1
|
Wu SS, Raymer C, Culbert A, Schafer R, Bernard S, Djohan R, Schwarz G, Bishop SN, Gurunian R. Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management. Plast Reconstr Surg 2023; 152:566e-577e. [PMID: 36862950 DOI: 10.1097/prs.0000000000010343] [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: 03/04/2023]
Abstract
BACKGROUND Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. METHODS This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. RESULTS In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time. CONCLUSIONS Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
Affiliation(s)
- Shannon S Wu
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Charles Raymer
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - August Culbert
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Rachel Schafer
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Steven Bernard
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Graham Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Sarah N Bishop
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Raffi Gurunian
- Department of Plastic Surgery, Cleveland Clinic, Abu Dhabi
| |
Collapse
|
2
|
Park JKH, Lee S, Heo CY, Jeong JH, Myung Y. The effect of immediate postoperative intravenous administration of ferric carboxymaltose after autologous free-flap breast reconstruction. Sci Rep 2022; 12:19125. [PMID: 36352090 PMCID: PMC9645745 DOI: 10.1038/s41598-022-23976-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 11/08/2022] [Indexed: 11/10/2022] Open
Abstract
Intravenous ferric carboxymaltose (IV-FCM) can effectively correct perioperative anemia in patients undergoing major surgeries. However, its efficacy and side effects in patients undergoing free flap-based breast reconstruction are yet to be investigated. At our institution, from year 2020, patients with breast cancer undergoing abdominal free flap-based breast reconstruction were injected 500 mg of IV-FCM immediately post-operation. Propensity-matched 82 IV-FCM injected (study group) and 164 historical control group patients were retrospectively analyzed for transfusion rates, changes in hematological parameters, and flap or donor-site related complications. The major and minor complication rates related to the operation site were similar between the two groups. There was no significant difference in the transfusion rate between the two groups (control 29.9% vs. study 32.9%, p = 0.71). However, the total amount of transfusion required was significantly higher in the historical control group (control-53.2% 1 pack, 42.6% 2 packs, 4.3% 3 packs of RBC vs. Study-66.7% 1 pack, 33.3% 2 packs, p = 0.02) than in the study group. Additionally, the historical control group showed a significantly higher drop in red blood cell count, hemoglobin, and hematocrit levels from postoperative days 1-2 and 2-3 compared to the study group. Immediate postoperative use of IV-FCM in free flap-based breast reconstruction was well tolerated by patients and reduced overall transfusion volume.
Collapse
Affiliation(s)
- Joseph Kyu-hyung Park
- grid.412480.b0000 0004 0647 3378Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, 463-707 Gyeonggi-Do Korea
| | - Seungjun Lee
- grid.412480.b0000 0004 0647 3378Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, 463-707 Gyeonggi-Do Korea
| | - Chan Yeong Heo
- grid.412480.b0000 0004 0647 3378Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, 463-707 Gyeonggi-Do Korea
| | - Jae Hoon Jeong
- grid.412480.b0000 0004 0647 3378Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, 463-707 Gyeonggi-Do Korea
| | - Yujin Myung
- grid.412480.b0000 0004 0647 3378Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, 463-707 Gyeonggi-Do Korea
| |
Collapse
|
3
|
Big data analysis of the risk factors and rates of perioperative transfusion in immediate autologous breast reconstruction. Sci Rep 2022; 12:5314. [PMID: 35351949 PMCID: PMC8964768 DOI: 10.1038/s41598-022-09224-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/24/2022] [Indexed: 11/08/2022] Open
Abstract
Patients undergoing autologous breast reconstruction (ABR) are more likely to require perioperative transfusions due to the increased intraoperative bleeding. In addition to the mastectomy site, further incisions and muscle dissection are performed at the donor sites, including the back or abdomen, increasing the possibility of transfusion. The purpose of this study was to evaluate perioperative transfusion rates and risk factors according to the type of ABR through analysis of big data. Patients who underwent total mastectomy for breast cancer between 2014 and 2019 were identified. The patients were divided into mastectomy only and immediate ABR groups. The transfusion rate was 14-fold higher in the immediate ABR group (16.1%) compared to the mastectomy only group (1.2%). The transfusion rate was highest with the pedicled transverse rectus abdominis myocutaneous flap (24.2%). Performance of the operation in medical institutions located in the provinces and coronary artery disease (CAD) were significant risk factors for the need for transfusion. The perioperative transfusion risk among patients undergoing immediate ABR was related to the flap type, location of medical institution, and CAD. Based on the higher transfusion rate in this study (16.1%) compared to previous studies, the risk factors for the need for transfusion should be determined and evidence-based guidelines should be developed to reduce the transfusion rates.
