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Hand-sewn, coupler and Doppler-assisted venous anastomosis in free flap surgery: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01854-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Heidekrueger P, von Fritschen U, Moellhoff N, Germann G, Giunta R, Zeman F, Prantl L. Comparison of venous couplers versus hand-sewn technique in 4577 cases of DIEP-flap breast reconstructions - A multicenter study. Microsurgery 2020; 42:5-12. [PMID: 33241589 DOI: 10.1002/micr.30686] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/23/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Venous anastomosis remains to be a challenging step in microsurgical tissue transfer and venous complications constitute to a common reason for free flap failure. While several studies have compared mechanical vs. hand-sewn venous anastomoses, there is no large-series study comparing the type of anastomosis exclusively in DIEP flap breast reconstructions. PATIENTS AND METHODS Between 2011 and 2019, 3926 female patients underwent 4577 free DIEP-flap breast reconstructions in 22 different breast cancer centers. Patient data was collected via an online database, files were screened and cases were divided into a hand- (HA) and a coupler-anastomosis (CA) group. Complications were accounted for and the two groups were then compared. RESULTS Mean ischemia time was significantly shorter in the CA group (46.88 ± 26.17 vs. 55.48 ± 24.70 min; p < .001), whereas mean operative time was comparable (316 ± 134.01 vs. 320.77 ± 120.29 minutes; p = .294). We found no significant difference between both groups regarding the rate of partial (CA: 1.0% vs. HA: 1.3%) and total flap loss (CA: 2.2% vs. HA: 1.8%). However, revision rates were significantly higher in the CA group (CA: 10.5% vs. HA: 7.9%; p = .003), with higher numbers of arterial (2.3 vs. 0.9%; p < .001) and venous thromboses (3.4 vs. 1.8%; p = .001) accounting for this finding. CONCLUSIONS All taken into account, our findings do support the feasibility of venous coupler anastomoses in principle, however the inflationary use of coupler devices should be evaluated critically.
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Affiliation(s)
- Paul Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - Uwe von Fritschen
- Department of Plastic and Esthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Berlin, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Munich, Germany
| | - Gunter Germann
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Plastic, Reconstructive, Esthetic and Handsurgery, ETHIANUM Klinik Heidelberg, Heidelberg, Germany
| | - Riccardo Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Munich, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Lukas Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
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Maruccia M, Fatigato G, Elia R, Ragusa LA, Vestita MG, Nacchiero E, Robusto F, Nicoli F, Pedro Ciudad, Giudice G. Microvascular coupler device versus hand-sewn venous anastomosis: A systematic review of the literature and data meta-analysis. Microsurgery 2020; 40:608-617. [PMID: 32246807 DOI: 10.1002/micr.30585] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 01/22/2020] [Accepted: 03/20/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Successful vascular anastomosis is essential for the survival of free tissue transfer. The aim of the study is to review the current literature and perform a meta-analysis to assess the potential advantages of a mechanical anastomosis coupler device (MACD) over the hand-sewn (HS) technique for venous anastomoses. METHODS A systematic Medline search was performed to gather all reports of articles related to MACD from 1984 until now. The following data were extracted: first author and publication date, study design, number of patients and anastomosis, coupler size, site and type of reconstruction, venous anastomotic time, flap failure. A meta-analysis was performed on articles that met the following inclusion criteria: studies comparing MACD and HS technique in venous anastomosis, reporting anastomotic time, and postoperative complications. RESULTS Thirty-three studies were included for the analysis. Twenty-four were retrospective case series and nine were retrospective comparative studies. A total of 12,304 patients were enrolled with a mean age of 49.23 years (range 31-72). A total of 13,669 flaps were accomplished. The thrombosis rate recorded with MACD was 1.47%. The meta-analysis revealed that MACD significantly decreased anastomotic time (standard difference in means = -0.395 ± 0.105; Z = -3.776; p < .001) and postoperative flap failure risk (odds ratio [OR] = 0.362, 95% confidence interval [CI] = 0.218-0.603, Z = -3.908, p < .001), but it did not decrease postoperative venous thrombosis risk (OR = 0.504, 95% CI = 0.255-1.129, Z = -1.666, p = .096). CONCLUSIONS MACDs are a safe and effective alternative to traditional anastomosis. The anastomotic coupler is easier, much faster, and requires less technical skills than a HS microvascular anastomosis.
