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Maus J, Pestana IA. Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction. J Reconstr Microsurg 2024; 40:363-370. [PMID: 37884059 DOI: 10.1055/a-2199-4151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized. METHODS A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey. RESULTS In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05). CONCLUSION The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.
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Affiliation(s)
- Jacob Maus
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ivo A Pestana
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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2
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Silverstein ML, Sorice-Virk S, Wan DC, Momeni A. Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity. J Reconstr Microsurg 2024. [PMID: 38815573 DOI: 10.1055/s-0044-1787266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction. METHODS A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m2) and Obese (BMI ≥ 30 kg/m2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups. RESULTS Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time. CONCLUSION The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.
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Affiliation(s)
- Max L Silverstein
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Sarah Sorice-Virk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Derrick C Wan
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
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3
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Daly L, Tsai J, Stone K, Wapnir I, Karin M, Wan D, Momeni A. Nipple-areola-complex preservation and obesity-Successful in stages. Microsurgery 2024; 44:e31043. [PMID: 37013250 DOI: 10.1002/micr.31043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 01/12/2023] [Accepted: 03/09/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population. METHODS Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed. RESULTS Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission. CONCLUSIONS Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.
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Affiliation(s)
- Lauren Daly
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jacqueline Tsai
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Kim Stone
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Irene Wapnir
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Mardi Karin
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Vollbach FH, Thomas BF, Fansa H. Identification of Independent Risk Factors for Skin Complications in a Multifactorial Logistic Regression Analysis of Simultaneous Immediate Autologous Breast Reconstruction and Skin Reduction Mastectomy in Large and Ptotic Breasts Using an Inferiorly Based Deepithelialized Dermal Breast Flap. J Pers Med 2022; 12:jpm12030332. [PMID: 35330332 PMCID: PMC8951157 DOI: 10.3390/jpm12030332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Autologous immediate breast reconstruction in large and ptotic breasts remains challenging. We aimed to identify independent risk factors for impaired wound healing and nipple necrosis after skin reducing wise pattern mastectomy in autologous reconstruction with an auxiliary deepithelialized inferiorly based dermal flap (IBDF). Methods. This retrospective study examined patients with wise pattern mastectomy with autologous immediate breast reconstruction (IBR) between 2017 and 2019. All cases of large and ptotic breasts were included. Demographic, oncologic, reconstructive, and surgical data were compiled, and multifactorial binary logistic regression models identified independent predictors for skin complications and nipple areolar complex (NAC) necrosis. Results. Of 591 autologous breast reconstructions, 62 (11%) met the inclusion criteria. Overall wound complication rate was 32% (n = 20, DIEP 11, thigh 9, p = 0.99), including 26% minor (n = 16, non-surgically treated) and 7% major complications (n = 4, surgically treated). Complete NAC necrosis occurred in one case. Nipple sparing mastectomy (NSM) (p = 0.003), high BMI (p = 0.019), longer operation time (p = 0.044) and higher patient age (p = 0.045) were independent risk factors for skin complications. Using internal mammary artery perforators (IMAP) as recipient vessels did not result in increased complication rates (p = 0.59). Conclusion. Higher patient age, BMI, and operation time (OT) significantly increase the risk for skin complications in combined reduction wise pattern mastectomies with autologous IBR. In this context, IBDFs help preserve the inframammary fold, providing vasculature to the T-junction and the mastectomy skin flaps. Acceptable complication rates can be achieved in large and ptotic breasts, regardless of preoperative chemotherapy or radiation. Gentle tissue handling with minimal thermal trauma preserves internal mammary artery perforators (IMAPs) as recipient vessels. In cases of flap failure and alloplastic conversion, the IBDF can serve as an autoderm, protecting the implant from exposure
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Affiliation(s)
- Felix H. Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; (F.H.V.); (B.F.T.)
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Benjamin F. Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; (F.H.V.); (B.F.T.)
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Hisham Fansa
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, 8125 Zollikerberg, Switzerland
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Klinikum Bielefeld, OWL-University, 33604 Bielefeld, Germany
- Correspondence:
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Patterson CW, Palines PA, Bartow MJ, Womac DJ, Zampell JC, Dupin CL, St Hilaire H, Stalder MW. Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity. J Reconstr Microsurg 2021; 38:1-9. [PMID: 33853129 DOI: 10.1055/s-0041-1727202] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. RESULTS When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications. CONCLUSION DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.