Collapse
|
4
|
Chen K, Beeraka NM, Sinelnikov MY, Zhang J, Song D, Gu Y, Li J, Reshetov IV, Startseva OI, Liu J, Fan R, Lu P. Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations. Front Surg 2022; 9:729181. [PMID: 35242802 PMCID: PMC8887567 DOI: 10.3389/fsurg.2022.729181] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/19/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Objective Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery. Evidence We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: “DIEP flap”, “Breast reconstruction”, “Patient management”, “Postoperative DIEP”, “Intraoperative anticoagulant therapy”, “Clinical recommendations”. A total of 106 research papers were retrieved pertaining to this systematic review. Conclusion A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.
Collapse
Affiliation(s)
- Kuo Chen
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Narasimha M. Beeraka
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Jin Zhang
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
| | - Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yuanting Gu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingruo Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - I. V. Reshetov
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
- L.L. Levshin Institute of Cluster Oncology, Moscow, Russia
- Academy of Postgraduate Education, The Federal State Budgetary Unit FSCC, Federal Medical Biological Agency, Moscow, Russia
| | - O. I. Startseva
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
| | - Junqi Liu
- Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Ruitai Fan
| | - Pengwei Lu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Pengwei Lu
| |
Collapse
|
5
|
A single-center experience with head-to-toe microsurgical reconstruction in bloodless medicine patients. J Plast Reconstr Aesthet Surg 2021; 75:823-830. [PMID: 34776392 DOI: 10.1016/j.bjps.2021.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 04/21/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.
Collapse
|
6
|
Sanchez-Porro Gil L, Leon Vintro X, Lopez Fernandez S, Vega Garcia C, Pons Playa G, Fernandez Garrido M, Masia Ayala J. The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses. J Clin Med 2021; 10:jcm10061333. [PMID: 33807085 PMCID: PMC8004983 DOI: 10.3390/jcm10061333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing complications in vascular anastomoses and the history of transfusions. Methods: We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses. Results: 130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients. Conclusions: Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.
Collapse
Affiliation(s)
- Lidia Sanchez-Porro Gil
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
- Correspondence: or
| | - Xavier Leon Vintro
- Department of Otolaryngology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain;
| | - Susana Lopez Fernandez
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Carmen Vega Garcia
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Gemma Pons Playa
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Manuel Fernandez Garrido
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Jaume Masia Ayala
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| |
Collapse
|
7
|
Starnoni M, Pinelli M, Porzani S, Baccarani A, De Santis G. Standardization and Selection of High-risk Patients for Surgical Wound Infections in Plastic Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3472. [PMID: 33907656 PMCID: PMC8062150 DOI: 10.1097/gox.0000000000003472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of the present study was to show that the Infection Risk Index (IRI), based on only 3 factors (wound classification, American Society of Anesthesiologists score, and duration of surgery), can be used to standardize selection of infection high-risk patients undergoing different surgical procedures in Plastic Surgery. METHODS In our Division of Plastic Surgery at Modena University Hospital, we studied 3 groups of patients: Group A (122 post-bariatric abdominoplasties), Group B (223 bilateral reduction mammoplasties), and Group C (201 tissue losses with first intention healing). For each group, we compared surgical site infection (SSI) rate and ratio between patients with 0 or 1 risk factors (IRI score 0 or 1) and patients with 2 or 3 risk factors (IRI score 2 or 3). RESULTS In group A, patients with IRI score 0-1 showed an SSI Ratio of 2.97%, whereas patients with IRI score 2-3 developed an SSI ratio of 27.27%. In group B, patients with IRI score 0-1 showed an SSI ratio of 2.99%, whereas patients with IRI score 2-3 developed an SSI ratio of 18.18%. In group C, patients with IRI score 0-1 showed an SSI ratio of 7.62%, whereas patients with IRI score 2-3 developed an SSI ratio of 30.77%. CONCLUSIONS Existing infection risk calculators are procedure-specific and time-consuming. IRI score is simple, fast, and unspecific but is able to identify patients at high or low risk of postoperative infections. Our results suggest the utility of IRI score in refining the infection risk stratification profile in Plastic Surgery.
Collapse
Affiliation(s)
- Marta Starnoni
- From the Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Division of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| | - Massimo Pinelli
- Division of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| | - Silvia Porzani
- Division of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| | - Alessio Baccarani
- Division of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| | - Giorgio De Santis
- Division of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| |
Collapse
|
8
|
Evidence-Based Performance Measures for Autologous Breast Reconstruction: An American Society of Plastic Surgeons Quality Performance Measure Set. Plast Reconstr Surg 2020; 145:284e-294e. [DOI: 10.1097/prs.0000000000006478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
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).
