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Cauley RP, Rahmani B, Adebagbo OD, Park J, Garvey SR, Chen A, Nickman S, Tobin M, Valentine L, Weidman AA, Singhal D, Dowlatshahi A, Lin SJ, Lee BT. Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review. J Reconstr Microsurg 2024. [PMID: 38782025 DOI: 10.1055/a-2331-7885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount. METHODS Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized. RESULTS (1) medical optimization and prehabilitation, (2) surgical mitigation techniques. CONCLUSION Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.
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Affiliation(s)
- Ryan P Cauley
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Rahmani
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun D Adebagbo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - John Park
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R Garvey
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sasha Nickman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Micaela Tobin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren Valentine
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allan A Weidman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan Dowlatshahi
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Fisher MH, Ohmes LB, Yang JH, Le E, Colakoglu S, French M, Siddikoglu D, Um G, Winocour J, Higdon K, Perdikis G, Inchauste S, Cohen J, Chong T, Kaoutzanis C, Mathes DW. Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study. J Plast Reconstr Aesthet Surg 2024; 90:88-94. [PMID: 38364673 DOI: 10.1016/j.bjps.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/13/2023] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.
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Affiliation(s)
- Marlie H Fisher
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lucas B Ohmes
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jerry H Yang
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elliot Le
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Mackenzie French
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Duygu Siddikoglu
- Department of Biostatistics, Canakkale OnSekiz Mart Faculty of Medicine, Canakkale, Turkey
| | - Grace Um
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Julian Winocour
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kent Higdon
- Department of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Galen Perdikis
- Department of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Suzanne Inchauste
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Justin Cohen
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tae Chong
- Department of Plastic and Reconstructive Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Christodoulos Kaoutzanis
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - David W Mathes
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
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Shen G, Yang Y, Huang M, Ding X, Li N, Yu X. Immediate breast reconstruction with laparoscopically harvested omental flap: A retrospective analysis with a maximum 12-year follow-up. Surg Today 2024; 54:186-194. [PMID: 37516998 DOI: 10.1007/s00595-023-02718-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/29/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To evaluate the clinical efficacy of immediate breast reconstruction with free or pedicled laparoscopically harvested omental flaps (LHOFs). METHODS Between March 2011 and 2021, 82 patients who underwent immediate breast reconstruction with free or pediculated omental flaps were enrolled. Breast total or partial mastectomy, laparoscopic greater omentum harvest, and breast reconstruction were carried out in an orderly manner. Postoperative operative results, cosmetic outcomes, and complications were investigated. RESULTS Seventeen cases of free LHOF and 65 cases of pedicled LHOF were performed. Cosmetic results were mostly satisfactory (61% excellent, 35% good), with a soft breast that was natural in appearance. Satisfaction investigation showed that 96.2% of patients were satisfied with the reconstructed breast. Uneventful follow-up showed no abdominal complications at the donor site, and the surface skin displayed no swelling. No major complications were found, except for three cases of necrosis. One patient developed slight hematoma. Two patients were found to have local recurrence, and one had distant metastasis. Twenty-four patients accepted radiotherapy, but no size reduction was noted after radiotherapy. We followed the patients to determine their survival status. All patients were alive, except for 1 in the free LHOF group who died 31.2 months after surgery. CONCLUSION Immediate breast reconstruction with LHOF provides a soft reconstructed breast with relatively little donor-site deformity and is useful for breast tumor-specific immediate reconstruction.
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Affiliation(s)
- Guangtai Shen
- Department of Thyroid and Breast Surgery, Xinganmeng People's Hospital, Inner Mongolia Autonomous Region, Ulanhot, 137400, People's Republic of China
| | - Yuqing Yang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Meiling Huang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Xiaoli Ding
- Department of Thyroid and Breast Surgery, Xinganmeng People's Hospital, Inner Mongolia Autonomous Region, Ulanhot, 137400, People's Republic of China
| | - Nanlin Li
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi'an, Shaanxi, 710032, People's Republic of China.
| | - Xiaoqiang Yu
- Department of Thyroid and Breast Surgery, Xinganmeng People's Hospital, Inner Mongolia Autonomous Region, Ulanhot, 137400, People's Republic of China.