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Affiliation(s)
- Michele Maruccia
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Giusy Fatigato
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Rossella Elia
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Luigi Amerigo Ragusa
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Michelangelo G Vestita
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Eleonora Nacchiero
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Fabio Robusto
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary Hospital Newcastle NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Giuseppe Giudice
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ transplantation, University of Bari, Bari, Italy
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Steiner D, Horch RE, Ludolph I, Schmitz M, Beier JP, Arkudas A. Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure. Front Oncol 2020; 10:177. [PMID: 32195171 PMCID: PMC7066123 DOI: 10.3389/fonc.2020.00177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/31/2020] [Indexed: 01/30/2023] Open
Abstract
Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.
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Affiliation(s)
- Dominik Steiner
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Marweh Schmitz
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Justus P Beier
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany.,Department of Plastic Surgery, Hand Surgery, Burn Center, University Hospital RWTH Aachen, Aachen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
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Geierlehner A, Rodi T, Mosahebi A, Tanos G, Wormald JCR. Meta-analysis of venous anastomosis techniques in free flap reconstruction. J Plast Reconstr Aesthet Surg 2019; 73:409-420. [PMID: 31928960 DOI: 10.1016/j.bjps.2019.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/12/2019] [Accepted: 11/22/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Coupler devices and hand-sewn anastomosis techniques are both routinely employed for venous anastomosis in microsurgical free flap transfer. However, uncertainty remains about whether those two techniques are different in terms of risk of venous thrombosis. The aim of this review was to evaluate the quality of the evidence and quantify the difference in venous thrombosis rates in both techniques. METHOD A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review and meta-analysis were performed according to a previously published protocol. MEDLINE and Embase databases were searched from inception to 1 October 2018. Clinical studies using coupler devices for venous anastomoses in free tissue transfer were included. The primary outcome was post-operative venous thrombosis risk. Surgical anastomosis time was a secondary outcome. The risk of bias was assessed with the ROBINS-I or NIH tool and recommendations were made using the GRADE criteria. RESULTS A total of 10,851 patients across 32 observational retrospective studies were included, with data available for 12,769 free flaps in breast, head and neck, limb and other reconstructions. Direct comparison meta-analysis of 7 studies showed a reduced post-operative thrombosis risk for venous coupler, although this was an imprecise estimate (RR 0.68 [95% CI 0.39-1.19]). The risk of bias was consistently high across all studies. CONCLUSION Venous couplers may reduce the risk of venous thrombosis, but further randomised trial data are needed to improve the accuracy of this estimate. Further research should also assess size-mismatch between donor and recipient vessel, and the influence of coupler size on outcomes (PROSPERO registration ID: CRD42018110111).
