Scientific Abstract Presentations: Breast Session 4 Thursday, September 26 Thu, Sep 26 5:00-6:00 p.m. PDT

PURPOSE: Breast implants trigger a foreign body response resulting in a fibrous encapsulation around the implant(1). Breast implant capsule is often benign; however, chronic capsule inflammation can promote excessive symptomatic capsule scarring or tumor formation around the device. Silicone particles in breast implant capsules have been linked to the pathoetiology of capsular contracture and are hypothesized to represent an inflammatory stimulus for breast implant capsular-associated diseases(2,3). Textured implants have a lower incidence of capsular contracture but are linked to ALCL. To date, the localized cellular response surrounding silicone particles has not been investigated. We aim to determine the differences in silicone infiltration in smooth and textured breast implant capsules and characterize the specific cellular responses to silicone particles in the capsule.

METHODS: Capsule tissue from textured silicone (N=15) and smooth silicone (N=15) breast implants was collected from consenting patients undergoing revisions. Silicone infiltration and capsular thickness were assessed histologically. Capsular cell populations were measured by immunohistochemistry (macrophages, CD3+ total T-cells, CD4+ helper T-cells, fibroblasts, and myofibroblasts).

RESULTS: Silicone infiltration was greater in textured implant capsules (radius=4.87 µm) than smooth implant capsules (radius= 4.28 µm) (p=0.47). Smooth implant capsules had an increased thickness (smooth implant capsule thickness=1058 µm, textured implant capsule thickness=848 µm) (p=0.27). In addition, they displayed increased total macrophages (p=0.01), M2 macrophages (p=0.03), myofibroblasts (p=0.04) and fibrotic cells (p=0.08). Textured implant capsules had increased CD4+ T-cells (p=0.88). The presence of all immune cells was enriched in silicone-dense areas, irrespective of implant surface (p<0.001).

CONCLUSIONS: Our results suggest that the immune response to silicone particles in capsular tissue varies according to both implant surface and silicone infiltration. Smooth implant capsules exhibit a macrophage-dominant response, potentially mediating the deposition of fibroblasts and myofibroblasts, leading to thicker capsules. Textured implants exhibit enhanced CD4+ T-cell infiltration, which may pertain to ALCL etiology. The increased immune response to silicone particles could underscore the link between silicone presence and capsular contracture. Expanding our understanding of these differences could determine the mechanisms underlying breast implant capsule-related pathology.

REFERENCES:

1 Siggelkow, W. et al. Histological analysis of silicone breast implant capsules and correlation with capsular contracture. Biomaterials 24, 1101-1109, doi:10.1016/s0142-9612(02)00429-5 (2003). 2 Wong, A. K., Lopategui, J., Clancy, S., Kulber, D. & Bose, S. Anaplastic large cell lymphoma associated with a breast implant capsule: a case report and review of the literature. Am J Surg Pathol 32, 1265-1268, doi:10.1097/PAS.0b013e318162bcc1 (2008). 3 Zomerlei, T. A., Samarghandi, A. & Terando, A. M. Primary Squamous Cell Carcinoma Arising from a Breast Implant Capsule. Plast Reconstr Surg Glob Open 3, e586, doi:10.1097/gox.0000000000000567 (2015).

Background: The Caprini Risk Assessment Model is the most clinically validated model to assess risk of venous thromboembolism (VTE) in surgical patients. This study aims to better understand the risk of VTE in women undergoing breast reconstruction using this model.

Methods: This was a retrospective cohort study utilizing The National Surgical Quality Improvement Quality Program (NSQIP) database to identify patients who underwent breast reconstruction between 2010-2021. After assigning a Caprini score to each patient, univariate regression analysis was performed to test for association with VTE.

