Jai-Kyong Pyon

Background In the realm of implant-based breast reconstruction, mastectomy flap necrosis (MFN) is a prevalent yet grave complication that poses a threat to the stability of the inserted prosthesis. Although numerous investigations have scrutinized the risk factors for MFN development, few have delved into the aftermath, specifically implant failure or salvage. This study seeks to appraise the prognosis of the implanted prosthesis following MFN occurrence, as well as identify predictors of such outcomes. Methods Among patients who underwent immediate implant-based reconstruction between 2010 and 2022, individuals with MFN development were identified and scrutinized regarding the fate of their prosthesis (salvaged/failed). Independent risk factors were identified using multivariable analyses and subgroup analyses accounting for diverse clinical settings. Results Among a total of 3128 cases, 422 of MFN (194 partial, 228 full-thickness necrosis) were examined. Of them, 384 prostheses (91%) were salvaged, while 38 (9%) failed. Multivariate analysis revealed predictors of reconstruction failure included nipple-sparing mastectomy, larger skin excision, type of acellular dermal matrix used, previous radiotherapy, and full-thickness necrosis, while operation procedures, including type of operation and plane for prosthesis insertion (prepectoral/subpectoral), showed no significant associations. Risk factors differed by insertion plane, with obesity, larger skin excision, and previous radiation history significant in the prepectoral group, and only MFN degree influencing successful salvage in the subpectoral. Conclusions This study sheds light on the importance of understanding the prognosis and potential predictors of implant failure/salvage following MFN, emphasizing the need for tailored approaches to minimize the risk of reconstruction failure. Level of Evidence III 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Yoo JW, et al. J Breast Cancer. 2025 Oct;28:e35. https://doi.org/10.4048/jbc.2025.0053

Lee CE, et al. J Breast Cancer. 2025 Feb;28:e4. https://doi.org/10.4048/jbc.2024.0219

Background: Despite the recent steep rise in the use of prepectoral direct-to-implant (DTI) breast reconstruction, concerns remain regarding the potential risk of complications, resulting in the selective application of the technique; however, the selection process was empirically based on the operator’s decision. Using patient- and operation-related factors, this study aimed to develop a nomogram for predicting postoperative complications following prepectoral DTI reconstruction. Methods: Between August of 2019 and March of 2023, immediate prepectoral DTI was performed for all patients deemed suitable for 1-stage implant-based reconstruction. A retrospective analysis of the complications was conducted for this cohort. The cohort was randomly divided into the training and the validation data sets. A nomogram was developed using least absolute shrinkage and selection operator logistic regression and Firth bias-reduced logistic regression. Results: The authors analyzed 433 breasts (362 patients). Complications developed in 131 patients (33.5%), including early complications within 90 days postoperatively (26.1%), infection (1.8%), wound revision (9.7%), and reconstructive failure (3.5%). Increased age and body mass index, therapeutic mastectomy, reduction pattern mastectomy, implant size, and projection, and radiotherapy history were associated with early complications. For infection and reconstructive failure, increased age and body mass index, heavier mastectomy specimen weight, implant projection, and previous and adjuvant radiotherapy showed association. The internal validation of each model demonstrated areas under the receiver operating characteristic curve of 68.9%, 68.0%, 84.9%, and 79.0% for early complications, delayed wound healing, infection, and reconstructive failure, respectively. Conclusion: A nomogram-based approach for predicting complications in prepectoral DTI reconstruction may enhance clinical decision-making, leading to optimized outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Purpose The widely used triple-antibiotics irrigation solution, comprising cefazolin, gentamycin, and povidone-iodine solution, has been employed for preventing infection and capsular contracture in implant-based breast reconstruction. However, potential overlapping in the coverage of such antimicrobial effects and the recent emergence of cefazolin-resistant gram-positive bacteria has prompted concerns regarding the efficacy of routine use of cefazolin in irrigation solutions. This study aims to evaluate clinical safety of omitting cefazolin from the traditional triple-antibiotic irrigation solution. Methods Patients who underwent immediate prepectoral direct-to-implant breast reconstruction between September 2020 and April 2022 were reviewed. They were divided into two groups: cases using the traditional triple-antibiotics for the former third and those using dual-antibiotics (omitting cefazolin) for the latter. Development of postoperative complications were compared by the type of irrigation solution and its independent associations with the adverse outcomes were evaluated. Results In total, 445 cases (126 using triple- and 319 using dual-regimen solution) were analyzed with a mean follow-up period of 12 months. The two groups had generally similar baseline characteristics. Overall complications developed in 126 cases (28.3%), including 12 (2.7%) of infection and 32 (7.2%) of capsular contracture. The complication profiles did not differ between the groups. Multivariable analyses exhibited that the type of irrigation solution was not associated with the development of overall and any kind of complication including infection and capsular contracture. Conclusion Omission of cefazolin from the irrigation solution may not elevate the risks of infection and capsular contracture in prepectoral direct-to-implant reconstruction. Further long-term studies would be warranted. Level of Evidence III 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.

