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BACKGROUND: Implant rotation is a known complication to breast reconstruction using anatomical implants. However, there is a lack of large studies investigating the risk of implant rotation and potential predisposing risk factors. METHOD: We reviewed the medical records of all patients who underwent breast reconstruction with Mentor anatomical implants from 2010 to 2021 at two Danish hospitals. We compared the risk of implant rotation between one- and two-stage breast reconstruction using univariate logistic regression. We analyzed the effect of biological mesh, immediate versus delayed reconstruction, and use of a higher final expander volume than the permanent implant volume on the risk of implant rotation. Finally, we analyzed the success rate of revision surgery for implant rotation. RESULTS: In total, 1134 patients were enrolled. Patients who underwent two-stage breast reconstruction (n = 720) had a significantly higher risk of implant rotation than those who underwent one-stage breast reconstruction (n = 426; 11% vs. 5%, p < 0.01). There was no significant association between implant rotation and the use of biological mesh, immediate breast reconstruction, or use of a higher final expander volume than the permanent implant volume. The success rate of revision surgery after implant rotation was 73% (62/85 rotations). CONCLUSIONS: Two-stage breast reconstruction significantly increased the risk of implant rotation compared to one-stage breast reconstruction. The overall risk of implant rotation was low and success rate of revision surgery was high. These findings suggest that anatomical implants are safe to use for breast reconstruction. However, surgeons and patients should be aware of the increased risk of implant rotation after two-stage reconstruction.

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(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.

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As prepectoral implant placement becomes widely adopted, recent studies investigating the use of acellular dermal matrix (ADM) during tissue expander placement have demonstrated no major benefit with regard to postoperative outcomes. We sought to evaluate second-stage outcomes 1 year after tissue expander exchange to implant with and without ADM. Consecutive patients who underwent prepectoral tissue expander-based breast reconstruction with and without ADM were identified. Patients were followed up for 1 year after tissue expander exchange to implant. Second-stage outcomes of interest including implant rippling, capsular contracture, implant explantation, additional revision surgeries, and patient-reported outcomes were collected and compared. Sixty-eight breasts in the ADM cohort and sixty-one breasts in the no ADM cohort underwent tissue expander exchange to implant. Second-stage outcomes of interest were similar between the ADM and no ADM cohorts with no statistically significant differences identified regarding incidences of implant rippling (24.6% vs. 12.1%, p = 0.08), capsular contracture (4.5% vs. 3.3%, p = 1.00), and explantation (6.6% vs. 1.7%, p = 0.67) between the two cohorts. BREAST-Q scores were similar between the two cohorts with the exception of physical wellbeing and satisfaction in terms of implant rippling, as can be seen, which improved in the no ADM cohort (p = 0.04). Our study reports no major benefit for the inclusion of ADM with respect to implant rippling, capsular contracture, explantation, need for additional revision surgeries, and patient-reported satisfaction in prepectoral second-stage implant-based breast reconstruction.

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BACKGROUND: Most breast reconstructions are implant-based and can be performed either in a one-stage, direct-to-implant or in a two-stage, expander-implant-based reconstruction. The objective of this systematic review is to compare the safety and patient satisfaction of the two reconstruction approaches. METHODS: A literature search was conducted on 27 September 2022 using various databases. Studies comparing one-stage and two-stage implant reconstructions and reporting the following outcomes were included: patient satisfaction, aesthetics, complications, and/or costs. Reviews, case reports, or series with less than 20 patients and letters or comments were excluded. Comparisons were made between the one-stage reconstruction with and without acellular dermal matrix (ADM) and two-stage implant-based breast reconstruction groups. The data extracted from all articles were analysed using random-effects meta-analyses. RESULTS: Of the 1381 records identified, a total of 33 articles were included, representing 21529 patients. There were no significant differences between the one-stage and two-stage groups, except for the costs. The one-stage operation without ADM had lower costs than the two-stage operation without ADM, although the use of an ADM substantially increased the price of the operation to more than a two-stage reconstruction. DISCUSSION: Equal patient satisfaction, aesthetic outcomes, and complication rates with lower costs justify one-stage breast reconstruction in carefully selected patients. This review shows that there is no evidence-based superior surgical approach. Future research should focus on the costs of the ADM versus an additional stage and patient-reported outcomes.