Results: A total of 73,176 patients were included. 325 patients developed VTE, with an overall incidence of 0.4%. For each unit increase in Caprini score, there was a 1.47 times increase in odds of developing VTE (OR 1.47, CI 1.303-1.648, p<0.001). Risk of VTE was 5.17 times higher in autologous reconstruction than implant-based (OR 5.17, CI 4.096-6.514, p<.001). In autologous reconstruction, a Caprini score of 6 or over was significantly associated with higher odds of VTE (OR 1.51, CI 1.136-2.017, p=.005); no significant association was noted in implant-based reconstruction (OR 1.356, CI 0.892-2.059, p=.154). Among patients who underwent autologous reconstruction, abdominal free flaps were associated with significantly higher odds of VTE compared to latissimus dorsi flap and pedicled TRAM reconstruction (OR 1.74, CI 1.253-2.421, p>.001).

Conclusion: This study validates the Caprini Risk Assessment model in breast reconstruction and confirms previous findings that autologous reconstruction is associated with higher risk of VTE. We recommend 7-10 days of post-operative VTE chemoprophylaxis for this high-risk population undergoing autologous reconstruction with a Caprini score of 6 or over. Similar prophylaxis measures can be considered in implant-based reconstruction.

PURPOSE: Breast cancer is a major global public health issue. Despite advancements in treatments improving survival rates, the journey to recovery encompasses more than just achieving remission. Breast reconstruction (BR) post-mastectomy is often crucial for physical and psychological well-being, however, decision-making for reconstruction is complicated by socioeconomic factors. Given that existing data largely reflects the experiences of white, educated women, this study aims to explore these factors in a broader demographic, contributing to a more equitable understanding of healthcare choices and outcomes.

METHODS: Four hundred thirteen women from diverse backgrounds with a history of surgical intervention for breast cancer were surveyed in May 2023. Conducted by Kantar Lightspeed LLC, the computer-based survey combined a 45-item questionnaire, developed with the BRAVE Coalition, and the 13-item Satisfaction with Breasts sub-scale of the BREAST-Q. It focused on socioeconomic factors such as income, education, social support, and information access, relating these to the decision to undergo BR. Statistical analyses included Chi-square tests to assess associations, and Cramer's V and odds ratios to assess the strength of these associations.

RESULTS: Highly statistically significant moderate associations were found between education level and BR decision (p < 0.01, V = 0.232), and between income level and BR decision (p < 0.001, V = 0.317). Women with a graduate degree were more than 3 times as likely to opt for reconstruction than those with a high school education (OR = 3.18, p < 0.01, 95% CI = 1.52–6.98), and women earning over $99,999 per year were more than 5 times as likely to opt for reconstruction compared to those earning less than $50,000 per year (OR = 5.77, p < 0.001, 95% CI = 3.12–11.09). Contrary to expectations, ethnicity was not significantly associated with BR decision (p > 0.1). Furthermore, factors like lack of social support or information did not show statistically significant differences in decision-making across ethnic group (p > 0.1 and p > 0.5, respectively).

CONCLUSION: Socioeconomic status (SES), particularly education and income, emerged as highly significant predictors in the decision to pursue BR. The lack of statistically significant differences between ethnicity and BR rates paves the way for deeper investigations into social determinants of health, an avenue we are currently exploring. Our findings emphasize the need to better understand how and why these associations between SES and BR rates exist, as well as the importance of providing specialized counseling when working with patients from disadvantaged socioeconomic backgrounds. Addressing these disparities will empower women to make more informed healthcare decisions and ensure access to their legal right to breast reconstruction.