Shin DS, et al. J Breast Cancer. 2024 Jan;27:e3. https://doi.org/10.4048/jbc.2023.0196

BACKGROUND: In two-stage expander-based breast reconstruction, the use of air as the initial filling medium has been suggested to confer clinical advantages over conventional saline, but this has not been demonstrated in a large series. The present study aimed to evaluate the association between material type (air versus saline) for initial expander filling and postoperative outcomes. METHODS: This retrospective study included patients who underwent immediate subpectoral tissue expander-based breast reconstruction between January 2018 and March 2021. The subjects were categorized into two groups according to the material used for initial filling; saline-inflated expanders, which were used during the first 22 months consecutively; and air-inflated expanders, which were used during the latter 17 months consecutively. Complications including mastectomy flap necrosis, and postoperative expansion profiles were compared. Multivariable analyses were performed to identify independent predictors of postoperative complications. RESULTS: A total of 443 breasts (400 patients), including 161 air-filled and 282 saline-filled, were analyzed. The two groups had similar baseline characteristics. The air-filled group showed a significantly lower rate of mastectomy flap necrosis; this difference remained significant after the adjustment for other variables in the multivariable analysis. The rates of other complications did not differ between the two groups. The air-filled group had fewer office visits and a shorter period to complete expansion. CONCLUSIONS: The use of air for initial expander filling could provide safe and reliable outcomes with reduced patient discomfort during postoperative expansion; thus, air-filled expanders might be an effective alternative to saline-filled expanders.

Background: Time intervals for expander-to-implant exchange from radiation therapy have been reported to reduce device failure. This study investigated the optimal timing of expander-to-implant exchange after irradiation in terms of short- and long-term outcomes. Methods: This retrospective review enrolled consecutive patients who underwent immediate two-stage breast reconstruction and radiation therapy to tissue expanders from 2010 to 2019. Receiver operating characteristic curves and the Youden index were used to estimate the optimal time from radiation therapy to implant placement in terms of 49-day (early) and 2-year (late) complications. Logistic regression analysis was performed to identify the risk factors for each complication. Results: Of the 1675 patients, 133 were included. The 49-day and 2-year complication rates were 8.3 percent and 29.7 percent, respectively. Capsular contracture was the most common 2-year complication. The Youden index indicated that implant placement at 131 days after radiation therapy was most effective in reducing the 49-day complications, but that the 2-year complication was less significant, with lower sensitivity and area under the curve. Modified radical mastectomy, expander fill volume at radiation therapy, and size of permanent implant increased the odds of 49-day complications; none of them was associated with the odds of 2-year complications. Conclusions: To reduce short-term complications, the best time point for permanent implant placement was 131 days after radiation therapy. However, there was no significant time interval for reducing long-term complications. Capsular contracture was an irreversible complication of radiation injury that was not modified by postirradiation variables including the time from irradiation or size of permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.