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BACKGROUND: Two-stage implant-based breast reconstruction remains the most commonly used technique for rebuilding a breast. Subpectoral implant placement minimizes complications, such as capsular contracture, implant visibility, malposition, and extrusion. Nevertheless, it is associated with high animation deformity (AD). Prepectoral reconstruction eliminates AD but is subject to a higher risk of implant extrusion and visibility. In this prospective, single-center study we present a new technique aimed to create a new hybrid pocket in which the upper portion of the implant is placed subcutaneously, whereas its inferior pole is still covered by a pectoralis muscle sling reducing implant lower pole visibility and palpability. MATERIAL AND METHODS: In each case, the prosthesis was removed and a new hybrid pocket was created by splitting the muscle into two portions, separating its cranial part from the overlying subcutaneous tissue and anchoring it back to the chest wall. The caudal muscle sling was left adherent to the subcutaneous tissue of the central part of the breast. Patient outcomes were evaluated with a BREAST-Q questionnaire preoperatively and 1 year after surgery. RESULTS: Forty-eight patients with severe postoperative breast animation were enrolled (8 bilateral and 40 unilateral). No major complications occurred. After a 1-year follow-up, the aesthetic and functional satisfaction rate was high and a good implant coverage was achieved. No residual AD of the breast was observed. CONCLUSIONS: Changing the implant placement from the subpectoral to a partially subcutaneous plane, both severe AD and implant extrusion can be avoided, expanding the indications for safe prosthetic breast reconstruction. LEVEL OF EVIDENCE: Level of evidence IV.

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Aim of this study is to compare early post-operative outcomes and patient's satisfaction after skin-sparing and/or nipple-sparing mastectomy (SSM/SNSM) followed either by breast reconstruction with one-stage prepectoral implantation or two-stage technique for breast cancer (BC) or BRCA1/2 mutation.From January 2018 to December 2021, 96 patients (mean age of 51.12 ± 10.9) underwent SSM/SNSM and were divided into two groups: in group A (65 patients, 67.7%), mastectomy was followed by one-stage reconstruction; in group B (31 patients, 32.3%) by two-stage. Operative time was significantly longer in A vs. B (307.6 ± 95.7 vs. 254.4 ± 90.91; P < 0.05). Previous breast surgery was more common in B vs. A (29.0% vs. 7.7%; P < 0.05), while bilateral surgery was performed more frequently in A vs. B (40% vs. 6.5%; P = 0.001). All SSM/SNSM for BRCA1/2 mutation were followed by immediate prepectoral implantation. No significant differences were found between groups in terms of post-operative complications. At pathology, DCIS and invasive ST forms, such as multicentric/multifocal forms, were detected more frequently in B, while NST type in A (all P < 0.05). A multivariate analysis showed improved post-operative satisfaction at BREAST-Q survey in Group A (P = 0.001). Encouraging oncologic outcomes after SSM/SNSM for BC enabled the improvement of breast reconstructive techniques. One-stage reconstruction is characterized by better aesthetic outcomes and by greater patient's satisfaction. When SSM/SNSM is technically difficult to perform, as in multicentric/multifocal forms or previous breast surgery, mastectomy followed by two-stage reconstruction should be considered to achieve a radical surgery.

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INTRODUCTION: Postmastectomy radiation therapy (PMRT) has a primary role in the treatment of locally advanced breast cancer; however, the most appropriate timing of irradiation in immediate tissue expander breast reconstruction (ITEBR) still remains unknown. METHODS: A retrospective review was performed on all women undergoing mastectomy and retropectoral ITEBR at Campus Bio-Medico University Hospital in Rome, Italy, between 2010 and 2019. The patients were categorized into three cohorts: patients undergoing PMRT with the tissue expander (TE) in situ, patients with PMRT delivered to the permanent implant (PI), patients who were not administered RT. Complications and failure rates were analysed and compared. Potential predictors of adverse outcomes were analysed. RESULTS: Over 10 years, 183 patients underwent retropectoral ITEBR (55 PMRT-TE, 50 PMRT-PI, 78 no-PMRT). The three groups were well matched with respect to patient- and treatment-related factors (p > 0.05), with the exception of neoadjuvant chemotherapy and irradiation. The mean follow-up was, respectively, 4.58, 7 and 5.75 years. Radiotherapy either to the TE or to the PI was independently associated with failure and conversion to autologous procedures (p < 0.0001). Failure rate was significantly higher when TE was irradiated (p = 0.03). PMRT was associated with severe capsular contracture development (p < 0.00001), the odds being higher when irradiation was delivered after implant exchange (p = 0.04). Increased BMI was significantly associated with failure. CONCLUSIONS: When PMRT is delivered to the TE, the risk of failure is higher (OR 2.77); when the PI is irradiated, reconstruction will more likely be affected by severe capsular contracture (OR 2.7). However, considering that the overall risk of severe capsular contracture correlated to PMRT is higher than failure, we believe that irradiation should be delivered to the TE. Performing a proper capsuloplasty at the time of implant exchange, indeed, allows to correct the deformities related to radiation-induced capsular contracture. Patients with unfavourable outcomes after TE placement and RT, instead, can be directly switched to autologous reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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BACKGROUND: The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry. METHODS: We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed. RESULTS: Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition. CONCLUSIONS: This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

