Predicting red breast syndrome after ADM-assisted breast reconstruction: An exploratory scoring model using routine hematologic markers
- 1Department of Plastic Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
- 2Department of Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
- 3Department of Neurosurgery, Busan Paik Hospital, Busan, Republic of Korea
Abstract
Background: Red breast syndrome (RBS) is a challenging complication of acellular dermal matrix (ADM)-assisted breast reconstruction. Its incidence and hematologic predictors in patients receiving neoadjuvant chemotherapy (NAC) remain poorly characterized. Methods: This retrospective cohort study included 70 patients who underwent skin-sparing mastectomy with immediate implant-based reconstruction following NAC (January 2011–May 2025) at a single tertiary institution. Patients were stratified into ADM (n = 47) and Non-ADM (n = 23) groups. Within the ADM group, Firth penalized logistic regression with backward elimination identified preoperative variables independently associated with RBS. Optimal cutoffs were determined by the Youden Index. A composite hematologic scoring model (WBC + PLT + Ki-67 High, cutoff ≥2) was developed and internally validated using bootstrap resampling (2,000 iterations). Results: RBS occurred in 31.9% (15/47) of ADM patients versus 0% in Non-ADM patients (p = 0.001). The final model identified WBC (OR 1.235, 95% CI 1.066–1.502, p = 0.004), PLT (OR 1.013, 95% CI 1.001–1.028, p = 0.037), and Ki-67 High (OR 8.975, 95% CI 1.356–155.173, p = 0.020) as independently associated with RBS. Individual biomarkers showed modest discrimination (AUC 0.605–0.641, all p > 0.10), while the composite score achieved AUC = 0.816 (p < 0.001; sensitivity 86.7%, specificity 71.9%, NPV 92.0%). Bootstrap-corrected AUC was 0.817 (95% CI 0.636–0.959; optimism=−0.001). No significant temporal trend in RBS incidence was observed (Cochran–Armitage, p = 0.527). Conclusions: RBS incidence is substantially elevated in post-NAC ADM patients. This exploratory, single-center study develops a hypothesis-generating combination score for preoperative RBS risk stratification using routine laboratory and pathology assessment. External validation in prospective multi-institutional cohorts is required before clinical application.
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BibTeX
@article{lee2026predicting,
title = {{Predicting red breast syndrome after ADM-assisted breast reconstruction: An exploratory scoring model using routine hematologic markers}},
author = {Dong Hun Lee and Kyung Do Byun and Tae Hyun Kim and Jin Lee and Jiyoung Yun and Hee Yeon Kim},
journal = {PLOS One},
year = {2026},
month = oct,
doi = {10.1371/journal.pone.0359415},
url = {https://doi.org/10.1371/journal.pone.0359415},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Predicting red breast syndrome after ADM-assisted breast reconstruction: An exploratory scoring model using routine hematologic markers
AU - Dong Hun Lee
AU - Kyung Do Byun
AU - Tae Hyun Kim
AU - Jin Lee
AU - Jiyoung Yun
AU - Hee Yeon Kim
PY - 2026
DA - 2026/10/07
JO - PLOS One
DO - 10.1371/journal.pone.0359415
UR - https://doi.org/10.1371/journal.pone.0359415
AB - Background: Red breast syndrome (RBS) is a challenging complication of acellular dermal matrix (ADM)-assisted breast reconstruction. Its incidence and hematologic predictors in patients receiving neoadjuvant chemotherapy (NAC) remain poorly characterized. Methods: This retrospective cohort study included 70 patients who underwent skin-sparing mastectomy with immediate implant-based reconstruction following NAC (January 2011–May 2025) at a single tertiary institution. Patients were stratified into ADM (n = 47) and Non-ADM (n = 23) groups. Within the ADM group, Firth penalized logistic regression with backward elimination identified preoperative variables independently associated with RBS. Optimal cutoffs were determined by the Youden Index. A composite hematologic scoring model (WBC + PLT + Ki-67 High, cutoff ≥2) was developed and internally validated using bootstrap resampling (2,000 iterations). Results: RBS occurred in 31.9% (15/47) of ADM patients versus 0% in Non-ADM patients (p = 0.001). The final model identified WBC (OR 1.235, 95% CI 1.066–1.502, p = 0.004), PLT (OR 1.013, 95% CI 1.001–1.028, p = 0.037), and Ki-67 High (OR 8.975, 95% CI 1.356–155.173, p = 0.020) as independently associated with RBS. Individual biomarkers showed modest discrimination (AUC 0.605–0.641, all p > 0.10), while the composite score achieved AUC = 0.816 (p < 0.001; sensitivity 86.7%, specificity 71.9%, NPV 92.0%). Bootstrap-corrected AUC was 0.817 (95% CI 0.636–0.959; optimism=−0.001). No significant temporal trend in RBS incidence was observed (Cochran–Armitage, p = 0.527). Conclusions: RBS incidence is substantially elevated in post-NAC ADM patients. This exploratory, single-center study develops a hypothesis-generating combination score for preoperative RBS risk stratification using routine laboratory and pathology assessment. External validation in prospective multi-institutional cohorts is required before clinical application.
SN - 1932-6203
ER -