A randomized controlled trial: application of inactivated Pseudomonas aeruginosa preparation in nipple-sparing mastectomy with immediate prosthetic reconstruction for breast cancer

Introduction

Breast cancer is one of the most commonly diagnosed malignancies worldwide, with approximately 2.3 million new cases reported in 2022 (1). In East Asia, including China, breast cancer exhibits a distinct age-specific incidence pattern, with over 40% of patients diagnosed before the age of 50 years. The peak age of onset in this region (approximately 45–49 years) is considerably earlier than that observed in Western countries (approximately 70 years) (2). Therefore, for this relatively younger patient population, achieving optimal oncologic safety while preserving the natural contour of the breast to maintain quality of life is of paramount importance. Nipple-sparing mastectomy with immediate prosthetic reconstruction (NSM-IPR) has emerged as a key surgical approach to address these dual objectives. This technique has been demonstrated to confer reliable oncologic safety and significantly improve patient-reported outcomes, including breast satisfaction, psychological well-being, and sexual health (3,4).

However, NSM-IPR is not without specific complication risks. Surgical site infection represents a common and significant postoperative complication that adversely affects reconstructive outcomes and is a leading cause of reconstructive failure (5). Studies have confirmed that patients who develop flap necrosis exhibit a significantly higher incidence of postoperative infection, which is closely associated with an elevated risk of early reconstructive failure (6). Furthermore, the presence of bacteria, including subclinical colonization, around the implant has been implicated in the pathogenesis of capsular contracture, a severe long-term complication (7). Postoperative drainage tubes have been identified as a potential route for bacterial ingress and subsequent infection, with prolonged indwelling duration significantly increasing the risk of infection (8). Consequently, minimizing drainage duration is a critical strategy for mitigating infection risk, and recent evidence supports the safety and efficacy of early drain removal in prosthetic breast reconstruction (9). Therefore, investigating adjunctive methods that can safely and effectively reduce postoperative drainage volume and shorten drainage duration holds substantial clinical value for improving surgical outcomes following NSM-IPR.

Inactivated Pseudomonas aeruginosa preparation (PAP), a biological agent capable of activating macrophages and enhancing local immune responses to accelerate wound healing, offers a potential solution in this context (10). Preliminary clinical studies have suggested that PAP may reduce postoperative exudation and shorten drainage duration in breast cancer and other oncologic surgeries (10,11). However, its comprehensive value in NSM-IPR—a procedure that balances oncologic safety with aesthetic outcome—specifically regarding drainage management, complication control, and cosmetic prognosis, has not been systematically evaluated. Accordingly, this study prospectively analyzed data from 102 patients who underwent breast cancer surgery at Liaoning Cancer Hospital between January 2024 and January 2026. The aim was to investigate the impact of intraoperative PAP application on outcomes of NSM-IPR, to validate its efficacy in reducing postoperative drainage volume and duration and lowering complication rates, and to assess its potential benefits for postoperative breast aesthetics. We present this article in accordance with the CONSORT reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0135/rc).

Methods

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Review Board of Liaoning Cancer Hospital (No. KY20241106). Prior to the commencement of the study, written informed consent was secured from all participants.

Clinical information

This study included breast cancer patients who underwent surgery performed by the same lead surgeon at Liaoning Cancer Hospital between January 2024 and January 2026. The inclusion criteria were as follows: (I) female patients; (II) distant metastasis ruled out by chest computed tomography (CT), cranial CT, upper abdominal ultrasound, and bone scan; (III) preoperative pathological confirmation of primary invasive breast cancer; (IV) no prior history of breast cancer surgery; (V) non-pregnancy-associated breast cancer; (VI) preoperative agreement to undergo nipple-sparing mastectomy with NSM-IPR. Exclusion criteria included: (I) requirement for additional flap surgery in the operative area; (II) intraoperative biopsy of the nipple-areola complex (NAC) indicating malignancy necessitating nipple excision; (III) allergy to penicillin or cephalosporins (confirmed by preoperative skin test).

Based on these criteria, 100 patients scheduled for NSM-IPR were selected. Among them, 75 patients (mean age 42.5±10.0 years) were intraoperatively assigned to the inactivated PAP treatment group (PAP group, further divided into three subgroups based on concentration), and 25 patients (mean age 43.02±11.28 years) were assigned to the non-PAP group. All patients received postoperative silicone drainage tubes for parasternal and axillary drainage. The patient screening process and group allocation are illustrated in Figure 1.