Background Breast cancer diagnosed during pregnancy or 1-2 years post-partum is termed pregnancy-associated breast cancer (PABC). Incidence of breast cancer in women 45 and younger increased globally over the past several decades. Concurrently, the US has seen an eightfold increase in the proportion of pregnancies among women over 35 years old. Changes in PABC incidence over this period have not been characterized, and standard management of patients with PABC has not been described. Here we examine trends in incidence and management of PABC and non-PABC in women 45 and younger in the Merative ™ MarketScan™ Commercial and Multi-State Medicaid Databases. Methods We examined claims data from the Merative MarketScan Commercial and Multi-State Medicaid Databases for female patients ages 18-45 with breast cancer diagnoses between 2007-2021. We analyzed trends in PABC incidence and treatments received in patients with PABC vs. non-PABC. PABC was defined as breast cancer diagnosis within one year of pregnancy, delivery, or lactation-related claims. Cochran-Armitage tests were used for incidence trend analysis. Only patients with post-index treatment claims were included in analysis of treatments. Student's t-tests and chi-squared tests were used for univariate comparisons of continuous and categorical variables, respectively. Kaplan-Meier survival analysis and univariate Cox regressions were used to assess the effect of pregnancy-association on latency to each treatment. Results 39,009 patients aged 18-45 were included, of whom 987 patients had PABC. Over the study period there was a significant increase in the proportion of breast cancer cases that were classified as PABC in this age group (Z= -5.7534; p<0.001). There was also a decrease in the proportion of both overall cases and PABC in women aged 40 or older over the study period (p≤0.004). 36,252 patients were included in analysis of treatments, of whom 920 (2.60%) had PABC. Patients with PABC experienced higher rates of chemotherapy, adjuvant chemotherapy, mastectomy, trastuzumab use, and ovarian suppression therapy than patients with non-PABC (p<0.001). However, they had lower rates of radiation or breast conserving surgery than patients with non-PABC (p<0.001). Patients with PABC who had mastectomies experienced comparable rates of both delayed and immediate tissue expander placement and both implant-based and autologous reconstruction as patients with non-PABC (p≥0.242). In both groups, implant-based reconstruction was more common than autologous reconstruction (PABC: 55.6% implant, 18.3% autologous; non-PABC: 58.0% implant, 19.5% autologous). Compared to patients with non-PABC, patients with PABC experienced increased latency between the index diagnostic event and tumor resection surgery (mastectomy or breast conserving surgery), radiation therapy, and adjuvant chemotherapy (p<0.001). Patients with PABC experienced comparable latency from mastectomy to delayed autologous or implant-based reconstruction (p≥0.142). Conclusions There has been an increase in PABC rates among women 45 and younger over the past 15 years in a national sample, with increasing rates in women under 40. Patients with PABC experience differences in types and timing of medical and surgical treatments, including delays in initial tumor resection surgery, but have comparable preferences for and timing of breast reconstruction.

Introduction: While there is evidence suggesting that marijuana use can have implications in the perioperative setting for various surgeries, specific research on its effects on breast reduction outcomes is limited. Given the increasing prevalence of marijuana use, understanding its impact on surgical procedures, especially those as sensitive as breast reduction, becomes imperative. This study elucidates the impact of marijuana consumption in breast reduction procedures. 

Methods: A retrospective review of patients who underwent breast reduction surgery performed by plastic and reconstructive surgeons within the University of Pennsylvania Health system between January 2016 and June 2022 was performed. Adult female (> 18 years) undergoing breast reduction with the wise pattern technique were included in the study. Patients with oncoplastic resection or concurrent procedures (i.e. mastopexy) were excluded. To control for confounding variables, a propensity score-matching analysis was performed comparing breast reduction patients who had no history of marijuana use with those that had a history of marijuana use. A 1:1 nearest-neighbor matching method was employed to account for the following covariates: age, body mass index, ptosis, and breast tissue mass. Patient demographics, clinical attributes, and postoperative details were analyzed. Quality of life (QoL) changes were gauged using pre- and postoperative BREAST-Q. 

Results: Of 415 patients who underwent breast reduction, 140 patients documented marijuana use. After propensity matching, a total of 108 patients (54 marijuana users vs 54 non-users) were analyzed. The average age was 39 years ± 12 and BMI 30.1kg/m2 ± 5.3. There were no differences between the two groups in comorbidities, breast symmetry, excision patterns, pedicle use, or drain count (p>0.05). Furthermore, surgical outcomes including surgical site occurrences (SSO), scarring, pain levels, hypersensitivity, or sensation loss were comparable between the groups (p>0.05). There were also no differences in number of readmissions, reoperations, or emergency department visits (p>0.05). Both groups showed enhanced postoperative QoL, regardless of marijuana usage. 

Conclusion: To the best of our knowledge, this study is the first to evaluate marijuana use in patients undergoing breast reduction surgery. The findings of this study suggest that marijuana consumption does not markedly affect the outcomes of breast reduction surgeries. Both groups, those who reported marijuana use and those who did not, demonstrated no differences in surgical outcomes and a notable improvement in postoperative QoL was evident. This study provides surgeons with the knowledge to offer more informed patient counseling regarding the implications of marijuana use in relation to breast reduction procedures.