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Escobar-Domingo MJ, Bustos VP, Kim EJ, Campbell T, Fanning JE, Foppiani JA, Merle C, Lin SJ, Lee BT. The impact of metabolic syndrome in breast reconstruction decision-making and postoperative outcomes: A nationwide analysis. J Plast Reconstr Aesthet Surg 2024; 89:21-29. [PMID: 38128370 DOI: 10.1016/j.bjps.2023.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities including hypertension, obesity, insulin resistance, and dyslipidemia. The safety profiles of patients with MetS undergoing breast reconstruction remain underreported. This study aims to evaluate the impact of MetS on the BR decision-making process and postoperative complication rates. METHODS The ACS-NSQIP database was utilized to identify women who underwent BR between 2012 and 2021. Baseline characteristics were compared based on the presence of MetS, defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Group differences were assessed using t tests and Fisher's exact tests. Multivariate logistic regression models evaluated postoperative complications between the groups. RESULTS A total of 160,115 patients underwent BR. A total of 4570 had a diagnosis of MetS compared to 155,545 without MetS. No statistically significant differences were observed in the type of BR patients received across cohorts. Logistic regression models demonstrated a higher likelihood of postoperative wound complications (OR 2.21; 95% CI 1.399, 3.478; p = 0.001), and readmission rates (OR 2.045; 95% CI 1.337, 3.128; p = 0.001) in the MetS group compared to the non-MetS patients. No significant differences were identified in other postoperative complications between groups. CONCLUSIONS Patients with MetS appear to have an increased risk of postoperative wound complications and readmission after breast reconstruction. The synergistic effects of these comorbidities on postoperative outcomes underscore the importance of addressing MetS as a holistic condition and considering choosing Delayed breast reconstruction over Immediate Breast Reconstruction in this population. Thus, integrating MetS management and patient counseling at various stages of BR may improve outcomes and facilitate patient decision-making.
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Affiliation(s)
- Maria J Escobar-Domingo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami, Miami, FL, USA
| | - Erin J Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tessa Campbell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - James E Fanning
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jose A Foppiani
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chamilka Merle
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Gallo L, Gallo M, Chin B, Copeland A, Avram R, McRae M, McRae M, Thoma A, Coroneos CJ, Voineskos SH. Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2023; 31:390-400. [PMID: 37915346 PMCID: PMC10617458 DOI: 10.1177/22925503211073840] [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: 10/08/2021] [Revised: 11/08/2021] [Accepted: 11/18/2021] [Indexed: 11/03/2023] Open
Abstract
Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.
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Affiliation(s)
- Lucas Gallo
- McMaster University, Hamilton, Ontario, Canada
| | | | - Brian Chin
- McMaster University, Hamilton, Ontario, Canada
| | | | - Ronen Avram
- McMaster University, Hamilton, Ontario, Canada
| | - Mark McRae
- McMaster University, Hamilton, Ontario, Canada
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Haddock NT, Martinez VM, Teotia SS. Surgical Outcomes of Autologous Breast Reconstruction in Low Body Mass Index Patients: Beyond the Standard DIEP Flap. Plast Reconstr Surg 2023; 152:3S-15S. [PMID: 37171382 PMCID: PMC10521770 DOI: 10.1097/prs.0000000000010490] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/02/2022] [Indexed: 05/13/2023]
Abstract
BACKGROUND Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low body mass index (BMI). However, the accepted standard of microvascular breast reconstruction, the deep inferior epigastric perforator (DIEP) flap, can be challenging to achieve due to the paucity of adnominal bulk in these patients. This study compared operative outcomes in women with BMI less than 23.5 following reconstruction after one of three free flap methods: the DIEP flap, alternative flaps (ie, lumbar artery perforator flap or profounda artery perforator flap), and stacked flaps. METHODS A retrospective study was conducted on thin patients (BMI <23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (N.T.H. and S.S.T.) at a single institution. One hundred fifteen patients were divided into three reconstructive groups. Flap weights, complication rates, secondary revisions, and fat grafting in each group were then compared. RESULTS The success rate in all three groups was 100%, with only one partial flap loss in the stacked group. There was a significant difference in overall minor complications and donor complications among the three groups, with alternative flaps experiencing the most. All three groups had similar incidences of recipient breast complications, medical complications, need for secondary revisions, and amount of fat grafted. CONCLUSIONS Autologous breast reconstruction in low BMI patients yields successful and durable results. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the standard DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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7
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Safeek R, Bryan J, Heath F, Satteson E, Maurer A, Safa B, Sorice-Virk S. Evidence based recommendations for perioperative vasopressor use and fluid resuscitation in microsurgery. Microsurgery 2023. [PMID: 37052570 DOI: 10.1002/micr.31047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023]
Abstract
Blood pressure regulation is critical in patients undergoing microsurgical free tissue transfer; however, guidelines for addressing and preventing perioperative hypotension remain highly debated, with two current thought paradigms: (1) intravenous fluid administration with a balanced salt solution (e.g., lactate ringer and normal saline) and/or colloid (e.g., albumin) and (2) vasoactive pharmacological support with vasopressors (e.g., dobutamine, norepinephrine, epinephrine), with fluid administration being the preferred conventional approach. Here, we review the most up to date available literature and summarize currents perspectives and practices for fluid resuscitation and vasopressor use, while offering evidence-based guidelines to each.