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Affiliation(s)
- Charles W Patterson
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Patrick A Palines
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Matthew J Bartow
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Daniel J Womac
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | | | - Charles L Dupin
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | - Hugo St Hilaire
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | - Mark W Stalder
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
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Dinis J, Junn A, Shah R, Allam O, Mehta S, Mozaffari MA, Avraham T, Alperovich M. Abdominal subcutaneous fat thickness as a substitute for BMI in predicting complications in abdominally-based autologous breast reconstruction. Microsurgery 2021; 41:341-347. [PMID: 33720454 DOI: 10.1002/micr.30732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/07/2021] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Patient selection for autologous tissue transfer for postmastectomy breast reconstruction often utilizes body mass index (BMI) to risk stratify patients, though it only estimates fat content and does not address fat distribution. This study aims to identify a measurement of abdominal subcutaneous fat thickness (ASFT) from preoperative computed tomography (CT) angiography imaging to better predict complications. METHODS A retrospective review of patients who underwent an abdominal microvascular free flap breast reconstruction was performed. The average of the bilateral distances from the lateral border of the rectus abdominus to the most proximal point of the dermis at the L4-L5 space was measured on preoperative imaging to estimate ASFT. This measurement was compared to BMI in regards to correlation with any complication, major or minor complications, and donor or recipient site complications. Statistical analysis utilized point-biserial correlations and multivariable logistic regression analyses. RESULTS Three hundred and nine cases comprising a total of 496 breast reconstructions were identified. BMI did not correlate with any of the grouped complications, while ASFT correlated with occurrence of any complication (p = .003), minor complications (p = .001), and recipient site complications (p = .001). Further analysis revealed ASFT is specifically correlated with fat necrosis (p = .005). In independent multivariable regression models, both BMI (p = .011) and ASFT (p = .001) were significant predictors of fat necrosis. The ASFT model had a BIC of 335.42 compared to the BMI model with a value of 340.89, with smaller numbers representing more predictive models. CONCLUSION Estimation of ASFT is easily performed and is a significantly better predictor of flap fat necrosis than BMI.
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Affiliation(s)
- Jacob Dinis
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexandra Junn
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rema Shah
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Omar Allam
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sumarth Mehta
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mohammad Ali Mozaffari
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tomer Avraham
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Alperovich
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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7
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Heidekrueger PI, Fritschen U, Moellhoff N, Germann G, Giunta RE, Zeman F, Prantl L. Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study. J Plast Reconstr Aesthet Surg 2021; 74:1718-1724. [PMID: 33461890 DOI: 10.1016/j.bjps.2020.12.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/26/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI). PATIENTS AND METHODS A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m2), normal weight/ control group (BMI: 18.5-24.9 kg/m2), overweight group (BMI: 25-29.9 kg/m2), moderately obese group (BMI: 30-34.9 kg/m2), and severely obese group (BMI ≥ 35 kg/m2). Surgical complications were accounted for and the five BMI groups were then compared. RESULTS Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01). CONCLUSION Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.
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Affiliation(s)
- P I Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Uv Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Berlin, Germany
| | - N Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich Germany
| | - G Germann
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany; Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany; Department of Plastic, Reconstructive, Aesthetic and Handsurgery, ETHIANUM Klinik Heidelberg, Vossstrasse 6, 69115 Heidelberg, Germany
| | - R E Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich Germany
| | - F Zeman
- Centre for Clinical Studies, University Medical Centre Regensburg, Regensburg, Germany
| | - L Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
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8
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The Value of Morphometric Measurements in Risk Assessment for Donor-Site Complications after Microsurgical Breast Reconstruction. J Clin Med 2020; 9:jcm9082645. [PMID: 32823954 PMCID: PMC7465816 DOI: 10.3390/jcm9082645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/24/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
Microsurgical abdominally-based reconstruction is considered the gold standard in autologous breast reconstruction. Despite refined surgical procedures, donor-site complications still occur, reducing patient satisfaction and quality of life. Recent work has outlined the potential of morphometric measurements in risk assessment for postoperative hernia development. With rising demand for personalised treatment, the goal of this study was to investigate their potential in risk assessment for any donor site complication. In this retrospective cohort study, 90 patients were included who each received microsurgical breast reconstruction at the hands of one surgeon between January 2015 and May 2017. Donor-site complications formed the primary outcome and were classified according to Clavien-Dindo. Morphometric measurements were taken on a routinely performed computed tomographic angiogram. Complications occurred in 13 of the 90 (14.4%) cases studied. All patients who developed any type of postoperative donor site complication had a history of abdominal surgery. The risk of postoperative complications increased by 3% with every square centimetre of omental fat tissue (OR 1.03, 95% CI 1.00-1.06, and p-value = 0.022). Morphometric measurements provide valuable information in risk assessment for donor-site complications in abdominally-based breast reconstruction. They may help identify personalised reconstructive options for maximal postoperative patient satisfaction and quality of life.
