Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

 

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

 

 

by Avila, Azalia; Bartholomew, Alex J.; Sosin, Michael; Deldar, Romina; Griffith, Kayla F.; Willey, Shawna C.; Song, David H.; Fan, Kenneth L.; Tousimis, Eleni A.

 

Plastic and Reconstructive Surgery:  December 2020 - Volume 146 - Issue 6 - p 715e-720e

 

Background:

Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement.

Methods:

A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes.

Results:

A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange.

Conclusions:

Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. Clinical Question/Level of Evidence: Therapeutic, III.

A Systematic Review and Meta-analysis on the Effect of Neoadjuvant Chemotherapy on Complications Following Immediate Breast Reconstruction

 

A Systematic Review and Meta-analysis on the Effect of Neoadjuvant Chemotherapy on Complications Following Immediate Breast Reconstruction

The Breast: VOLUME  55, P55-62, FEBRUARY 01, 2021

by Jajini Varghese, Shireen S. Gohari, Hirah Rizki, F.R.C.S. ichael Faheem, Benjamin Langridge, Sherko Kümmel, Laura Johnson, Peter Schmid

 

Background

The impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not.

Methods

PubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals.

Results

A total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I2 = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I2 = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30).

Conclusion

Immediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.

The changes of quality of life and their correlations with psychosocial factors following surgery among women with breast cancer from the post-surgery to post-treatment survivorship

The changes of quality of life and their correlations with psychosocial factors following surgery among women with breast cancer from the post-surgery to post-treatment survivorship

by Fei-Hsiu Hsiao, Wen-Hung Kuo, Guey-Mei Jow, Ming-Yang Wang, King-Jen Chang, Yu-Ming Lai, Yu-Ting Chen, Chiun-Sheng Huang

The Breast: April 2019, Volume 44, pages 59-65

This 14-month study aimed to examine the changes of quality of life following breast cancer surgery and associations of such changes with depression and anxiety levels, and protective factors (attachment styles in close relationship, and meaning in life) based on positive psychology theory.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Afonso, A et al

Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1053–1061

Background: At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center. 
Methods: A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption. 
Results: In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre–enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre–enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6). 
Conclusion: The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model
Dumestre, D et al 
Plastic & Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 550–559

Background: Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction. 
Methods: Length of stay, emergency room visits, and complications within 30 days of surgery were compared among three groups: traditional recovery after surgery, transition (some elements of enhanced recovery protocol, not transitioned to outpatient care), and enhanced recovery after surgery (day surgery, provided with standardized perioperative education and multimodal analgesia). Prospective data collection allowed quality-of-recovery assessment using a validated questionnaire for enhanced recovery/transition groups. Results were statistically analyzed (analysis of variance/chi-square). 
Results: The traditional recovery, transition, and enhanced recovery cohorts comprised 29, 11, and 29 patients, respectively. No significant differences were present regarding age, smoking status, preoperative radiation, single stage direct-to-implant versus tissue expander, bilateral versus unilateral surgery, or immediate versus delayed reconstruction among groups. Average length of stay was 1.6 nights in both the traditional recovery and transition groups, compared with 0 nights in the enhanced recovery group (p < 0.001). Enhanced recovery patients had less severe pain (p = 0.02) and nausea (p = 0.01), and better enjoyed their food (p = 0.0002) and felt more rested (p = 0.02) than their transition counterparts. There were no differences in the number of emergency room visits among the three groups (p = 0.88). There was no difference in the rate of hematoma (p = 0.36), infection requiring intravenous antibiotics (p = 0.36), or infection requiring explantation (p = 0.36) among the three groups. Conclusion: An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely, with improved patient satisfaction and same-day discharge and with no increase in complications. 

Shifting Autologous Breast Reconstruction into an Ambulatory Setting: Patient-Reported Quality of Recovery

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 657–665

Davidge, Kristen et al

As bundled payment models gain popularity, it is imperative that providers use patient outcomes and patient experience to define evidence-based pathways of care. The purpose of this study was to evaluate the quality of recovery experienced by women undergoing early discharge (less than 24 hours) after autologous breast reconstruction with a pedicled flap and determine predictors of postoperative quality of recovery. Methods: A prospective cohort study was performed on all women undergoing autologous breast reconstruction at Women’s College Hospital between September of 2011 and July of 2013 that met study inclusion criteria. 

Factors influencing postoperative length of hospital stay after breast cancer surgery

Factors influencing postoperative length of hospital stay after breast cancer surgery. The breast, June 2013, Vol. 22(3), p.289-294

Marla, S., et al.

http://www.thebreastonline.com/article/PIIS0960977612001609/abstract?rss=yes

As part of a feasibility study to restructure the breast cancer services in Glasgow, factors influencing ‘postoperative length of stay’ and bed utilisation in patients undergoing surgery for breast cancer were examined.

British Journal of Surgery Vol 98 Iss 2 February 2011

Evidence-based review of enhancing postoperative recovery after breast surgery (pages 181–196)
R. Arsalani-Zadeh et al.
p181-196
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