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Affiliation(s)
- Rachel Safeek
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Jaimie Bryan
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Frederick Heath
- Stanford University School of Medicine, Stanford, California, USA
| | - Ellen Satteson
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Adrian Maurer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Bauback Safa
- The Buncke Clinic, San Francisco, California, USA
| | - Sarah Sorice-Virk
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
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Mori S, Wakabayashi T, Mishima K, Ozaki T, Fujiyama Y, Wakabayashi G. Benefits of laparoscopic liver resection in elderly patients. Surg Endosc 2023:10.1007/s00464-023-09986-9. [PMID: 36947226 DOI: 10.1007/s00464-023-09986-9] [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: 12/03/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND The indications of laparoscopic liver resection (LLR) have expanded to high-risk patients, such as elderly people. However, to date, little evidence has been established of the safety and feasibility of LLR in elderly patients. The short-term outcomes of LLR in elderly patients as compared to non-elderly patients were investigated. METHODS Data of a total of 297 patients who underwent LLR were reviewed. Among these 297 patients, 181 patients were < 75 years age (non-elderly) and 116 patients were ≥ 75 years age (elderly), and the surgical outcomes were compared between the groups. In addition, we evaluated the risk factors for postoperative morbidity (Clavien-Dindo grade ≥ IIIa) utilizing the preoperative, operative, and postoperative variables RESULTS: The preoperative liver/renal function, frequency of anti-thrombotic drug use, number of comorbidities, and American Society of Anesthesiologists-physical status classification were more unfavorable in elderly patients than in non-elderly patients. No significant inter-group differences were observed in the operation time, blood loss, conversion rate, postoperative morbidity, or 30-day mortality. The 3-year overall survival rate was comparable between the two groups. Multivariate analysis identified anti-thrombotic drug use, operation time > 7 h, and peak serum total bilirubin > 2 mg/dl within postoperative day 3 as independent risk factors for Clavien-Dindo ≥ IIIa postoperative morbidity (P = 0.016, P < 0.001, and P = 0.001, respectively). CONCLUSIONS LLR in elderly patients may provide comparable short-term outcomes to those in non-elderly patients.
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Affiliation(s)
- Shozo Mori
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan.
| | - Taiga Wakabayashi
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Kohei Mishima
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Takahiro Ozaki
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Yoshiki Fujiyama
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Go Wakabayashi
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
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Xie J, Wang M, Cao Y, Zhu Z, Ruan S, Ou M, Yu P, Shi J. ADM-assisted prepectoral breast reconstruction is not associated with high complication rate as before: a Meta-analysis. J Plast Surg Hand Surg 2023; 57:7-15. [PMID: 34581645 DOI: 10.1080/2000656x.2021.1981351] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Implant-related breast reconstruction can be divided into subpectoral breast reconstruction (SPBR) and prepectoral breast reconstruction (PPBR) according to the different anatomical planes. The previous stereotype was that PPBR had a high complication rate and was not suitable for clinical use. However, with the emergence of acellular dermal matrix (ADM), the clinical effect of PPBR has been improved. To compare the outcomes difference between SPBR and PPBR, We conducted this meta-analysis. Articles on SPBR versus PPBR were searched in PubMed, Web of Sciences, Embase, and Cochrane databases, strictly following the PRISMA guidelines. According to the set criteria, we included the literature that met the requirements. Extracted data were the incidence of adverse events and the duration of drainage. Results show that SPBR has a higher incidence rate in capsular contracture, animation deformity, infection, hematoma and delayed healing wound than PPBR. There are no significant differences in skin flap necrosis, seroma, implant loss, reoperation and duration of drainage between the two groups. Hence, PPBR is no longer a high complication surgical method and can be used in the clinical practice. However, there are few large sample studies at present, so it is necessary to carry out further studies on PPBR.
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Affiliation(s)
- Jiaheng Xie
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ming Wang
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuan Cao
- Fourth School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhechen Zhu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shujie Ruan
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mengmeng Ou
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Pan Yu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jingping Shi
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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10
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Sergesketter AR, Geng Y, Shammas RL, Denis GV, Bachelder R, Hollenbeck ST. The Association Between Metabolic Derangement and Wound Complications in Elective Plastic Surgery. J Surg Res 2022; 278:39-48. [PMID: 35588573 PMCID: PMC9329200 DOI: 10.1016/j.jss.2022.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/17/2022] [Accepted: 03/19/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk. METHODS Patients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI] > 30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI > 30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status. RESULTS Of 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P < 0.001) and adverse events (12.4% versus 9.6%; P < 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P < 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P < 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P < 0.001). CONCLUSIONS Diabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.
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Affiliation(s)
- Amanda R Sergesketter
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina
| | | | - Ronnie L Shammas
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina
| | - Gerald V Denis
- Section of Hematology/Oncology, Boston University School of Medicine, Boston, Massachusetts
| | - Robin Bachelder
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina
| | - Scott T Hollenbeck
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina.