Figure 1 CONSORT 2025 flow diagram. NAC, nipple-areola complex; PAP, Pseudomonas aeruginosa preparation.

Data collection

Preoperative data, including baseline patient characteristics and surgical details, were collected. Postoperative complications were monitored within one month after drain removal, including fever, infection, flap necrosis, seroma, and other adverse events. Total drainage volume and drainage duration (defined as the time until all drains were removed) were also recorded. Wound infection and flap necrosis were assessed at each dressing change, which was performed every 4 days by the same two attending physicians. Drains were removed when the output from a single drain was ≤15 mL per day for three consecutive days, provided the drain remained patent and no clinical evidence of seroma was observed. Seroma was defined according to the criteria established by Marquez and Srivastava as any fluid collection in the subcutaneous tissue or axilla following mastectomy and axillary lymph node dissection that required aspiration, either clinically or under imaging guidance.

The primary endpoint was drainage duration (days from surgery until all drains were removed). Secondary endpoints included total postoperative drainage volume (mL), postoperative complications (fever, incision infection, seroma, flap/NAC necrosis), and cosmetic outcomes [Breast Symmetry Index (BSI), BREAST-Q scores, and Baker grade] assessed at 3 months postoperatively.

Postoperative cosmetic outcomes were evaluated at the three-month follow-up visit. Both subjective and objective assessments of breast appearance were conducted, including the BSI, Baker grading, and BREAST-Q scores. The BSI was calculated using postoperative standing photographs: the breast contours were outlined, the NAC was marked, and specialized software was used to compare the overlap between the two sides, yielding the BSI.

Randomization and grouping

The random allocation sequence was generated by an independent statistician using a computer-generated random number table with a block size of 4. Allocation was concealed using sequentially numbered, opaque, sealed envelopes.

The PAP group was further subdivided into low-, medium-, and high-concentration subgroups. Intraoperatively, 2, 4, or 6 vials of the inactivated PAP (equivalent to 4, 8, and 12 mL, respectively) were added to 50 mL of undiluted povidone-iodine solution. The implant was immersed in the mixture using a no-touch technique for at least five minutes (Figure 2). Following immersion, the implant was placed into the retropectoral pocket, and the lateral bare area was covered with a mesh. Two drainage tubes were inserted: one positioned along the inframammary fold and the other in the axillary region. The incision was closed with continuous sutures. External low-negative pressure suction was applied to the axillary drain, while the inframammary drain was maintained under positive pressure. In the non-PAP (control) group, the implant was immersed in 50 mL of undiluted povidone-iodine solution alone using the identical procedure (12); all other surgical steps remained the same. The surgeon enrolled participants, and a research coordinator not involved in the surgery assigned them to groups.

Figure 2 Intraoperative procedure demonstration. (A) Prefilled syringe of the inactivated Pseudomonas aeruginosa preparation (2 mL per vial). (B,C) Implant handling procedure: after opening, the implant was immediately placed in 50 mL of undiluted povidone-iodine solution; in the experimental groups, the Pseudomonas aeruginosa preparation was added concurrently (minimizing air exposure). Only the surgeon handled the implant to reduce postoperative infection risk. (D) All surgical incisions were made along the lateral breast border near the mid-axillary line. Implants were placed in the retropectoral plane, and a Tiloop^® mesh was sutured to cover the lateral bare area of the implant (one edge fixed to the lateral border of the pectoralis minor muscle, the other folded over to wrap the implant surface).

Blinding

Outcome assessors and data analysts were blinded to group allocation. Participants and the surgeon could not be blinded due to the nature of the intervention.

The inactivated PAP used in this study was manufactured by Beijing Wanter Bio-Pharmaceutical Co., Ltd. (Beijing, China). It is derived from a heat-inactivated, genetically engineered strain of Pseudomonas aeruginosa—the mannose-sensitive hemagglutinin (MSHA) strain—which exhibits mannose-sensitive binding activity and has been shown to induce apoptosis in tumor cells.

Statistical analysis

All statistical analyses were performed using SPSS version 22.0. Continuous variables with approximately normal distribution are presented as mean ± standard deviation and were compared using paired t-tests. Ordinal data were analyzed using the Kruskal-Wallis test for multiple independent samples. A two-sided P value <0.05 was considered statistically significant.