Introduction Ensuring proper nutritional intake for elective surgery patients has long been identified as a cornerstone of wound healing. However, albumin alone is a poor predictor of complications in breast reconstruction, patients commonly presenting with albumin values within the normal range [1]. Therefore, there remains a need for a more complete measure of nutritional status in this patient population. The Controlling Nutritional Status (CONUT) Score evaluates nutritional risk based on three commonly tested and widely available parameters: serum albumin, lymphocytes, and cholesterol [2]. In microsurgery, the CONUT score was shown to be a predictor of flap complications [3]. Given the complex nutritional status of microsurgical breast reconstruction patients, we seek to identify if the CONUT score is a predictor of postoperative outcomes in patients undergoing autologous reconstruction.

Methods We conducted an 8-year retrospective review of patients who underwent autologous breast reconstruction at our institution. Patients who had lab results enabling the calculation of the CONUT score (albumin, cholesterol, and lymphocyte count) within 90 days of surgery were identified. Charts were reviewed for operative details and post-operative complications. The primary endpoint was returning to the operating room within 30 days due to flap complications. Secondary endpoints were hematoma, seroma, ischemia, congestion, or infection requiring operating room return. Patients with a minimum of 30 days of follow-up were included. In total, 29 patients with 44 individual flaps were identified.

Results In our population, the CONUT score demonstrated an AUC of 0.736 (95% CI: 0.529-0.944) for predicting 30-day flap complication rate requiring a return to the OR. Total flap loss occurred in one instance (n = 1, 2.3%). Our analysis identified the optimal cut point as a CONUT score of 2. We then separated our population into two groups: those with a CONUT score of 0-1 and those with a CONUT score of 2 or more. Those with a higher CONUT score had a significantly higher 30-day return to OR complication rate (7.4% vs 35.3%, p = 0.04).

Conclusion The CONUT score is a promising method for evaluating nutritional status in patients undergoing autologous breast reconstruction. In our population, a CONUT score of 2 or more was significantly predictive of complications requiring return to the OR. Future directions for this research include investigating additional breast procedures, such as implant-based reconstruction, and assessing a larger population.

1. Rich MD, Sorenson TJ, Lamba A, Hillard C, Mahajan A. Routine Preoperative Nutritional Optimization Not Required in Patients Undergoing Breast Reconstruction. Breast Care (Basel). 2022;17(5):495-500. doi:10.1159/000524638
2. Ignacio de Ulíbarri J, González-Madroño A, de Villar NG, et al. CONUT: a tool for controlling nutritional status. First validation in a hospital population. Nutr Hosp. 2005;20(1):38-45. 
3. Rocans RP, Zarins J, Bine E, et al. The Controlling Nutritional Status (CONUT) Score for Prediction of Microvascular Flap Complications in Reconstructive Surgery. J Clin Med. 2023;12(14):4794. Published 2023 Jul 20. doi:10.3390/jcm12144794

INTRODUCTION: Safety and aesthetic outcomes of nipple-sparing mastectomy (NSM) are suboptimal in patients that have macromastia or ptosis. Emerging literature suggests advantage to preconditioning such patients with mastopexy or reduction mammaplasty (M/RM) prior to NSM. However, published studies are small, leaving surgeons without a comprehensive overview of the outcomes and implications of such an approach. This systematic review aims to synthesize the existing literature regarding the surgical outcomes of NSM in patients with a history of M/RM.

METHODS: A systematic review adhering to the PRISMA guidelines was conducted. Identification of records included a literature of five databases, including CINAHL, EMBASE, PubMed, Scopus, and Web of Science. Only original reports of patients who underwent M/RM with subsequent NSM were considered. Studies that did not adequately report surgical outcomes were excluded. Data relating to surgical and oncologic outcomes were collected. Pooled analyses were performed on collected data after standardization.