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9
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Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2668. [PMID: 32537332 PMCID: PMC7253236 DOI: 10.1097/gox.0000000000002668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 11/26/2022]
Abstract
Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population.
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10
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Munder B, Andree C, Witzel C, Fertsch S, Stambera P, Schulz T, Fleischer O, Hagouan M, Grüter L, Aufmesser B, Staemmler K, Kornetka J, Aldeeri M, Seidenstücker K, Abu-Ghazaleh A, Wolter A. The DIEP Flap as Well-established Method of Choice for Autologous Breast Reconstruction with a Low Complication Rate - Retrospective Single-centre 10-Year Experience. Geburtshilfe Frauenheilkd 2020; 80:628-638. [PMID: 32565553 PMCID: PMC7299686 DOI: 10.1055/a-1116-2102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background
Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications.
Patients and Methods
Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months.
Results
A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates.
Conclusion
DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.
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Affiliation(s)
- Beatrix Munder
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Christoph Andree
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Christian Witzel
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Sonia Fertsch
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Peter Stambera
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Tino Schulz
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Olaf Fleischer
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Mazen Hagouan
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Lukas Grüter
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Birgit Aufmesser
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Katinka Staemmler
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Julia Kornetka
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Mohammed Aldeeri
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Katrin Seidenstücker
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Alina Abu-Ghazaleh
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Andreas Wolter
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany.,Universität Witten-Herdecke, Fakultät für Gesundheit, Witten, Germany
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11
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Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study. Plast Reconstr Surg 2020; 145:481e-490e. [DOI: 10.1097/prs.0000000000006543] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tevlin R, Wan DC, Momeni A. Should free deep inferior epigastric artery perforator flaps be considered a quality indicator in breast reconstruction? J Plast Reconstr Aesthet Surg 2019; 72:1923-1929. [PMID: 31570216 DOI: 10.1016/j.bjps.2019.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/15/2019] [Accepted: 08/18/2019] [Indexed: 12/27/2022]
Abstract
Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.
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Affiliation(s)
- Ruth Tevlin
- Division of Plastic and Reconstructive Surgery, Hagey Laboratory for Pediatric Regenerative Medicine, Stanford University School of Medicine, 770 Welch Road, Suite 400, Stanford, Palo Alto, CA 94304, United States
| | - Derrick C Wan
- Division of Plastic and Reconstructive Surgery, Hagey Laboratory for Pediatric Regenerative Medicine, Stanford University School of Medicine, 770 Welch Road, Suite 400, Stanford, Palo Alto, CA 94304, United States
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Hagey Laboratory for Pediatric Regenerative Medicine, Stanford University School of Medicine, 770 Welch Road, Suite 400, Stanford, Palo Alto, CA 94304, United States.
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Cai A, Suckau J, Arkudas A, Beier JP, Momeni A, Horch RE. Autologous Breast Reconstruction with Transverse Rectus Abdominis Musculocutaneous (TRAM) or Deep Inferior Epigastric Perforator (DIEP) Flaps: An Analysis of the 100 Most Cited Articles. Med Sci Monit 2019; 25:3520-3536. [PMID: 31079136 PMCID: PMC6528547 DOI: 10.12659/msm.914665] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Post-mastectomy autologous reconstruction with abdominal tissue has evolved over the past 4 decades and is a common reconstructive modality today. To gain more insight into this evolution, we performed an analysis of the 100 most commonly cited articles focusing on autologous breast reconstruction with transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. A review of the ISI Web of Knowledge database was performed. Only peer-reviewed articles in English were included for analysis. Articles were ranked by their total citations as well as citation density (citations divided by years since publication). The 100 most cited articles were analyzed by their bibliographic parameters. The 100 most cited articles were published in 12 journals. The highest ranked plastic surgery journal published almost 2/3 of the articles. All articles were published within 23 years and marked the “rising age” of autologous breast reconstruction with TRAM and DIEP flaps. The focus of clinical research changed over this time period and ranged from innovations in surgical technique to analysis of clinical outcomes, comparative analyses with other reconstructive modalities, timing of reconstruction, and preoperative diagnostic workup, as well as cost-effectiveness analyses. This literature review illustrates the dramatic change that has occurred subsequent to introduction of abdominal flaps for breast reconstruction. While the use of abdominal flaps has become widely accepted for breast reconstruction, many questions remain unanswered, thus highlighting the need for ongoing clinical investigation.