Sample size calculation

The required sample size was determined a priori using G*Power software (version 3.1), based on a one-way analysis of variance (ANOVA) model. The calculation assumed a two-tailed significance level (α) of 0.05, a statistical power (1 − β) of 80%, and four groups.

The effect size was estimated from preliminary experimental data and prior clinical evidence. A previous study (10) reported a clinically meaningful difference in the primary endpoint (time to drain removal) between the blank control group and the low-concentration experimental group. To ensure a conservative sample size estimate, a relatively large standard deviation (8.837) was adopted. Based on the dose-response trend observed in the pilot study, the calculated Cohen’s f effect size was 0.424, indicating a large effect.

The software calculation indicated that 17 subjects per group (total n=68) would be sufficient to detect this effect size. To account for potential dropouts and missing data during follow-up, the sample size was increased to 25 subjects per group, yielding a total of 100 participants. This ensures adequate statistical power for the final analysis.

Results

Participant flow

Of 112 patients assessed for eligibility, 12 were excluded (7 due to concomitant flap surgery, 5 due to NAC malignancy on frozen section). The remaining 100 patients were randomized: 75 to the PAP group (25 each in low-, medium-, and high-concentration subgroups) and 25 to the non-PAP group. All patients received the allocated intervention. No patients were lost to follow-up or discontinued intervention. All 100 patients were included in the primary analysis (Figure 1).

Comparison of baseline characteristics

A total of 100 patients were enrolled (25 in each of the PAP low-, medium-, and high-concentration groups, and 25 in the non-PAP control group). There were no significant differences among the groups in terms of age, height, weight, menopausal status, body mass index (BMI), family history, tumor size, lymph node metastasis, or clinical stage (all P>0.05; Table 1).

Comparison of efficacy

The time to drain removal was significantly shorter in all intervention groups compared with the control group (Figure 3). Specifically, the drain duration was 13.4±1.98 days in the low-concentration group, 10.76±2.17 days in the medium-concentration group, and 10.76±1.88 days in the high‑concentration group, all significantly shorter than the control group (15.92±2.58 days; all P<0.001). Further pairwise comparisons showed that the low-concentration group had a significantly longer drain time than both the medium- and high-concentration groups (P<0.001), while no statistical difference was observed between the medium- and high-concentration groups (P>0.99).

Figure 3 Comparison of time to drain removal and total drainage volume among the four groups. h, high; l, low; m, medium; PAP, Pseudomonas aeruginosa preparation.

Total drainage volume differed significantly among the four groups (χ²=82.64, P<0.001). Compared with the control group (733.0±99.43 mL), all PAP concentrations significantly reduced total drainage volume (all P<0.001). The medium-concentration group (477.8±35.53 mL) had significantly lower drainage volume than the low-concentration group (578.4±39.34 mL, P<0.001). Increasing the concentration to the high‑concentration group (444.8±34.26 mL) further reduced drainage volume, with a statistically significant difference compared with the medium-concentration group (P<0.001).

Comparison of complications

Regarding postoperative complications, the data were as follows: fever occurred in a total of 8 cases, including 5 in the high-concentration group and 1 each in the control, low-concentration, and medium-concentration groups. All fever episodes presented with a body temperature <39 ℃ and resolved within 24 h after symptomatic antipyretic treatment. Incisional infection occurred in 2 cases, both in groups with low or no PAP exposure (1 in the control group and 1 in the low-concentration group). Seroma was observed in 3 cases (2 in the control group and 1 in the low-concentration group). No flap or NAC necrosis occurred in any group (Table 2).

Comparison of cosmetic outcomes

Different patterns were observed across cosmetic outcome measures (Figure 4).

Figure 4 Example of BSI calculation and Breast-Q scores. (A) A postoperative frontal photograph of the patient, with the right side representing the surgical (reconstructed) side and the left side showing the normal glandular tissue. (B) The outlined contour of the right reconstructed breast and the marked NAC position, after which the image was flipped axially for symmetry. (C) The outlined contour and NAC position of the left normal breast. After processing (B,C) by software, the overlap rate was calculated as the BSI. (D) The comparison of BSI scores among the four groups, while (E,F) show the Breast-Q scores for satisfaction with breasts and physical well-being, respectively. BSI, Breast Symmetry Index; h, high; l, low; m, medium; NAC, nipple-areola complex; PAP, Pseudomonas aeruginosa preparation.