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BACKGROUND: Contralateral augmentation mammoplasty in implant-based reconstruction could potentially lead to deterioration of the thickness of the mastectomy skin flap and increase postoperative complications of the reconstructed breast. We compared the complication rates of the reconstructed breast in the augmentation and no-augmentation groups among patients undergoing tissue expander/implant breast reconstruction. METHODS: Patients who underwent mastectomy followed by tissue expander/implant breast reconstruction between February 2010 and April 2018 were retrospectively reviewed. The primary outcome measures were complications and the need for a revision operation. The augmentation and no-augmentation groups underwent propensity score-matched analysis and the matched cases underwent multivariable logistic regression analysis. RESULTS: From the 234 patients in the augmentation group and 517 patients in the no-augmentation group, 200 propensity score-matched pairs were obtained. Analysis of the matched pairs revealed that the augmentation group as compared to the no-augmentation group showed a significantly higher overall complication rate (13.5 percent versus 6.5 percent; P=0.025) and revision operation rate (9.0 percent versus 3.0 percent; P=0.019). Multivariable conditional logistic regression analyses of the matched cases revealed that contralateral augmentation (odds ratio, 3.457; 95% confidence interval, 1.039-11.498; P=0.043) was associated with increased odds for a revision operation of the reconstructed breast. CONCLUSIONS: This study investigated the postoperative complications of the reconstructed breast associated with contralateral augmentation mammoplasty in patients who underwent mastectomy followed by tissue expander/implant breast reconstruction. The augmentation group had a higher revision operation rate than did the no-augmentation group. A clinical evaluation of the risks and benefits of contralateral augmentation and preoperative counseling may be indicated for patients who are undergoing implant-based breast reconstruction and are candidates for contralateral augmentation mammoplasty.

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BACKGROUND: Despite a trend towards immediate breast reconstruction in recent years, delayed breast reconstruction using a tissue expander remains a common procedure. Radiotherapy after mastectomy but before reconstruction is a risk factor, although studies examining the effect of this are limited. The aim of this retrospective cohort study is to evaluate the impact of pre-reconstructive radiotherapy (PRT) in patients undergoing breast reconstruction using an expander/implant. MATERIALS AND METHODS: Two hundred twenty-three consecutive patients underwent unilateral mastectomy followed by expander-based reconstruction over a 10-year period (2004-2013). Fifty patients (22%) received radiotherapy before reconstruction (PRT group), and 173 patients (78%) did not (non-PRT group). Descriptive patient data as well as data regarding the operations, hospitalisation and complications were collected. Statistical analyses such as logistic regression, Fisher exact test and multivariate analysis were performed using R-statistics. RESULTS: PRT was a significant predictor of loss of reconstruction, and when adjusted for smoking and body mass index (BMI), it showed an odds ratio (OR) of 17.8 [95% confidence interval (CI): 5.7-70.6; p<0.01] for loss of reconstruction, with 15 (30%) in the PRT group and 7 (4%) in the non-PRT group. We found no difference in short-term reoperations or infections at either stage of reconstruction. CONCLUSION: In patients undergoing delayed breast reconstruction using an expander/implant, radiotherapy is a significant risk factor for loss of reconstruction. It should be considered a relative contraindication for this reconstructive modality, and careful selection and advisement of the patient about the risks of complications and potential need for additional corrective surgery or later autologous breast reconstruction should be discussed.