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Affiliation(s)
- Aijia Cai
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Jan Suckau
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Justus P Beier
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany.,Department of Plastic Hand and Burn Surgery, University Hospital, RWTH Aachen, Aachen, Germany
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
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Moshrefi S, Kanchwala S, Momeni A. Should planned/desired pregnancy be considered an absolute contraindication to breast reconstruction with free abdominal Flaps? A retrospective case series and systematic review. J Plast Reconstr Aesthet Surg 2018; 71:1295-1300. [PMID: 29970346 DOI: 10.1016/j.bjps.2018.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 05/21/2018] [Accepted: 05/28/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Autologous breast reconstruction is considered by many to be the gold standard reconstructive modality following mastectomy. Despite the advantages of autologous reconstruction, however, surgeons have been cautious in recommending this approach to patients who desire to become pregnant postoperatively because of concerns related to abdominal wall morbidity. While intuitive, this approach does not appear to be based on robust data. Hence, the authors examined the clinical outcome in patients who became pregnant following autologous breast reconstruction. METHODS Patients who underwent autologous breast reconstruction with free abdominal flaps that required an incision in the anterior rectus sheath were identified. Of them, patients who became pregnant post reconstruction were included for subsequent analysis. Of particular interest were any peripartal and postpartal complications that could be attributed to the preceding abdominal flap harvest. Additionally, a systematic review of the literature was performed. RESULTS We identified five patients who met inclusion criteria. All five patients underwent bilateral breast reconstruction with free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps. None of the patients had any preexisting abdominal wall morbidity. All five patients proceeded to full-term pregnancy and successfully delivered newborns, four of which were delivered by normal vaginal delivery and one by cesarean section. No abdominal wall complications were noted during pregnancy, delivery, or postpartum. CONCLUSION Contemporary data do not support the notion that breast reconstruction with free abdominal flaps is contraindicated in the setting of desired or planned pregnancy.
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Affiliation(s)
- Shawn Moshrefi
- Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA
| | - Suhail Kanchwala
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Perelman Center for Advanced Medicine, South Pavilion 14th floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104
| | - Arash Momeni
- Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA.
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Dec W. Optimizing aesthetic outcomes for breast reconstruction in patients with significant macromastia or ptosis. JPRAS Open 2018; 16:24-30. [PMID: 32158807 PMCID: PMC7061626 DOI: 10.1016/j.jpra.2018.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/31/2018] [Indexed: 12/01/2022] Open
Abstract
Background Achieving excellent aesthetic outcomes in reconstruction of large or ptotic breasts is especially challenging. Incorporating a Wise pattern into the mastectomy design is effective in reducing the excess breast skin, however it increases the risk of mastectomy skin necrosis. The aim of this study is to describe surgical maneuvers which optimize aesthetic outcomes, anticipate flap volume requirements, and limit mastectomy skin necrosis in autologous reconstruction in patients with macromastia and grade III ptosis. Methods This is a retrospective review of operative and clinical records of patients who underwent unilateral or bilateral breast reconstruction with autologous tissue between August 2015 and May 2017. Patients were divided into macromastia and ptosis groups. Key surgical maneuvers for safely achieving aesthetically optimal results were identified. Results A total of 29 breasts were successfully reconstructed in 19 patients with a Wise pattern mastectomy skin reduction. Free flap weights were similar in both groups, mastectomy weights were greater in the macromastia group, p < 0.05. Complications were limited to three cases of wound breakdown and one case of mastectomy skin necrosis. Total number of revision stages was reduced in unilateral reconstructions when a contralateral breast reduction or mastopexy was performed during the first stage. Conclusions A Wise pattern can safely and effectively be incorporated into a mastectomy incision design in patients who are not candidates for a nipple sparing mastectomy. Optimal aesthetics are achieved with similar volume flaps for both macromastia and ptosis patients. In cases of unilateral breast reconstruction a contralateral breast reduction or mastopexy should be performed at the time of the immediate breast reconstruction.