For BSI scores, there was no significant difference between the low-concentration group and the control group (88.64±2.69 vs. 84.52±5.97, P=0.19), whereas both the medium-concentration group (93.48±1.29) and the high-concentration group (94.52±1.05) scored significantly higher than the control and low-concentration groups (all P<0.001). Furthermore, the high-concentration group scored significantly higher than the medium-concentration group (P=0.04).

On the BREAST-Q scales, all intervention groups showed significantly higher scores than the control group in both satisfaction with breasts (low-, medium-, high-concentration groups: 75.92±6.06, 78.84±5.60, 80.08±6.46, vs. control: 59.84±7.07; all P<0.001) and physical well-being (chest) (74.92±5.11, 77.80±5.05, 78.56±5.67, vs. control: 62.04±7.06; all P<0.001). However, pairwise comparisons among the three intervention groups revealed no statistically significant differences in either scale (all P>0.05).

Discussion

This prospective randomized controlled trial represents the first evaluation of the impact of intraoperative application of inactivated PAP on postoperative recovery following NSM-IPR. All patients received povidone-iodine-based implant immersion and surgical field irrigation, a regimen selected based on established evidence-based benefits: systematic reviews have demonstrated that povidone-iodine irrigation significantly reduces rates of capsular contracture and reoperation compared with saline alone, and this practice is Food and Drug Administration (FDA)-approved for such procedures (13). Building upon this standard antimicrobial foundation, the present study further investigated whether adjunctive PAP could confer additional clinical benefits.

The primary findings demonstrated that intraoperative PAP application significantly shortened drainage tube indwelling time and reduced total postoperative drainage volume. Notably, the medium-concentration subgroup achieved comparable efficacy in drainage control to the high-concentration subgroup, while exhibiting a lower incidence of adverse effects such as postoperative fever. This suggests that the medium concentration achieves a more favorable balance between therapeutic efficacy and safety, providing direct evidence to inform clinical decision-making.

Early drain removal represents a clinically significant benefit, as substantially shortened drainage duration directly reduces the risk of retrograde infection via the drain as a foreign-body conduit (9), thereby contributing to decreased postoperative infection rates. Furthermore, minimizing drain indwelling—whether through early removal or avoidance of placement—is recognized as an integral component of enhanced recovery after surgery (ERAS) protocols, and has been shown to effectively reduce postoperative pain and improve patient comfort, thereby optimizing the recovery experience (14).

From a clinical management perspective, this study offers novel insights into the currently heterogeneous practices regarding postoperative drainage management following NSM-IPR. A noteworthy phenomenon exists in current drain removal decision-making: for instance, in the study by Zhou et al., which employed endoscopic techniques aimed at minimizing surgical trauma, a relatively lenient drain removal criterion was adopted (<50 mL/day for three consecutive days) (15). In contrast, most studies on conventional open surgery tend to favor stricter criteria (<20–30 mL/day for 2–3 consecutive days) (16). This disparity reflects a degree of uncertainty in clinical judgment regarding optimal drain removal timing—specifically, whether the decision should be primarily guided by the anticipated trauma of the predefined surgical approach, or by the individual patient’s actual exudative response. Overemphasizing the former may overlook genuine inter-individual differences in healing, whereas uniformly stringent criteria may unnecessarily prolong drainage duration and increase patient discomfort. The present study, by employing intraoperative immunomodulation with PAP, offers an alternative pathway. Under the premise of adhering to a rigorous safety margin (≤15 mL/day for three consecutive days), PAP intervention still achieved significantly earlier drain removal, with recovery rates surpassing those typically observed in conventional open NSM-IPR surgery. This suggests that proactively managing exudation through intraoperative intervention may represent a more fundamental strategy than rigidly adhering to fixed drainage thresholds—one that ensures safety while effectively promoting individualized enhanced recovery.

Regarding safety, the study data indicated that PAP application did not increase the risk of severe complications. Specifically, the adverse effect profile exhibited two characteristic features. First, transient febrile responses associated with immune activation were dose-dependent, with a higher incidence in the high-concentration subgroup. Fever represents the most commonly reported adverse effect of this class of immunomodulatory agents, and systematic reviews suggest its association with preparation-induced immune activation (17). Importantly, the medium-concentration subgroup achieved a significantly lower fever rate while maintaining effective drainage control, indicating a more favorable therapeutic window. Second, other surgery-related complications, such as seroma and postoperative infection, occurred only in the control and low-concentration subgroups, with no such events observed in the medium- or high-concentration groups. This distribution pattern suggests that PAP may effectively control surgical field exudation through its immunomodulatory effects. Indeed, previous studies have successfully employed topical PAP application to treat refractory postoperative lymphorrhea, supporting its ability to promote lymphatic vessel closure and tissue healing via local immune activation (18). This may represent the underlying mechanism for achieving earlier drain removal and reducing associated infection risk in the present study—although this causal relationship warrants confirmation in larger-sample studies.

