Grant W. Carlson

Background: Aesthetic outcomes after nipple-sparing mastectomy (NSM) with implant-based reconstruction are influenced by varying clinical and technical factors. BCCT.core, a validated objective assessment, provides a reproducible evaluation of postoperative symmetry. This study examined predictors of aesthetic outcome after bilateral NSM using BCCT.core. Methods: A retrospective review of 123 patients undergoing bilateral NSM with immediate implant-based reconstruction was performed. BCCT.core software assigned postoperative cosmetic classifications (classes 1 to 4). Patients were stratified by reconstructive method [direct-to-implant (DTI) vs. tissue expander (TE)], implant pocket, post-mastectomy radiation therapy (PMRT), mastectomy weight, and prior augmentation. Logistic regression identified independent predictors of poor aesthetic outcome (class 3/4). Results: Overall, 24.4% of patients achieved class 1, 60.2% class 2, and 15.4% class 3/4 results, with a mean classification of 1.93±0.64. PMRT had the strongest adverse effect on aesthetic outcome, with irradiated patients demonstrating markedly higher rates of class 3/4 results and worse mean postoperative classification. TE reconstruction produced more favorable outcomes than DTI, especially among nonirradiated patients, and remained an independent predictor on multivariable analysis. Higher mastectomy weight correlated with worse postoperative classification. Prior augmentation increased preoperative asymmetry but did not compromise postoperative aesthetic quality when TE reconstruction was used. Major complications were associated with poorer classification. Conclusion: PMRT and reconstructive methods are the strongest determinants of postoperative symmetry after NSM with implant-based reconstruction. TE reconstruction is associated with more favorable aesthetic outcomes than DTI, particularly in nonirradiated patients, while PMRT remains the principal driver of asymmetry. These retrospective findings support more individualized reconstructive planning and highlight the value of objective BCCT.core analysis in aesthetic evaluation.

Background: Late-onset peri-implant fluid collections require rigorous evaluation to exclude Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). While milky effusions often raise concern for malignancy or silicone gel bleed, their occurrence in saline implant reconstructions is rare. Case Description: A 63-year-old female presented with volume loss 28 years after right total mastectomy and subpectoral textured McGhan saline implant reconstruction followed by adjuvant radiotherapy. Computed tomography confirmed implant deflation and a small peri-implant fluid collection. Surgical exploration revealed a ruptured saline implant and 30 cc of thick, milky-white fluid within a densely calcified capsule. Flow cytometry and hematopathology were negative for CD30 expression and monoclonality, excluding BIA-ALCL. A total capsulectomy was performed. A dense fibrous capsule with calcification was noted and no malignancy identified. Conclusion: This case demonstrates that late peri-implant fluid collections occurring around textured saline implants, even when grossly milky in appearance, are not pathognomonic for BIA-ALCL. Comprehensive pathologic evaluation remains essential to distinguish benign delayed seromas from implant-associated malignancy.

Background: Fat grafting is commonly used in implant-based breast reconstruction to improve contour and soft-tissue quality. Cannula-related implant injury during fat grafting is considered rare and is infrequently discussed in the literature. Methods: A focused review of PubMed and Embase identified reports describing implant puncture or rupture associated with fat grafting. In addition, we present an institutional case of delayed implant infection following fat grafting, with intraoperative identification of intraprosthetic fat. Results: Four published case reports and a case discussion within a retrospective review of fat grafting patients describe cannula-induced implant puncture with intraprosthetic fat deposition, presenting variably with pain, capsular contracture, shape change, or infection. Larger series report low but non-zero rates of implant injury following fat grafting. Our case involved a radiated breast with delayed infection 18 months after fat grafting; explantation revealed multiple implant punctures and intraprosthetic fat without free silicone extrusion. Conclusions: Cannula-related implant injury during fat grafting is an uncommon but likely underrecognized complication with heterogeneous presentation and limited detectability on imaging. Awareness and adherence to protective techniques are essential to minimize risk.

Background: Complications of implant-based reconstruction have been shown to be related to increasing body mass index (BMI) and breast size. The impact of skin reducing mastectomy (SRM) with a dermal flap is examined. Methods: A retrospective review of a single surgeon's experience with immediate submuscular tissue expander (TE) reconstruction from 2011 to 2019 was performed. The outcomes of SRM were compared with those of skin sparing mastectomy (SSM). Results: A total of 162 patients (292 breasts) were identified. Mastectomy types were as follows: SRM, 73 (136 breasts) and SSM, 89 (156 breasts). Acellular dermal matrix (ADM) was used to supplement TE coverage in 65.4% of SRM cases. Mean BMI was 29.2 among SRM patients and 25.9 in SSM patients (P < 0.001). Obesity (BMI ≥ 30) was more prevalent in the SRM group (SRM, 38.4% vs SSM, 22.5%; P = 0.03). Mean mastectomy weight was higher in the SRM group (SRM, 833.6 g vs SSM, 425.6 g; P < 0.001). Mean BMI and mastectomy weight were lower in SRM patients who were reconstructed with ADM (ADM, 28.1 vs no ADM, 30.8; P = 0.01; ADM, 746.1 g vs no ADM, 1006.3 g; P < 0.001). Minor complications were more prevalent in the SRM group (SRM, 22.8% vs SSM, 4.5%; P < 0.001). Mastectomy skin flap necrosis (MSFN) was more common in the SRM group (SRM, 22.8% vs SSM, 7.7%; P < 0.001), but MSFN necessitating operative debridement was similarly low in both groups (SRM: 1.9% vs SSM: 4.5%). Major complication rates (SRM 11.0% vs SSM 10.9%) and reconstructive failure rates (SRM 5.9% vs SSM 5.1%) were similar between groups. Mastectomy weight 800 g or higher and BMI of 30 or higher were found to be risk factors for complications on analysis of the SRM cohort (P < 0.05). Conclusions: Mastectomy weight and BMI were positive predictors of complications after immediate TE reconstruction. Mastectomy skin flap necrosis is more common after SRM than SSM. The use of SRM with a dermal flap has a similar major complication rate as SSM despite its use in obese, large-breasted women. The dermal flap provides soft tissue coverage, which prevents implant exposure and seroma. The use of ADM does not adversely affect the complication rate of SRM.