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Affiliation(s)
- A Geierlehner
- UCL Division of Surgery & Interventional Science, Royal Free Hospital, London, United Kingdom; Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg (FAU), Germany
| | - T Rodi
- UCL Division of Surgery & Interventional Science, Royal Free Hospital, London, United Kingdom; Heidelberg Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - A Mosahebi
- UCL Division of Surgery & Interventional Science, Royal Free Hospital, London, United Kingdom; Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, United Kingdom
| | - G Tanos
- Department of Plastic, Reconstructive and Burns Surgery, Buckinghamshire Healthcare NHS Trust, United Kingdom
| | - J C R Wormald
- Department of Plastic, Reconstructive and Burns Surgery, Buckinghamshire Healthcare NHS Trust, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
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Vernier-Mosca M, Feuvrier D, Obert L, Mauvais O, Loisel F, Pluvy I. [Use of coupler for venous anastomoses in cervico-facial reconstruction. Retrospective study on 51 free flaps]. ANN CHIR PLAST ESTH 2019; 65:236-243. [PMID: 31353075 DOI: 10.1016/j.anplas.2019.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/28/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of our study was to evaluate the interest of the mechanical anastomosic coupling device for venous anastomoses in a series of cervico-facial reconstructions after carcinologic excision. PATIENTS AND METHODS Between January 2010 and December 2017, 46 patients underwent free flap cervico-facial reconstruction. We performed 54 venous anastomoses for 51 free flaps. Mechanical venous anastomoses were performed with a coupler (Coupler®). Thrombotic complications and choice of recipient vessels were assessed for the entire series. RESULTS Venous anastomoses were performed using a coupler in 33.3% of the flaps (n=18). Mean operative time was lower for reconstructions with mechanical coupler anastomoses, and significantly for fibula flaps. Of eight thromboses, six were venous, two of which after the coupler anastomosis. The thrombosed veins were the branches of the internal jugular vein and the anterior jugular veins. The diameter of the couplers used was respectively 2.5mm and 2mm. CONCLUSION The use of the microvascular coupling system for venous anastomoeis would help reduce the occurrence of venous thrombosis, but larger and prospective studies should be conducted. This coupling system, relatively easy to use, would overcome the lack of congruence of anastomosing veins and reduce the risk of intimal injury. Regarding the recipient vessels, the anterior jugular vein should not be used as first line because the risk of vascular complications seems more important.
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Affiliation(s)
- M Vernier-Mosca
- Service de chirurgie orthopédique, traumatologique, plastique, reconstructrice et assistance main, CHRU Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon, France.
| | - D Feuvrier
- Service de chirurgie orthopédique, traumatologique, plastique, reconstructrice et assistance main, CHRU Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon, France; Laboratoire de nano-médecine, imagerie, thérapeutique, EA 4662, université de Franche-Comté, 16, route de Gray, 25030 Besançon, France
| | - L Obert
- Service de chirurgie orthopédique, traumatologique, plastique, reconstructrice et assistance main, CHRU Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon, France; Laboratoire de nano-médecine, imagerie, thérapeutique, EA 4662, université de Franche-Comté, 16, route de Gray, 25030 Besançon, France
| | - O Mauvais
- Service d'ORL et audiophonologie, CHRU Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon, France
| | - F Loisel
- Service de chirurgie orthopédique, traumatologique, plastique, reconstructrice et assistance main, CHRU Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon, France; Laboratoire de nano-médecine, imagerie, thérapeutique, EA 4662, université de Franche-Comté, 16, route de Gray, 25030 Besançon, France
| | - I Pluvy
- Service de chirurgie orthopédique, traumatologique, plastique, reconstructrice et assistance main, CHRU Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon, France; Laboratoire de nano-médecine, imagerie, thérapeutique, EA 4662, université de Franche-Comté, 16, route de Gray, 25030 Besançon, France
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Pafitanis G, Cooper L, Hadjiandreou M, Ghanem A, Myers S. Microvascular anastomotic coupler application learning curve: A curriculum supporting further deliberate practice in ex-vivo simulation models. J Plast Reconstr Aesthet Surg 2018; 72:203-210. [PMID: 30501971 DOI: 10.1016/j.bjps.2018.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Microvascular anastomosis with coupler devices has revolutionized microsurgery practice. Couplers are considered easier to apply and offer improved operating time while maintaining success rates. This study aims to map the learning curve, skill acquisition, and decay of novice microsurgeons in performing coupler anastomosis. METHODS Novice microsurgeons performed consecutive coupler applications on a three-layer silastic vessel in two phases. Overall time, total movements, and total path-length were objectively measured and the overall surgical performance was calculated using hand motion analyzer (Dextrous MD, Inition, London, UK). RESULTS Sixty coupler anastomoses were performed using the synthetic, three-layered silicone vessel by 5 novices, 40 for phase 1, 12 for phase 2 and 8 for phase 3. During the phase 1 and phase 2 learning curves deliberate practice, the novices required an average of 8 (6-9) and 4 (2-6) consecutive repetitions, respectively, before reaching the experts' performance. There was an average improvement of 69% (p < 0.001) from their baseline performance during phase I and 37% (p < 0.001) during phase II. End-product assessment revealed that 4 out of 40 coupler applications during phase 1 (10%), 3 out of 20 during phase 2 (15%), and 1 out of 8 during exit performance-phase 3 (12.5%). During phase 3 end-product assessment with f-cMP, 7 out of 8 arterial and venous coupler anastomoses demonstrated an adequate range of flow measures. CONCLUSION This study demonstrated objectively learning curves and skill decay following a suggested coupler application curriculum and quantified objective thresholds for ethical animal model training and safe supervised clinical sessions in the OR.