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Today's demographic of the breast reconstruction patient is younger, often prophylactic or at an early stage of diagnosis, and is more likely to be bilateral. These factors combined with an increase in breast implant options, internal support matrices, fat transfer, technologies for intraoperative real time assessment of tissue perfusion, and an increasing appreciation for morbidity associated with autogenous procedures have resulted in an increase in the percentage of women seeking alloplastic breast reconstruction. This article discusses the indications for implant-only reconstruction and reviews the authors' approach to the use of adjunctive techniques that are used in most of their patients.

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Acellular dermal matrix (ADM) is commonly employed to create an inferior pocket for the tissue expander in two-stage breast reconstruction. The authors sought to determine whether placement of ADM during the first stage of reconstruction decreases the amount of capsule formation at implant exchange. Patients who underwent mastectomy and tissue expander reconstruction were included in this study. Two biopsies were obtained at the time of implant exchange, one from the pocket adjacent to the ADM and the other from the area adjacent to the pectoralis muscle. Pathology analysis was performed on each sample. Ten patients underwent immediate breast reconstruction with Alloderm during the 3-month study period. Capsule thickness was significantly greater in the areas where the expander was in direct contact with the pectoralis muscle (782 ± 194 µm) compared to those in contact with human acellular dermal matrix (hADM) (47·91 ± 110·82 µm; P < 0·05). Analysis of the sub-pectoral capsule demonstrated diffuse deposition of collagen, neutrophils, contractile myofibroblasts and synovia-like metaplasia, characteristic of a foreign body response. Conversely, within the inferior pocket where the hADM was in direct contact with the expander, we noted migration of host epithelial cells, fibroblasts, mesenchymal cells and angiogenesis, indicating host tissue regeneration. Acellular dermal matrix, when placed at the first stage of breast reconstruction, significantly reduces thickness and inflammatory character of the capsule in comparison to the patient's native tissue.

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BACKGROUND: The aim of this review is to comprehensively compare the outcomes of one-stage and two-stage prosthesis-based breast reconstruction via meta-analytic methodology. DATA SOURCES: Seventeen studies comparing one-stage and two-stage prosthesis-based breast reconstruction were reviewed. The analysis divided the outcomes into 3 categories: complications, esthetic satisfaction, and total cost for completing reconstruction. CONCLUSIONS: The one-stage reconstruction group was at significantly higher risk for reconstruction failure and overall complications than the two-stage group. No significant difference was observed between the 2 groups in the results of nipple-sparing mastectomy. The esthetic result analysis demonstrated that both methods showed comparably positive outcomes. The one-stage group incurred lower cost for completing reconstruction than the two-stage group, despite the higher cost for treatment-related complications. Our results suggest that the risks for adverse outcome in patients undergoing one-stage reconstruction may be comparable with that of two-stage reconstruction when performed in patients receiving a nipple-sparing mastectomy. However, further well-controlled studies are required to draw more solid conclusions.

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Implants used for two-stage breast reconstruction are selected exclusively on the basis of the directly measured linear parameters. Therefore, the relevant implant is not always chosen despite the wide range of available products. The aim was to analyze the clinical usefulness of three-dimensional (3D) imaging in the breast implant selection. In 50 patients after unilateral two-stage breast reconstruction, height, width, projection and total volume of both breasts were triply obtained with measuring tape (anthropometric method), thermoplastic casting (thermoplastic method) and 3D imaging (optical method). We measured skin fold thickness with skin caliper. In the optical method, we subtracted the covering tissues and calculated the parameter - "estimated breast implant volume" (EBIV), together with the corresponding "anthropometrically estimated breast implant volume" (aEBIV) in the anthropometric method. Reliability of the three methods was described as repeatability and accuracy, both quantified with parameters: "technical error measurement" (TEM) and "reliability factor" (R). Repeatability showed variation among the repeated measurements. Accuracy determined variability between the real volume of the implant used for reconstruction and the obtained volumetric parameters. Repeatability was the highest for the optical method, comparing to anthropometric and thermoplastic methods (p<0.0001). Accuracy was the highest in the optical method for EBIV, comparing to aEBIV in the anthropometric method and the total volume in three methods (p<0.0001). Level of accuracy for EBIV was in the range of variability among the commercially available implants (p>0.05). In conclusion, implants for breast reconstruction are precisely selected with the 3D scanning method, in comparison to widely used direct measurements or thermoplastic casting.

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