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11
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Joo A, Giatsidis G. "In Free Flap Autologous Breast Reconstruction Frailty Is a More Accurate Predictor of Postoperative Complications than Age, Body Mass Index, or ASA class: A Retrospective Cohort Analysis on the ACS-NSQIP Database.". Plast Reconstr Surg 2022; 150:82S-94S. [PMID: 35943961 DOI: 10.1097/prs.0000000000009531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Free flap autologous breast reconstruction (f-ABR) improves quality of life in cancer survivors but has a 5-47% higher postoperative complication (PCs) rate in vulnerable patients, such as those with obesity or the elderly. Given the high (respectively: 43% and 16%) and rising prevalence of these conditions, operative risk prediction is critical to guide targeted care. Age, BMI, and ASA class have shown inaccuracies as predictive factors of PCs in f-ABR. Since frailty, a measure of vulnerability, was reported to be a reliable predictor of PCs in multiple other surgical fields, we hypothesized that it would be an accurate predictor of PCs also in f-ABR. METHODS Patients undergoing f-ABR (CPT: 19364) were identified using the ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program) database (01/2010-12/2018). Frailty was calculated using the validated modified Frailty Index (mFI). Rates of wound complications, bleeding episodes, readmissions, returns to operating room (ROR), and DVTs were compared across mFI score, BMI, age, and ASA class. RESULTS mFI ≥ 2 was associated with 22.22% (p <0.001) wound complications; 15.79% (p <0.001) bleeding episodes; 8.20% (p <0.001) readmissions; 17.19% (p <0.001) ROR; and 1.81% (p <0.05) DVTs. Higher BMI, age, and ASA class did not significantly correlate with increased rates in one or more PCs. Only a high mFI was consistently associated with significantly higher odds of complications in all complication types. CONCLUSIONS As a reliable and accurate predictor of PCs in f-ABR, frailty could be used preoperatively to counsel patients and guide surgical care.
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Affiliation(s)
- Alex Joo
- Division of Plastic Surgery, University of Massachusetts Medical School
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12
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An Ounce of Prediction is Worth a Pound of Cure: Risk Calculators in Breast Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4324. [PMID: 35702532 PMCID: PMC9187190 DOI: 10.1097/gox.0000000000004324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Abstract
Preoperative risk calculators provide individualized risk assessment and stratification for surgical patients. Recently, several general surgery–derived models have been applied to the plastic surgery patient population, and several plastic surgery–specific calculators have been developed. In this scoping review, the authors aimed to identify and critically appraise risk calculators implemented in postmastectomy breast reconstruction.
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13
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Palve J, Luukkaala T, Kääriäinen M. Is there any difference in perioperative characteristics or postoperative complications between overweight, normal-weight and obese patients in delayed DIEP reconstructions? J Plast Surg Hand Surg 2021; 56:236-241. [PMID: 34370604 DOI: 10.1080/2000656x.2021.1962334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Increased number of overweight and obese women are seeking breast reconstruction. Studies have demonstrated that obese experience increased rates of complications, but less data is available considering overweight patients. We analyzed the impact of body mass index (BMI) on perioperative characteristics and complications in unilateral delayed deep inferior epigastric perforator flap (DIEP) reconstructions. The records of patients with DIEP reconstruction performed between 2014 and 2020, were retrospectively analyzed. Patients were categorized into obese (BMI ≥30), overweight (BMI 25.0-29.9), and normal-weight groups (BMI <25). Patient characteristics (age, comorbidity, radiation, abdominal surgery, ASA category, and smoking), perioperative characteristics (length of operation, blood loss, vasoactive drugs, fluid administration, and urine output), and postoperative complications were recorded. The study included 308 patients. Of these, 104 (34%) were normal-weighted, 142 (46%) overweight and 62 (20%) obese. Among patients with BMI ≥ 25, blood loss increased (p = 0.002) and the length of operation tended to be longer (p = 0.072). No between-groups difference existed in fluid administration (p = 0.319), urine output (p = 0.425), or use of vasoactive drugs (p = 0.815). There was no statistically significant difference in overall complications (p = 0.122) between BMI groups. Blood loss >150ml was associated with both minor and major complications (p = 0.022). Greater BMI moderated with the radiation therapy for higher risk of minor complications (OR 42.0, 95%CI 3.54-49.7, p = 0.003). We conclude that greater BMI alone is not associated with a higher overall complication rate, but both overweight and obesity may be moderators for other risk factors.
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Affiliation(s)
- Johanna Palve
- Department of Plastic Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tiina Luukkaala
- Research, Development and Innovation Center, Tampere University Hospital and Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Minna Kääriäinen
- Department of Plastic Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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14
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Laterality and Patient-Reported Outcomes following Autologous Breast Reconstruction with Free Abdominal Tissue: An 8-Year Examination of BREAST-Q Data. Plast Reconstr Surg 2020; 146:964-975. [PMID: 33141527 DOI: 10.1097/prs.0000000000007239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making. METHODS The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years. RESULTS Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively). CONCLUSIONS These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.