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Affiliation(s)
- Wojciech Dec
- Department of Plastic Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY, USA
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Seo BF, Lee J, Oh DY. The Efficacy of Midline Barbed Absorbable Sutures in Progressive Tension Closure of Abdominal Flap Donor Sites. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2018. [DOI: 10.14730/aaps.2018.24.1.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bommie Florence Seo
- Department of Plastic and Reconstructive Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Junho Lee
- Department of Plastic and Reconstructive Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Chattha A, Bucknor A, Kamali P, Van Veldhuisen CL, Flecha-Hirsch R, Sharma R, Tobias AM, Lee BT, Lin SJ. Comparison of risk factors and complications in patients by stratified mastectomy weight: An institutional review of 1041 consecutive cases. J Surg Oncol 2017; 116:811-818. [DOI: 10.1002/jso.24753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 06/12/2017] [Indexed: 01/18/2023]
Affiliation(s)
- Anmol Chattha
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Alexandra Bucknor
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Parisa Kamali
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Charlotte L. Van Veldhuisen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Renata Flecha-Hirsch
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Ranjna Sharma
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Adam M. Tobias
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Bernard T. Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Samuel J. Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
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Thorarinsson A, Fröjd V, Kölby L, Lidén M, Elander A, Mark H. Patient determinants as independent risk factors for postoperative complications of breast reconstruction. Gland Surg 2017; 6:355-367. [PMID: 28861376 DOI: 10.21037/gs.2017.04.04] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling. METHODS We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications. RESULTS Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially. CONCLUSIONS Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.
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Affiliation(s)
- Andri Thorarinsson
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Victoria Fröjd
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lidén
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Mark
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Cook JA, Tholpady SS, Momeni A, Chu MW. Predictors of internal mammary vessel diameter: A computed tomographic angiography-assisted anatomic analysis. J Plast Reconstr Aesthet Surg 2016; 69:1340-8. [DOI: 10.1016/j.bjps.2016.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/20/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
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Shin JY, Roh SG, Lee NH, Yang KM. Is obesity a predisposing factor for free flap failure and complications? Comparison between breast and nonbreast reconstruction: Systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4072. [PMID: 27368049 PMCID: PMC4937963 DOI: 10.1097/md.0000000000004072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Obesity is a risk factor for postoperative morbidity in breast reconstruction. Although existing studies about nonbreast reconstruction are limited, previous research has demonstrated that obesity is not an important factor in poor outcomes in nonbreast reconstruction. Our study evaluates the effects of obesity on postoperative morbidity in nonbreast reconstruction in comparison to breast reconstruction. A systematic literature review and meta-analysis was performed using Medline, EMBASE, and Cochrane databases. Obesity was extracted for predictor variables and partial, total loss of flap, and complication were extracted for outcome variables. Subgroup analyses were performed according to reconstruction site. The Newcastle-Ottawa scale (NOS) was used to assess the quality of the studies, and the Cochrane risk of bias tool was used. Publication bias was evaluated using funnel plots. The search strategy identified 944 publications. After screening, 19 articles were selected for review. Partial flap loss, total flap loss, and complications in breast reconstruction occurred significantly more often in obese patients in comparison to nonobese patients (OR = 2.479, P = 0.021 for partial loss, OR = 3.083, P = 0.002 for total loss, OR = 2.666, P = 0.001 for complications). In contrast, partial flap loss, total flap loss, and complications in nonbreast reconstruction were not significantly different in obese patients in comparison to nonobese patients (OR = 0.786, P = 0.629 for partial loss, OR = 0.960, P = 0.961 for total loss, and OR = 1.009, P = 0.536 for complications). In contrast to the relationship between obesity and poor outcomes in breast reconstruction, our study suggests the obesity is not a predisposing factor for poor outcomes in nonbreast reconstruction. Long-term studies are needed to confirm these findings.