Collapse
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.
| |
Collapse
|
10
|
Masoomi H, Blumenauer BJ, Blakkolb CL, Marques ES, Greives MR. Predictors of blood transfusion in autologous breast reconstruction surgery: A retrospective study using the nationwide inpatient sample database. J Plast Reconstr Aesthet Surg 2019; 72:1616-1622. [DOI: 10.1016/j.bjps.2019.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/29/2019] [Accepted: 06/09/2019] [Indexed: 01/05/2023]
|
11
|
Total breast reconstruction with fat graft after serial expander deflation: a case series. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-01526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
12
|
Parikh RP, Myckatyn TM. Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res 2018; 11:1567-1581. [PMID: 30197532 PMCID: PMC6112815 DOI: 10.2147/jpr.s148544] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.
Collapse
Affiliation(s)
- Rajiv P Parikh
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA,
| | - Terence M Myckatyn
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA,
| |
Collapse
|
13
|
Ali SR, Chetwynd-Stapylton R, Holmes WJM, Vermaak L, Wilson SM. Time to re-group and save: Do we routinely need to perform group-and-save in patients undergoing free deep inferior epigastric perforator (DIEP) flap breast reconstruction? J Plast Reconstr Aesthet Surg 2018; 71:780-781. [PMID: 29402667 DOI: 10.1016/j.bjps.2018.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/21/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Stephen R Ali
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK.
| | | | - Will J M Holmes
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK
| | - Liam Vermaak
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK
| | - Sherif M Wilson
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK
| |
Collapse
|
14
|
DIEP flap for breast reconstruction: Is abdominal fat thickness associated with post-operative complications? J Plast Reconstr Aesthet Surg 2017; 70:1068-1075. [DOI: 10.1016/j.bjps.2017.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/04/2017] [Accepted: 05/09/2017] [Indexed: 11/22/2022]
|
15
|
Thorarinsson A, Fröjd V, Kölby L, Modin A, Lewin R, Elander A, Mark H. Blood loss and duration of surgery are independent risk factors for complications after breast reconstruction. J Plast Surg Hand Surg 2017; 51:352-357. [PMID: 28122466 DOI: 10.1080/2000656x.2016.1272462] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Complications after breast reconstructive surgery are common, and they can be caused by a wide range of factors. The aim of the present study was to identify independent perioperative risk factors for postoperative complications after breast reconstruction. METHODS A retrospective study was performed of 623 consecutive breast cancer patients who had undergone deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) flap, lateral thoracodorsal flap (LTDF), or tissue expander with secondary implant (EXP). Data on demography, perioperative parameters, and complications were collected. Logistic regression models adjusted to the reconstruction method and to confounding demographic factors were used for statistical analysis. RESULTS Increased blood loss for each 10-ml step increased the risk for overall early complications (p = 0.017), early seroma (p = 0.037), early resurgery (p = 0.010), late local overall complications (p = 0.024), and late fat necrosis (p = 0.031). Longer duration of surgery for each 10-minute step increased the risk of overall early complications (p = 0.019), but, in the univariate model, there was an increased risk for nine different types of complications (p = 0.004-0.029). There was no association between the experience of the surgeon performing the procedure and the frequency of complications. CONCLUSIONS Duration of surgery and blood loss during surgery are independent risk factors for postoperative complications, and should be minimised. Further research is needed to establish the association between the experience of the surgeon and the occurrence of complications.
Collapse
Affiliation(s)
- Andri Thorarinsson
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| | - Victoria Fröjd
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| | - Lars Kölby
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| | - Albert Modin
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| | - Richard Lewin
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| | - Anna Elander
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| | - Hans Mark
- a Sahlgrenska Academy, Department of Plastic Surgery , Institute for Clinical Sciences , Gothenburg , Sweden
| |
Collapse
|
16
|
Fitzgerald O'Connor E, Rozen WM, Chowdhry M, Patel NG, Chow WTH, Griffiths M, Ramakrishnan VV. The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes. Gland Surg 2016; 5:88-92. [PMID: 27047776 DOI: 10.3978/j.issn.2227-684x.2015.05.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature. METHODS A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014. RESULTS Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001). CONCLUSIONS The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.