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15
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Rattay T, Seibold P, Aguado-Barrera ME, Altabas M, Azria D, Barnett GC, Bultijnck R, Chang-Claude J, Choudhury A, Coles CE, Dunning AM, Elliott RM, Farcy Jacquet MP, Gutiérrez-Enríquez S, Johnson K, Müller A, Post G, Rancati T, Reyes V, Rosenstein BS, De Ruysscher D, de Santis MC, Sperk E, Stobart H, Symonds RP, Taboada-Valladares B, Vega A, Veldeman L, Webb AJ, West CM, Valdagni R, Talbot CJ. External Validation of a Predictive Model for Acute Skin Radiation Toxicity in the REQUITE Breast Cohort. Front Oncol 2020; 10:575909. [PMID: 33216838 PMCID: PMC7664984 DOI: 10.3389/fonc.2020.575909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/15/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Acute skin toxicity is a common and usually transient side-effect of breast radiotherapy although, if sufficiently severe, it can affect breast cosmesis, aftercare costs and the patient's quality-of-life. The aim of this study was to develop predictive models for acute skin toxicity using published risk factors and externally validate the models in patients recruited into the prospective multi-center REQUITE (validating pREdictive models and biomarkers of radiotherapy toxicity to reduce side-effects and improve QUalITy of lifE in cancer survivors) study. Methods: Patient and treatment-related risk factors significantly associated with acute breast radiation toxicity on multivariate analysis were identified in the literature. These predictors were used to develop risk models for acute erythema and acute desquamation (skin loss) in three Radiogenomics Consortium cohorts of patients treated by breast-conserving surgery and whole breast external beam radiotherapy (n = 2,031). The models were externally validated in the REQUITE breast cancer cohort (n = 2,057). Results: The final risk model for acute erythema included BMI, breast size, hypo-fractionation, boost, tamoxifen use and smoking status. This model was validated in REQUITE with moderate discrimination (AUC 0.65), calibration and agreement between predicted and observed toxicity (Brier score 0.17). The risk model for acute desquamation, excluding the predictor tamoxifen use, failed to validate in the REQUITE cohort. Conclusions: While most published prediction research in the field has focused on model development, this study reports successful external validation of a predictive model using clinical risk factors for acute erythema following radiotherapy after breast-conserving surgery. This model retained discriminatory power but will benefit from further re-calibration. A similar model to predict acute desquamation failed to validate in the REQUITE cohort. Future improvements and more accurate predictions are expected through the addition of genetic markers and application of other modeling and machine learning techniques.
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Affiliation(s)
- Tim Rattay
- Cancer Research Centre, University of Leicester, Leicester, United Kingdom
| | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Miguel E Aguado-Barrera
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Altabas
- Radiation Oncology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - David Azria
- Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditérranée, Département d'Oncologie Radiothérapie, ICM Montpellier, INSERM U1194 IRCM, University of Montpellier, Montpellier, France
| | - Gillian C Barnett
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Renée Bultijnck
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ananya Choudhury
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Alison M Dunning
- Centre for Cancer Genetic Epidemiology, Department of Oncology, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Rebecca M Elliott
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Marie-Pierre Farcy Jacquet
- Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditérranée, Département d'Oncologie Radiothérapie, CHU Carémeau, Nîmes, France
| | - Sara Gutiérrez-Enríquez
- Hereditary Cancer Genetics Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - Kerstie Johnson
- Cancer Research Centre, University of Leicester, Leicester, United Kingdom
| | - Anusha Müller
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Giselle Post
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Victoria Reyes
- Radiation Oncology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Barry S Rosenstein
- Department of Radiation Oncology, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dirk De Ruysscher
- MAASTRO Clinic, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Maria C de Santis
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Sperk
- Department of Radiation Oncology, Universitätsklinikum Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Hilary Stobart
- Independent Cancer Patients' Voice, London, United Kingdom
| | - R Paul Symonds
- Cancer Research Centre, University of Leicester, Leicester, United Kingdom
| | - Begoña Taboada-Valladares
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain.,Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, Servizo Galego de Saúde (SERGAS), Santiago de Compostela, Spain
| | - Ana Vega
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Adam J Webb
- Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Catharine M West
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Riccardo Valdagni
- Hereditary Cancer Genetics Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Campus, Barcelona, Spain.,Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Hematology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Christopher J Talbot
- Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
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16
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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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17
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Nelson JA, Sobti N, Patel A, Matros E, McCarthy CM, Dayan JH, Disa JJ, Cordeiro PG, Mehrara BJ, Pusic AL, Allen RJ. The Impact of Obesity on Patient-Reported Outcomes Following Autologous Breast Reconstruction. Ann Surg Oncol 2019; 27:1877-1888. [PMID: 31811437 DOI: 10.1245/s10434-019-08073-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant. OBJECTIVE Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients. METHODS An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction. RESULTS Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04). CONCLUSION Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.