RESULTS: A total of 372 records were identified from database searching, of which 11 met inclusion criteria. One additional eligible study was included via citation chaining, resulting in a total of 12 studies. These studies encompassed data from 288 patients, with a mean age of 45 years, and 534 breasts. There was an average nine-month (range 0.8-140.4) interval between M/RM and NSM and 13-month (range 0.3-132) follow-up. The pooled analysis of 12 studies revealed a total of 24 cases (4.5%) of nipple/NAC necrosis. Across the 11 studies reporting mastectomy skin flap necrosis, there were 15 cases (2.9%). NAC epidermolysis incidence was reported in just four studies, with a total of eight cases (5.0%). Among the studies examining hematoma outcomes, a total of 12 cases (3.7%) were identified, with seven necessitating evacuation in the operating room. In the seven studies reporting seroma incidence, there were 16 cases (6.3%). Additionally, only half of studies reported oncologic outcomes, and across these 6 studies, there was only one reported case (0.3%) of positive margins requiring NAC resection.

CONCLUSION: Preliminary findings suggest that NSM can be performed safely in patients with prior M/RM, with acceptable rates of complications and oncologic outcomes. However, heterogeneity among studies necessitates cautious interpretation of the results. Further well-designed studies with larger sample sizes and longer follow-up periods are warranted to elucidate the optimal surgical approach and long-term outcomes.

Purpose – Breast augmentation is one of the most common breast procedures, with over 3.5 million Americans having breast implants. The incidence of ruptured implants ranges from 1–35%, with risk increasing with time and comorbidities. We aim to study trends and post-operative outcomes after ruptured breast implant surgery.

Methods – The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients that underwent removal of a breast implant due to rupture (CPT 19330) between 2016 and 2021. Patients were categorized based on whether they received an immediate implant replacement (during the same anesthetic event) or not. Univariate analyses were performed to assess any group differences in patient characteristics and post-operative outcomes. Subgroup analyses were performed for patients with ICD10 codes specific for "encounter for cosmetic surgery" and breast cancer history.

Results – A total of 2,509 patients who underwent removal of ruptured breast implants were identified, out of which 483 patients (19.3%) had immediate replacement. The proportion of surgeries occurring on an outpatient basis was notably greater in the patients who had same-day breast implant replacement compared to patients who had delayed or no replacement (p < 0.001). Out of the patients who were admitted, length of total hospital stay was significantly longer in patients not receiving an immediate replacement (2.8 days v. 1.5 days; p < 0.001). Moreover, BMI was significantly higher in the non-replacement group (26.7 vs. 26.1; p = 0.049). There was no difference in other patient risk factors or comorbidities. The total complication rate within 30 days postoperatively was 3.4%, with no statistical significance between the two groups. Within the cosmetic subgroup (94 patients), 34 (37.2%) had immediate replacement, of which 3 had complications while no postoperative events occurred in the non-replacement group (p = 0.045). Within the breast cancer subgroup (397 patients), 63 (15.9%) had immediate replacement. Amongst these patients, complication rates were not statistically different (p = 0.695), although operating time, total hospital stay, and age were significantly lower with immediate replacement (p < 0.001, p < 0.001, p = 0.031).

Conclusion – Receiving an immediate breast implant after removal of a ruptured one appears to be safe in the short-term and may be better than no replacement. While immediate replacement was associated with decreased length of stay, these patients may also inherently present less intricate rupture scenarios compared to their abstaining counterparts. Further research with more longitudinal data and clearer documentation of breast augmentation indications is needed to evaluate long-term outcomes.

Purpose: The ideal timing of deep inferior epigastric perforator flap (DIEP) breast reconstruction remains unclear. Options for autologous breast reconstruction following mastectomy include immediate breast reconstruction that is performed on the same day as the mastectomy or delayed reconstruction where a tissue expander is placed at the time of mastectomy and autologous reconstruction is performed at a later date. The purpose of this study is to assess the complication rate following DIEP breast reconstruction in patients undergoing immediate versus delayed surgery.

