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Implant-based breast reconstruction is a common plastic surgery procedure with well documented clinical outcomes. Despite this, the natural history and timing of key complication endpoints are not well described. The goal of this study is to determine when patients are most likely to experience specific adverse events after implant-based reconstruction.Retrospective consecutive series of patients who received mastectomy and implant-based reconstruction over a 6-year period were included. Complications and unfavorable outcomes including hematoma, seroma, wound infection, skin-flap necrosis, capsular contracture, implant rippling, and implant loss were identified. A time to event analysis was performed and Cox regression models identified patient and treatment characteristics associated with each outcome.Of 1473 patients and 2434 total reconstructed breasts, 785 complications/unfavorable outcomes were identified. The 12-month cumulative incidence of hematoma was 1.4%, seroma: 4.3%, infection: 3.2%, skin-flap necrosis: 3.9%, capsular contracture: 5.7%, implant rippling: 7.1%, and implant loss: 3.9%. In the analysis, 332/785 (42.3%) complications occurred within 60 days of surgery; 94% of hematomas, 85% of skin necrosis events, and 75% of seromas occurred during this period. Half of all infections and implant losses also occurred within 60 days. Of the remaining complications, 94% of capsular contractures and 93% of implant rippling occurred60 days from surgery.Complications following mastectomy and implant-based reconstruction exhibit a discrete temporal distribution. These data represent the first comprehensive study of the timing of adverse events following implant-based reconstruction. These findings are immediately useful to guide post-operative care, follow-up and clinical trial design.

Purpose As our hospitals conserve and re-allocate resources during the COVID-19 crisis, there is urgent need to determine how best to continue caring for breast cancer patients. During the time window before the COVID-19 critical peak and particularly thereafter, as hospitals are able to resume cancer operations, we anticipate that there will be great need to maximize efficiency to treat breast cancer. The goal of this study is to present a same-day protocol that minimizes resource utilization to enable hospitals to increase inpatient capacity, while providing care for breast cancer patients undergoing mastectomy and immediate breast reconstruction during the COVID-19 crisis. Methods IRB exempt patient quality improvement initiative was conducted to detail the operationalization of a novel same-day breast reconstruction protocol. Consecutive patients having undergone immediate breast reconstruction were prospectively enrolled between February and March of 2020 at Massachusetts General Hospital during the COVID-19 crisis. Peri-operative results and postoperative complications were summarized. Results Time interval from surgical closure to patient discharge was 5.02 ± 1.29 h. All patients were discharged home, with no re-admissions or emergency department visits. No postoperative complications were observed. Conclusion This report provides an instruction manual to operationalize a same-day breast reconstruction protocol, to meet demands of providing appropriate cancer treatment during times of unprecedented resource limitations. Pre-pectoral implant-based breast reconstruction can be the definitive procedure or be used as a bridge to autologous reconstruction. Importantly, we hope this work will be helpful to our patients and community as we emerge from the COVID-19 pandemic. Electronic supplementary material The online version of this article (10.1007/s10549-020-05739-7) contains supplementary material, which is available to authorized users.

The European Society for Therapeutic Radiology and Oncology Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) recently released new contouring guidelines for postmastectomy radiation therapy (PMRT) after implant-based reconstruction (IBR). As compared to prior ESTRO guidelines, the new guidelines primarily redefined the chest wall (CW) target to exclude the breast prosthesis. In this study, we assessed the impact of these changes on treatment planning and dosimetric outcomes using volumetric-modulated arc therapy (VMAT) and proton pencil-beam scanning (PBS) therapy.We performed a treatment planning study of 10 women with left-sided breast cancer who underwent PMRT after IBR. All target structures were delineated first using standard (ESTRO) breast contouring guidelines and then separately using the new (ESTRO-ACROP) guidelines. Standard organs-at-risk (OARs) and cardiac substructures were contoured. Four sets of plans were generated: (1) VMAT using standard ESTRO contours, (2) VMAT using new ESTRO-ACROP contours, (3) PBS using standard contours, and (4) PBS using new contours.VMAT plans using the new ESTRO-ACROP guidelines resulted in modest sparing of the left anterior descending coronary artery (LAD) (mean dose: 6.99 Gy standard ESTRO vs. 6.08 Gy new ESTRO-ACROP,PMRT after IBR using the new ESTRO-ACROP contouring guidelines with both VMAT and PBS therapy is associated with significant changes in exposure to several cardiopulmonary structures.

This meta-analysis provides a large-scale comparison of prepectoral vs. subpectoral implant-based breast reconstruction, with primary outcomes of patient safety and efficacy. Literature review was performed via PRISMA criteria, 33 studies met inclusion criteria for prepectoral review and 13 studies met inclusion criteria for meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS. In 4692 breasts of 3014 patients that underwent prepectoral breast reconstruction, rippling was observed as the most common complication, followed by seroma and skin flap necrosis. Meta-analysis demonstrated statistically significant decrease in odds of skin flap necrosis and capsular contracture in prepectoral groups compared to subpectoral groups. Odds of infection, seroma, and hematoma were equal between the two groups. Prepectoral breast reconstruction has surged in popularity in recent years. This review and large-scale analysis corroborates current literature reporting a favorable safety profile with emphasis on patient selection. Variability in skin flap thickness and vascularity mandates thoughtful selection of patients whose overall health and intra-operative skin flap assessment can tolerate a muscle-sparing reconstruction.