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Affiliation(s)
- Jonas A Nelson
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Nikhil Sobti
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aadit Patel
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Colleen M McCarthy
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph J Disa
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter G Cordeiro
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Brigham and Womens Hospital, Boston, MA, USA
| | - Robert J Allen
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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18
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Abstract
BACKGROUND There is an increasing prevalence of obesity in society, often associated with increased medical comorbidities and surgical complications. Some health providers are now placing a body mass index (BMI) limit on whom can be offered breast reconstruction. The objective of this study was to determine the impact of obesity on quality of life as measured by the BREAST-Q, in women undergoing breast reconstruction. METHODS A review of the breast reconstruction database (n = 336) at the Flinders Breast Reconstruction Service was performed, with demographic data, complication rates, and BREAST-Q data being extracted and analyzed. Participants were divided into 2 groups: nonobese (BMI <30 kg/m) and obese (BMI ≥30 kg/m) for comparison. RESULTS Preoperatively, obese women scored lower than nonobese women in terms of BREAST-Q scores. Mean prereconstruction scores were 51.62 versus 57.10 (psychosocial), 40.18 versus 48.14 (satisfaction with breasts), and 34.30 versus 40.72 (sexual well-being) (all P < 0.05), and 68.48 versus 72.15 (physical well-being) (P = 0.08). At 12 months post-mound reconstruction, there was a significant improvement in scores in both groups. Additionally, there were no significant differences for BREAST-Q scores between the 2 groups 12 months after surgery. While there was a significantly higher minor complication rate in the obese group compared with the nonobese group, there was no significant difference in the rate of major complications (eg, requiring revision surgery) between the 2 groups. CONCLUSIONS Obese participants gain a similar, if not better, improvement in quality of life after breast reconstruction, despite a higher rate of minor complications. This study did not support withholding breast reconstruction from obese women.
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19
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O'Neill AC, Sebastiampillai S, Zhong T, Hofer SO. Increasing body mass index increases complications but not failure rates in microvascular breast reconstruction: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2019; 72:1518-1524. [DOI: 10.1016/j.bjps.2019.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022]
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20
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Tran BNN, Johnson AR, Shen C, Lee BT, Lee ES. Closed-Incision Negative-Pressure Therapy Efficacy in Abdominal Wall Reconstruction in High-Risk Patients: A Meta-analysis. J Surg Res 2019; 241:63-71. [DOI: 10.1016/j.jss.2019.03.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/14/2019] [Accepted: 03/22/2019] [Indexed: 12/26/2022]
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21
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Hong W, Lillemoe KD, Pan S, Zimmer V, Kontopantelis E, Stock S, Zippi M, Wang C, Zhou M. Development and validation of a risk prediction score for severe acute pancreatitis. J Transl Med 2019; 17:146. [PMID: 31068202 PMCID: PMC6505180 DOI: 10.1186/s12967-019-1903-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/02/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The available prognostic scoring systems for severe acute pancreatitis (SAP) have limitations that restrict their clinical value. The aim of this study was to develop a simple model (score) that could rapidly identify those at risk for SAP. METHODS We derived a risk model using a retrospective cohort of 700 patients by logistic regression and bootstrapping methods. The discriminative power of the risk model was assessed by calculating the area under the receiver operating characteristic curves (AUC). The classification and regression tree (CART) analysis was used to create risk categories. The model was internally validated by a tenfold cross-validation and externally validated in a separate prospective cohort of 194 patients. RESULTS The incidence of SAP was 9.7% in the derivation cohort and 9.3% in the validation cohort. A prognostic score (We denoted it as the SABP score), ranging from 0 to 10, consisting of systemic inflammatory response syndrome, serum albumin, blood urea nitrogen and pleural effusion, was developed by logistic regression and bootstrapping analysis. Patients could be divided into three risk categories according to total SABP score based on CART analysis. The mean probability of developing SAP was 1.9%, 12.8% and 41.6% in patients with low (0-3), moderate (4-6) and high (7-10) SABP score, respectively. The AUCs of prognostic score in tenfold cross-validation was 0.873 and 0.872 in the external validation. CONCLUSION Our risk prediction score may assist physicians in predicting the development of SAP.