Methods: A retrospective cohort study was conducted at our institution from 2020 to 2023 and included patients who underwent autologous DIEP flap breast reconstruction. Patient demographics, indication for surgery, and postoperative major and minor complications were recorded, including soft tissue infection, dehiscence, seroma, hematoma, and 90-day readmission and reoperation. Patients were analyzed based on the timing of breast reconstruction: immediately following mastectomy versus delayed reconstruction. Univariate analysis was performed to determine differences in postoperative complications between the two cohorts.

Results: A total of 340 DIEP flap reconstructions in 186 patients were included. Of these, 220 flaps in 119 patients were performed immediately following mastectomy; 121 flaps in 67 patients were delayed. There was no significant difference in age, body mass index, American Society of Anesthesiologists (ASA) classification, or length of hospital stay between groups. There was no significant difference in major complications, including 90-day hospital readmission and reoperation between patients undergoing immediate and delayed autologous breast reconstruction. There was a difference in minor complications, with a significantly higher rate of postoperative soft tissue infection for those requiring antibiotics and had erythema (42.8% vs 23.8%, p=0.0096) in patients undergoing immediate DIEP flap reconstruction. There was no significant difference in the number of patients with soft tissue infections that required washout for management. There was no significant difference in other minor postoperative complications, including wound dehiscence, fat necrosis, seroma, or hematoma.

Conclusions: This study reveals a higher rate of postoperative soft tissue infections in patients undergoing immediate DIEP flap reconstruction with no significant difference in other minor or major complications. These findings suggest that the timing of autologous reconstructive surgery may impact the postoperative course and have an effect on wound healing. This information can aid in operative planning, especially in high-risk patients.

Introduction Breast cancer remains a significant public health concern, especially in low- and middle-income countries (LMICs), with a 12-53% five-year survival rate. Post-mastectomy breast reconstruction is a crucial component of comprehensive cancer care, yet rates of utilization remain low in LMICs. Studies have documented the psychosocial benefits of this procedure, citing the improved quality of life, self-esteem, and body image experienced by women who undergo reconstruction. This review aims to consolidate the factors driving the limited rates of post-mastectomy breast reconstruction in LMICs to identify areas for intervention.

Methods We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched 5 databases for peer-reviewed articles published between January 2013 and October 2023 discussing challenges and perceived barriers to post-mastectomy breast reconstruction. We included original articles published in English within the last decade, and set in LMICs as per World Bank classifications. We assessed for quality using STROBE and JBI guidelines. Two independent reviewers extracted data into three categories: socio-cultural, structural, and financial themes. Data was summarized in graphic and numeric formats.

Results 15 papers were included in this review; 11 countries and spanning over 3 continents. Study settings were patient-based (n=10), provider/hospital-based (n=3), or both (n=2). 73% of studies mentioned barriers under 2 or more categories; 20% mentioned only structural barriers, and 7% mentioned only socio-cultural factors. Percentages in parentheses represent the frequency of each theme in the studies included.

A significant socio-cultural barrier to reconstruction was the perception that it was purely aesthetic rather than a therapeutic surgery (47%). Barriers noted in 33% of studies included fear of anesthesia, recovery time, and stress. Higher education was mentioned as a positive predictor of reconstruction in 27% of papers. Younger age and employment were associated with higher rates of reconstruction overall.

The most prevalent structural barrier noted was a lack of patient awareness, especially prior to mastectomy (47%). Limited numbers of practicing plastic surgeons (40%); urban-clustered tertiary treatment facilities (33%), and low surgeon referral rates (27%) reduced reconstruction utilization. Other structural barriers highlighted were the surgeon's perception of the patient's "desire" for reconstruction and lengthy commutes to care centers in 27% of studies.

Self-payment was the most cited (60%) financial limitation to reconstruction and most significant barrier overall. Exclusion clauses in insurance coverage for defining breast reconstruction as purely cosmetic or vague government policy language was described in 7% of studies.

Conclusion Barriers to post-mastectomy breast reconstruction in LMICs are multifaceted involving financial, socio-cultural, and structural aspects of care. The perception of reconstruction as strictly cosmetic is pervasive beyond social settings, thus impacting patient willingness, provider practice and insurance/government policy. Reconstruction remains highly unaffordable to patients.