Purpose Nipple-sparing mastectomy (NSM) has a higher incidence of mastectomy skin flap necrosis (MSFN) than skin-sparing mastectomy. The purpose of this study is to analyze predisposing factors for nipple and skin necrosis after bilateral NSM with immediate implant reconstruction. Methods Sixty-two consecutive patients (124 breasts) from a single breast/plastic surgeon underwent bilateral NSM with immediate implant-based breast reconstruction were included. Factors influencing MSFN were analyzed. Results The mean age was 45.7 years, and mean body mass index was 22.9. Reconstructive methods were as follows: tissue expander (TE), 76 (61.3%); and direct to implant, 48 (38.7%). Mastectomy skin flap necrosis occurred in 39 (31.5%) breasts, nipple necrosis 38 and skin flap necrosis 19. Thirty-seven breasts healed uneventfully, and 2 (1.6%) required reoperation. Cancer pathology, mastectomy weight greater than 279 g, TE reconstruction, and nipple-notch (N-N) distance greater than 23 cm were predictive of nipple necrosis on univariate analysis. The mean mastectomy weight (380.1 g vs 220.7 g, P < 0.0001), N-N distance greater than 23 cm (30 vs 0, P < 0.0001), and mean implant size (490 cm³ vs 373 cm³, P < 0.0001) were greater in the TE group. On logistic regression model controlling for all significant variables, predictors of MSFN were as follows: diagnosis of cancer (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.41–8.03; P = 0.006), TE reconstruction (OR, 2.87; 95% CI, 1.03–8.03; P = 0.04), and N-N distance (OR, 1.31; 95% CI, 1.03–1.66; P = 0.03). Conclusions Mastectomy skin flap necrosis after NSM and implant reconstruction is common. In this series, only 2 (1.6%) cases required surgical intervention with no implant loss. Treatment of breast cancer, TE reconstruction, and increasing N-N notch distance were positive predictors of MSFN.

The surgical management of breast cancer began to change in the middle of the last decade. The use of unilateral mastectomy decreased while the rate of contralateral prophylactic mastectomy for unilateral cancer increased sixfold from 1998 to 2011. The use of immediate breast reconstruction increased from 30% in 2005 to 45% in 2012. Four changes came together in the middle of the last decade to cause this paradigm shift in the surgical management of early breast cancer. (a) Breast MRI would be available in nearly 75% of breast imaging centers. (b) Genetic counseling would become a standard of care for patients with potential hereditary breast cancer. (c) In 2006, the FDA would approve the use of silicone‐gel implants. (d) Nipple‐sparing mastectomy would become a standard of care in the treatment of early breast cancer.

This paper is a single surgeon retrospective review that examined the impact of radiotherapy on capsular contracture after two-stage implant breast reconstruction using polyurethane (PU) implants.1 Ninety-two patients had 115 PU covered implants placed after tissue expander reconstruction. Patients were stratified into those receiving radiotherapy prior to implant insertion (n = 56 implants) and those not receiving radiation (n = 59 implants). Nine breasts developed grade III/IV capsular contracture (irradiated, 6; non-irradiated, 3) with a median follow up of 103 months. The overall capsular contracture rate was 8.1% (irradiated group, 10.7%; non-irradiated group, 5.1%). Irradiation accelerated the time to appearance of capsular contracture …

Background: Acellular dermal matrices (ADM) are now routine in postmastectomy prosthetic-based breast reconstruction. The goal of the current study was to compare the complications of 2 ADM products—AlloDerm and Cortiva. Methods: A retrospective analysis of prosthetic-based breast reconstruction in Atlanta, Ga., over 5 years. Inclusion criteria were the use of the ADM types (AlloDerm or Cortiva) and use of a tissue expander or implant. Statistical analysis compared group demographics, risk factors, and early complications. Results: Of the 298 breast reconstructions, 174 (58.4%) used AlloDerm and 124 (41.6%) used Cortiva. There was no difference in overall complication frequency (16 AlloDerm and 18 Cortiva; P = 0.195). Within specific categories, there was a difference in mastectomy skin flap necrosis, but, based on further regression analysis, this was attributable to differences in body mass index (P = 0.036). Furthermore, there were no differences in the rates of infection (6 AlloDerm and 5 Cortiva; P = 1.0), seroma/hematoma (9 AlloDerm and 7 Cortiva; P = 1.0), or drain duration (13.2 day AlloDerm and 14.2 day Cortiva, P = 0.2). By using a general estimating equation for binomial logistical regression, it was found that only current tobacco use (P = 0.033) was a significant predictor for a complication. Trending predictors were body mass index (P = 0.074) and age (P = 0.093). The type of matrix was not a significant predictor for any of the recorded complication (P = 0.160). Conclusions: Although AlloDerm is well established, we have shown that Cortiva has an equivalent complication frequency. Future work will focus on long-term outcome measures and histological evaluation of vascularization and integration.