Collapse
Affiliation(s)
- Edmund Fitzgerald O'Connor
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Warren Matthew Rozen
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Muhammad Chowdhry
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Nakul Gamanlal Patel
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Whitney T H Chow
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Matthew Griffiths
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Venkat V Ramakrishnan
- 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| |
Collapse
|
17
|
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
| |
Collapse
|
18
|
Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction. Aesthetic Plast Surg 2014; 38:681-91. [PMID: 24902911 DOI: 10.1007/s00266-014-0333-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 04/18/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps have been increasingly adopted for breast reconstruction. However, their safety, patient satisfaction with them, and factors contributing to complications are not well understood. METHODS PubMed, MEDLINE, EMBASE, and The Cochrane Library were searched to identify eligible studies for inclusion in our analysis. The complication rates of and patient satisfaction rates with the flaps were measured as the outcome, and factors contributing to complications and patient satisfaction were also studied. The data were extracted, and pooled relative risks (RRs) and 95 % confidence intervals (CIs) were calculated. RESULTS Thirteen studies involving 1,843 patients met the inclusion criteria. The results of the meta-analysis showed that patients with MS-TRAM had a higher rate of abdominal hernias (RR 2.354, 95 % CI 1.154-4.802, P = 0.019) and a lower rate of fat necrosis (RR 0.502, 95 % CI 0.347-0.727, P = 0.000) than patients with DIEP. In addition, there was no significant difference between MS-TRAM and DIEP with respect to other complications (P > 0.05), between MS-TRAM and DIEP with respect to patient satisfaction (P = 0.923), and between DIEP and SIEA with respect to complication rates (P = 0.377). The complication rates of MS-TRAM, DIEP, and SIEA were 25.6, 27.9, and 26.7 %, respectively. Diabetes mellitus (P = 0.078) influenced the complication rate of MS-TRAM, and obesity (P = 0.086) and diabetes mellitus (P = 0.110) were the potential factors correlated with complications with DIEP flaps. CONCLUSION There were no obvious differences in the overall incidence of complications between MS-TRAM and DIEP and between DIEP and SIEA. In addition, the patient satisfaction rates of MS-TRAM and DIEP were similar. However, MS-TRAM showed a higher rate of abdominal hernias and a lower rate of fat necrosis than DIEP. Obesity and diabetes mellitus were potential factors associated with the incidence of complications. Additional multicenter, large-sample-size, randomized controlled trials with long-term follow-up visits are necessary. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
|
19
|
Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction. Microsurgery 2014; 34:434-8. [DOI: 10.1002/micr.22240] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/06/2014] [Accepted: 02/14/2014] [Indexed: 11/07/2022]
|
20
|
Agha RA, Goodacre T, Orgill DP. Use of autologous fat grafting for reconstruction postmastectomy and breast conserving surgery: a systematic review protocol. BMJ Open 2013; 3:e003709. [PMID: 24154518 PMCID: PMC3808755 DOI: 10.1136/bmjopen-2013-003709] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/06/2013] [Accepted: 09/13/2013] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION There is growing interest in the potential use of autologous fat grafting (AFG) for the purposes of breast reconstruction. However, concerns have been raised regarding the technique's clinical effectiveness, safety and interference with screening mammography. The objective of this systematic review was to determine the oncological, clinical, aesthetic and functional, patient reported, process and radiological outcomes for AFG. METHODS AND ANALYSIS All original studies, including randomised controlled trials, cohorts studies, case-control studies, case series and case reports involving women undergoing breast reconstruction. All AFG techniques performed for the purposes of reconstruction in the postmastectomy or breast conserving surgery setting will be considered. Outcomes are defined within this protocol along; oncological, clinical, aesthetic and functional, patient reported, process and radiological domains. The search strategy has been devised to find papers about 'fat grafting and breast reconstruction' and is outlined within the body of this protocol. The full search strategy is outlined within the body of the protocol. The following electronic databases will be searched from 1 January 1986 to 6 June 2013: PubMed, MEDLINE, EMBASE, SCOPUS, CINAHL, PsycINFO, SciELO, The Cochrane Library, including the Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effect (DARE), the Cochrane Methodology Register, Health Technology Assessment Database, the NHS Economic Evaluation Databases and Cochrane Groups, ClinicalTrials.gov, Current Controlled Trials Database, the World Health Organisation (WHO) International Clinical Trials Registry Platform, UpToDate.com, NHS Evidence and the York Centre for Reviews and Dissemination. Grey literature searches will also be conducted as detailed in our review protocol. Eligibility assessment occurred in two stages, title and abstract screening and then full text assessment. Data were extracted and stored in a database with standardised extraction fields to facilitate easy and consistent data entry. ETHICS AND DISSEMINATION This systematic review will be published in a peer-reviewed journal. It will also be presented at national and international conferences in the fields of plastic, reconstructive and aesthetic surgery and at more general surgical and methodological conferences. It will be disseminated electronically and in print. Brief reports of the review findings will be disseminated directly to the appropriate audiences of surgeons and societies through email and other modes of communication. Updates of the review will be conducted to inform and guide healthcare practice and policy. PROTOCOL REGISTRATION PROSPERO-National Institute of Health Research (NIHR) Prospective Register of Systematic Reviews (CRD42013005254).
Collapse
Affiliation(s)
- Riaz A Agha
- Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, Bucks, UK
| | - Tim Goodacre
- Department of Plastic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Dennis P Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|