervention. This information can be used by plastic surgeons when counseling MWL patients considering DIEP that their chance of postoperative complication is similar to commonly performed abdominal body contouring procedures.

Background In reconstructive breast surgery, there is insufficient literature on threshold values for hemoglobin A1C (A1C) and body mass index (BMI) to identify patients at high risk for complications. This study aimed to evaluate the effectiveness of A1C, BMI, and other patient factors in predicting complications and to identify cutoff values for plastic surgeons to use in preoperative evaluation.

Methods Retrospective analysis of breast reconstruction complications was conducted utilizing data from the National Surgical Quality Improvement Program Database (2020-2022). Logistic regressions examined the association of A1C, BMI, age, and diabetes, smoking, and hypertension status with complications. Receiver operating characteristic curves were constructed to identify cutoff values with the highest sensitivity and specificity for predicting complications. The discriminatory ability of A1C and BMI to predict complications was assessed using area under the curve (AUC).

Results The study included 2,713 cases. At least one complication was documented in 12.8% of cases (n = 348). BMI was the only significant predictor of complications based on logistic regression. Patients with BMIs 35 kg/m2 or greater had the highest odds of complications (OR 2.060, p<0.001). AUCs for A1C and BMI curves for all complications were significantly different (0.516 vs. 0.586, p < 0.0004), indicating BMI as having superior ability to predict complications. A BMI cutoff of 27.9 kg/m2 provides the greatest specificity and sensitivity for complications.

Conclusions Based on odds ratios, A1C, age, and diabetes, smoking, and hypertension statuses were not significant predictors of complications after breast reconstruction, however BMI was. Based on AUCs, BMI is a stronger predictor than A1C. Our findings suggest a cutoff value for A1C is unnecessary because it has limited utility in predicting a patient's risk of developing the examined complications.

Purpose: Implant-based breast reconstruction requires patients' understanding of its complex perioperative management to make informed decisions and optimize care. Despite it being the most common method of breast reconstruction after mastectomy, patients still lack a thorough understanding of what this procedure entails. We aim to utilize patient-provider perioperative communications to identify knowledge gaps in post-mastectomy implant-based breast reconstruction.

Methods: Patients who underwent immediate post-mastectomy tissue expander (TE) or implant placement at a single academic institution from September 2021 to September 2022 were included. Patient-generated calls and messages in the perioperative period – defined as from the time of referral to plastic surgery to the first postoperative visit after their most recent implant-based breast reconstructive surgery – were extracted from medical records and qualitatively analyzed.

Results: Of the 82 patients identified, 72 (87.8%) underwent staged reconstruction with TE placement and 10 (12.2%) had direct implant placement. 59 (72.0%) patients received implants as their final reconstruction, while 19 (23.2%) required TE or implant explantation due to infection or flap necrosis. The median distance to the hospital was 93.7 miles (SD=169.5). The median perioperative period was 248 days (SD=176). 393 communications were generated by 75 patients (91.5%), and the subjects of inquiry and encounter resolutions were recorded. Most communications were generated after TE placement and before implants were placed or removed (74%). Qualitative analysis showed the most common subjects of inquiry to be about postoperative management (44.5%), surgical site concerns (26.5%), and general questions about the procedure (17.0%). Within postoperative management inquiries, patients most often inquired about activity restrictions (23.4%), drain management (16.6%), and wound management (15.4%). Most inquiries were resolved through patient re-education (60.8%), which included answering questions (60.7%), providing reassurance (29.7%), and giving instructions (10.0%).

Conclusions: Our study revealed that most patient-generated inquiries pertained to postoperative management following TE placement, with specific recurring questions related to TEs. Most inquiries were resolved through re-education, emphasizing a gap in patient education. While secure patient-provider messaging systems are increasingly utilized, there may be patients who lack the resources to access this platform, underscoring the importance of healthcare providers considering clinic visits as an invaluable opportunity for comprehensive postoperative management education.