Furthermore, the favorable outcomes observed in this study, particularly the low seroma risk and zero incidence of flap necrosis, may also be attributable to surgical technique. First, all reconstructions in this study were performed in the retropectoral plane. Systematic review evidence indicates that, compared with prepectoral reconstruction, retropectoral placement effectively reduces the risk of postoperative seroma (19,20). The underlying mechanism involves the coverage provided by the pectoralis major muscle, which offers support to the implant and helps minimize dead space beneath the mastectomy flap. Second, all procedures employed a lateral incision approach. Prospective studies have identified lateral inframammary fold incision as a significant protective factor against postoperative flap necrosis in NSM (21). The rationale lies in the ability of this incision location to better preserve the major vascular perforators supplying the mastectomy flap, particularly those destined for the NAC, thereby optimizing flap perfusion.

Postoperative breast contour represents a critical outcome measure for evaluating reconstructive success. In this study, PAP application was associated with superior objective symmetry (as measured by the BSI) and higher patient-reported satisfaction (BREAST-Q scores) at three months postoperatively. This confirms that, alongside effective exudation management, PAP contributes to favorable early aesthetic outcomes. This effect may be mediated by several mechanisms. PAP promotes macrophage polarization toward the M1 phenotype (10), thereby establishing an efficient and controlled inflammatory microenvironment in the immediate postoperative period, facilitating rapid debridement and reducing infection risk. A recent mathematical model of capsular contracture has revealed that early postoperative immune events serve as a critical “switch” determining the trajectory of healing toward either “normal, pliable capsule” or “pathological, contracture capsule” homeostasis (22). This model posits that excessive, dysregulated early inflammation—often triggered by factors such as infection—propels the system toward the latter. PAP-mediated optimization of early inflammation may intervene at the very initiation of the capsular contracture pathway. Of course, immunomodulation is inherently complex. Some studies suggest that infiltration of M2 macrophages within the tumor microenvironment is paradoxically associated with increased postoperative complication risk, underscoring the context-dependent nature of macrophage function (22,23). The value of PAP may lie not in simply promoting a single phenotype, but in orchestrating a “timely and orderly” immune response program that creates optimal conditions for tissue repair. In summary, we hypothesize that PAP not only benefits early healing and aesthetic outcomes but also, through the aforementioned immunomodulatory mechanisms, may theoretically create favorable conditions for implant healing, but this hypothesis requires validation through long-term follow-up studies.

Limitations

This study has several limitations. First, as a single-center study involving a single surgeon, the generalizability of the findings requires cautious interpretation. Second, direct evidence elucidating the precise molecular and cellular mechanisms underlying PAP’s effects, as well as its long-term impact on capsular formation around implants, is lacking. Future multicenter studies, incorporating both long-term complication surveillance and patient-reported outcome measures as endpoints, are warranted to comprehensively evaluate the value of PAP in the field of breast reconstruction. Concurrent basic research is also necessary to explore its mechanisms of action in greater depth. Third, the follow-up period was only 3 months, which is insufficient to evaluate long-term complications such as capsular contracture or late implant stability. Longer follow-up is needed.

Conclusions

In NSM-IPR for breast cancer, intraoperative immersion of the implant in a medium-dose preparation of inactivated Pseudomonas aeruginosa effectively reduces postoperative drainage volume and shortens drain duration, and may also benefit postoperative breast contour. This treatment approach helps alleviate local symptoms, improves quality of life, and secures valuable time for subsequent therapies.

Acknowledgments

The abstract of this work has been accepted for presentation at the ESMO Breast Cancer 2026 congress (Berlin, Germany, 6–8 May, 2026).

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0135/rc

Trial Protocol: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0135/tp

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0135/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0135/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0135/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Review Board of Liaoning Cancer Hospital (No. KY20241106). Prior to the commencement of the study, written informed consent was secured from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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