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Affiliation(s)
| | - Si-Gyun Roh
- Department of Plastic and Reconstructive Surgery, Medical School of Chonbuk National University, Jeonju-si, Chonbuk, Republic of Korea
- Correspondence: Si-Gyun Roh, Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-Gu, Jeonju-si, Chonbuk 561-712, Republic of Korea, (e-mail: )
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23
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Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap. Ann Plast Surg 2016; 76:576-84. [DOI: 10.1097/sap.0000000000000400] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alipour S, Omranipour R, Akrami R. Obesity Should Not Prevent from TRAM Flap Breast Reconstruction in Developing Countries. Indian J Surg 2016; 77:341-4. [PMID: 26730022 DOI: 10.1007/s12262-013-0833-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 01/15/2013] [Indexed: 10/27/2022] Open
Abstract
Transverse rectus abdominis musculocutaneous (TRAM) flap is the most common procedure performed for breast reconstruction after mastectomy for breast cancer. Obesity is a relative contraindication, and complex modifications have been proposed in the pedicled technique for obese patients. We studied ischemic complications in our patients to investigate the effect of body weight on the outcome of TRAM flap breast reconstruction. Pertinent data from medical records of patients receiving a TRAM flap surgery from 1986 to 2011 were extracted. Patients were divided into three groups based on the body mass index (BMI): normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (>30 kg/m(2)). Flap necrosis is defined as any visible nonviable tissue in the reconstructed breast. It was observed that 117 patients had received TRAM flap reconstruction. Fifty-eight patients were excluded. Of the remaining 59 cases, 24 had normal BMI, 21 were overweight, and 14 were obese. No patient was found to develop flap necrosis. Outcome of TRAM flap breast reconstruction in obese patients is similar to nonobese patients. No major necrosis in need of reoperation was identified in the studied obese patients. It was concluded that categorizing obesity as a relative contraindication to TRAM flap breast reconstruction should be revisited based on larger cohort studies.
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Affiliation(s)
- Sadaf Alipour
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran ; Department of Surgery, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Ramesh Omranipour
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran ; Department of Surgery, Cancer Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Rahim Akrami
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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Sinha S, Ruskin O, D'Angelo A, McCombe D, Morrison WA, Webb A. Are overweight and obese patients who receive autologous free-flap breast reconstruction satisfied with their postoperative outcome? A single-centre study. J Plast Reconstr Aesthet Surg 2016; 69:30-6. [DOI: 10.1016/j.bjps.2015.08.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/15/2015] [Accepted: 08/28/2015] [Indexed: 12/21/2022]
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Ludolph I, Horch RE, Harlander M, Arkudas A, Bach AD, Kneser U, Schmitz M, Taeger CD, Beier JP. Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J 2015; 21:588-95. [DOI: 10.1111/tbj.12493] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Ingo Ludolph
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Marina Harlander
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Alexander D. Bach
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Ulrich Kneser
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Marweh Schmitz
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Christian D. Taeger
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
| | - Justus P. Beier
- Department of Plastic and Hand Surgery - University Hospital of Erlangen; Friedrich-Alexander-University of Erlangen-Nürnberg (FAU); Erlangen Germany
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Kantak NA, Koolen PG, Martin C, Tobias AM, Lee BT, Lin SJ. Are patients with low body mass index candidates for deep inferior epigastric perforator flaps for unilateral breast reconstruction? Microsurgery 2015; 35:421-7. [DOI: 10.1002/micr.22407] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/12/2015] [Accepted: 03/10/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | - Pieter G.L. Koolen
- Division of Plastic Surgery; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
| | - Colette Martin
- Division of Plastic Surgery; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
| | - Adam M. Tobias
- Division of Plastic Surgery; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
| | - Bernard T. Lee
- Division of Plastic Surgery; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
| | - Samuel J. Lin
- Division of Plastic Surgery; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
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29
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Schaverien MV, Mcculley SJ. Effect of obesity on outcomes of free autologous breast reconstruction: A meta-analysis. Microsurgery 2014; 34:484-97. [DOI: 10.1002/micr.22244] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 02/22/2014] [Accepted: 02/28/2014] [Indexed: 12/18/2022]
Affiliation(s)
- Mark V. Schaverien
- Department of Plastic Surgery; Nottingham City Hospital; Nottingham NG5 1PB UK
| | - Stephen J. Mcculley
- Department of Plastic Surgery; Nottingham City Hospital; Nottingham NG5 1PB UK
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30
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Fischer JP, Wes AM, Kanchwala S, Kovach SJ. Effect of BMI on modality-specific outcomes in immediate breast reconstruction (IBR)—a propensity-matched analysis using the 2005-2011 ACS-NSQIP datasets. J Plast Surg Hand Surg 2014; 48:297-304. [DOI: 10.3109/2000656x.2013.877915] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Fingeret MC, Nipomnick SW, Crosby MA, Reece GP. Developing a theoretical framework to illustrate associations among patient satisfaction, body image and quality of life for women undergoing breast reconstruction. Cancer Treat Rev 2013; 39:673-81. [PMID: 23380309 DOI: 10.1016/j.ctrv.2012.12.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 12/21/2012] [Accepted: 12/24/2012] [Indexed: 01/15/2023]
Abstract
Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient.
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