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Affiliation(s)
- Wandong Hong
- grid.414906.e0000 0004 1808 0918Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000 Zhejiang People’s Republic of China
| | - Keith D. Lillemoe
- grid.32224.350000 0004 0386 9924Department of Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA 02114 United States
| | - Shuang Pan
- grid.414906.e0000 0004 1808 0918Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang People’s Republic of China
| | - Vincent Zimmer
- grid.11749.3a0000 0001 2167 7588Department of Medicine II, Saarland University Medical Center, Saarland University, 66424 Homburg, Germany
- Department of Medicine, Marienhausklinik St. Josef Kohlhof, 66539 Neunkirchen, Germany
| | - Evangelos Kontopantelis
- grid.5379.80000000121662407Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9GB UK
- grid.5379.80000000121662407NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Simon Stock
- Department of Surgery, World Mate Emergency Hospital, Battambang, Cambodia
| | - Maddalena Zippi
- grid.415113.30000 0004 1760 541XUnit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy
| | - Chao Wang
- grid.429222.d0000 0004 1798 0228Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Jiangsu, People’s Republic of China
| | - Mengtao Zhou
- grid.414906.e0000 0004 1808 0918Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang People’s Republic of China
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22
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Intraoperative Tissue Perfusion Measurement by Laser Speckle Imaging: A Potential Aid for Reducing Postoperative Complications in Free Flap Breast Reconstruction. Plast Reconstr Surg 2019; 143:287e-292e. [PMID: 30688880 DOI: 10.1097/prs.0000000000005223] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Adequate tissue perfusion is essential to minimize postoperative complications following microsurgery. Intraoperative knowledge of tissue perfusion could aid surgical decision-making and result in reduced complications. Laser speckle imaging is a new, noninvasive technique for mapping tissue perfusion. This article discusses the feasibility of using laser speckle imaging during free flap breast reconstruction and its potential to identify areas of inadequate perfusion, thus reducing surgical complications. Adult patients scheduled to undergo free flap breast reconstruction were recruited into the study. Laser speckle images were obtained from the abdominal and breast areas at different stages intraoperatively. Zonal perfusion was compared with the Holm classification and clinical observations. Twenty patients scheduled to undergo free flap breast reconstruction were recruited (23 reconstructed breasts) (mean age, 50 years; range, 32 to 68 years). Flap zonal perfusion was 238 (187 to 313), 222 (120 to 265), 206 (120 to 265), and 125 (102 to 220) perfusion units for zones I, II, III, and IV, respectively (analysis of variance, p < 0.0001). Zonal area with perfusion below an arbitrary perfusion threshold were 20 (0.3 to 75), 41 (3 to 99), 49 (9 to 97), and 99 (25 to 100) percent, respectively (analysis of variance, p < 0.0001). One example is presented to illustrate potential intraoperative uses for laser speckle imaging. This study shows that laser speckle imaging is a feasible, noninvasive technique for intraoperative mapping of tissue perfusion during free flap breast reconstruction. Zonal tissue perfusion was reduced across the Holm classification. Observations indicated the potential for laser speckle imaging to provide additional information to augment surgical decision-making by detection of inadequate tissue perfusion. This highlights the opportunity for surgeons to consider additional aids for intraoperative tissue perfusion assessment to help reduce perfusion-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.
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Masoomi H, Fairchild B, Marques ES. Frequency and Predictors of 30-Day Surgical Site Complications in Autologous Breast Reconstruction Surgery. World J Plast Surg 2019; 8:200-207. [PMID: 31309057 PMCID: PMC6620817 DOI: 10.29252/wjps.8.2.200] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Surgical site complication (SSC) is one of the known complications following autologous breast reconstruction. The aim of this study was to evaluate the frequency and predictors of 30-day surgical site complications in autologous breast reconstruction. METHODS American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database was used to identify patients who underwent autologous breast reconstruction during 2011-2015. Multivariate regression analysis was performed to identify independent perioperative risk factors of SSC. RESULTS Totally, 7,257 patients who underwent autologous breast reconstruction surgery were identified. The majority of the procedures were free flap (60%) versus pedicled flap (40%). The mean age was 51 years and the majority of patients were classified as American Society of Anesthesiologists (ASA)-II (60%) and 15% of patients had BMI>35. The overall 30-day SSC rate was 6.3%. The overall frequency of different types of SSC were superficial incisional infection (3.2%), wound dehiscence (1.8%), deep incisional infection (1.4%) and organ space infection (0.6%). BMI>35 (adjusted odds ratio [AOR]=2.38), smoking (AOR=2.0), diabetes mellitus (AOR=1.67) and hypertension (AOR=1.38) were significant risk factors of SSC. There was no association with age, ASA classification, steroid use, or reconstruction type. CONCLUSION The rate of 30-day SSC in autologous breast reconstruction was noticeable. The strongest independent risk factor for SSC in autologous breast reconstruction was BMI>35. The type of autologous breast reconstruction was not a predictive risk factor for SSC. Plastic surgeons should inform patients about their risk for SSC and optimizing these risk factors to minimize the rate of surgical site complications.