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Affiliation(s)
- Georgios Pafitanis
- Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK; Group for Academic Plastic Surgery, The Blizard Institute, Queen Mary University of London, London, UK.
| | - Lilli Cooper
- Department of Plastic Surgery, St. George's Hospital, London, UK
| | | | - Ali Ghanem
- Group for Academic Plastic Surgery, The Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Myers
- Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK; Group for Academic Plastic Surgery, The Blizard Institute, Queen Mary University of London, London, UK
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Bodin F, Bruant-Rodier C, Ruffenach L, Dissaux C. [Breast reconstruction with free flap of gracilis]. ANN CHIR PLAST ESTH 2018; 63:486-497. [PMID: 30318054 DOI: 10.1016/j.anplas.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 06/18/2018] [Indexed: 11/30/2022]
Abstract
Breast reconstruction with free flap of gracilis has been described since 2004. The procedure consists in harvesting a flap made of the gracilis muscle and a transverse cutaneous paddle originating from the internal root of the thigh. The pedicle of the flap is the main pedicle of the gracilis muscle. After weaning, the vessels are anastomosed to the internal thoracic artery and vein. The modeling of the breast is done by folding the cut points in front of the muscle to obtain the shape of a cone. This surgical technique allows the realization of autologous breast reconstructions of small to medium size, immediate or delayed, unilateral or bilateral.
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Affiliation(s)
- F Bodin
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Civil, 1, place de l'Hôpital, 67091 Strasbourg cedex, France.
| | - C Bruant-Rodier
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Civil, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - L Ruffenach
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Civil, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - C Dissaux
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Civil, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
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Smaller Diameter Anastomotic Coupling Devices Have Higher Rates of Venous Thrombosis in Microvascular Free Tissue Transfer. Plast Reconstr Surg 2017; 140:1293-1300. [DOI: 10.1097/prs.0000000000003865] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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[Benefit of simultaneous contralateral breast symmetry procedure with unilateral breast reconstruction using DIEP flaps. About 33 cases]. ANN CHIR PLAST ESTH 2015; 60:472-7. [PMID: 26456280 DOI: 10.1016/j.anplas.2015.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 09/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with DIEP flap. METHODS We evaluated 33 consecutive patients (mean age, 52.1 years) who underwent DIEP flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed and 2 patients with delayed controlateral symmetry procedures. A single-stage breast cancer reconstruction is successful if after the original reconstruction no correction for revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction. RESULTS In 24 patients (73%), breast reconstruction was completed after a single stage with one general anesthetic, and in 8 patients (24%), revisions were performed with two general anesthetic (7 patients) and three general anesthetic in one case. Reconstructions requiring more than one general anesthetic were due to 4 of 39 (10%) postoperative complications. Mean operating time was 485 minutes. CONCLUSIONS For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.
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