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Affiliation(s)
- Hossein Masoomi
- University of Texas Health Science Center at Houston, Division of Plastic and Reconstructive Surgery, Houston, Texas, USA
| | - Berry Fairchild
- University of Texas Health Science Center at Houston, Division of Plastic and Reconstructive Surgery, Houston, Texas, USA
| | - Erik S Marques
- University of Texas Health Science Center at Houston, Division of Plastic and Reconstructive Surgery, Houston, Texas, USA
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Willoughby LI, D'Abbondanza JA, Baltzer HL, Mahoney JL, Musgrave MA. Body mass index impacts infection rates in immediate autogenous breast reconstruction. Breast Cancer Res Treat 2019; 175:765-773. [PMID: 30937658 DOI: 10.1007/s10549-019-05215-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Risk of postoperative infection following breast cancer reconstruction warrants consideration of both classic and procedure-specific risk factors. We performed a retrospective chart review of patients with breast cancer over a 10-year period that underwent reconstructive surgery to identify factors that increase risk of postoperative infection. METHODS Rates of postoperative infection were assessed in primary (immediate or delayed, alloplastic or autogenous) and secondary reconstructive procedures. Patient characteristics, surgical details, and cancer features were analyzed using two-sample t test and Fisher's exact test for continuous and categorical data, respectively. RESULTS 456 procedures were performed on 264 patients with 29 cases of postoperative infection (6%). Infection was more likely to occur in earlier reconstructive procedures (p < 0.03). Overall, primary reconstructive procedures were associated with a higher infection rate (p = 0.005). Other associated risk factors included: autogenous reconstruction (p < 0.018), length of admission (p < 0.001) and immediate reconstruction (p = 0.01). Subgroup analysis revealed increased risk of infection with immediate autogenous reconstruction (p < 0.03). Furthermore, patients with greater body mass index (BMI) receiving immediate autogenous reconstruction had a greater risk of infection (p < 0.003). Factors unrelated to risk of infection included history of irradiation, smoking, cancer stage, tumor type and tumor size. CONCLUSIONS Our findings suggest that risk of infection is higher in immediate autogenous reconstructions particularly when patients are overweight (BMI > 30). Our data do not support a relationship between infection and irradiation, features of cancer, or repeated reconstructive procedures. Prospective studies may be required to further validate these findings.
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Affiliation(s)
- Lauren I Willoughby
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Josephine A D'Abbondanza
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Suite 508, Toronto, ON, M5T 1P5, Canada.
| | - Healther L Baltzer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Suite 508, Toronto, ON, M5T 1P5, Canada
| | - James L Mahoney
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Suite 508, Toronto, ON, M5T 1P5, Canada
| | - Melinda A Musgrave
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Suite 508, Toronto, ON, M5T 1P5, Canada
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Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction. Plast Reconstr Surg 2019; 142:299-305. [PMID: 29782396 DOI: 10.1097/prs.0000000000004547] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, the authors determine how postoperative complications impact chemotherapy timing, and identify factors associated with greater risk for delays. METHODS Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of postoperative complications and time to chemotherapy. RESULTS A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86 percent) reconstructions did not experience postoperative complications, and 34 (13.9 percent) did. Patients who experienced postoperative complications had an older mean age (53.6 years versus 48.1 years; p = 0.002) and higher rates of diabetes (23.5 percent versus 3.8 percent; p < 0.001). The complication group had delays in initiation of chemotherapy (56 versus 45 days; p = 0.017). Patients who initiated chemotherapy more than 48.5 days after reconstruction were of older mean age (55.9 years versus 50.7 years; p = 0.074) and had increased rates of diabetes (36.8 percent versus 6.7 percent; p = 0.053) and immediate autologous reconstruction (31.6 percent versus 0 percent; p = 0.027). A predictive model determined that patients with at least one of these three risk factors have a 74 percent chance of experiencing prolonged times to chemotherapy initiation. CONCLUSIONS Risk factors for delayed chemotherapy in the context of postoperative complications are age older than 51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Schülein S, Taylor KJ, Braun B, Heyl V, Zoche H, Peek A, Solbach C, Schott S, Blettner M, Klug SJ. Evaluation of the methodological quality of articles on autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2018; 71:1286-1294. [PMID: 30173715 DOI: 10.1016/j.bjps.2018.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/27/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Breast cancer remains the most common cancer among women worldwide. Autologous breast reconstruction may contribute toward restoring body image and improving quality of life after mastectomy. This systematic literature review describes differences in the quality and type of studies investigating autologous breast reconstruction techniques over time. METHODS MEDLINE was searched for articles related to the surgical techniques, namely, TRAM, LADO, DIEP, and SGAP/IGAP, for the periods 1970 to 2007 and 2008 to 2010. The quality and type of studies were compared across the two time periods. Full-texts were evaluated according to prespecified quality criteria. RESULTS The MEDLINE searches yielded 1,057 articles for review; of them, 517 articles were excluded, and 314 had a completed quality criteria checklist and hence were included; of these 314 articles, 206 articles investigated TRAM flaps, 85 investigated LADO flaps, 74 investigated DIEP flaps, and 6 investigated SGAP/IGAP flaps. A total of 218 articles were published between 1970 and 2007 compared to 96 articles published between 2008 and 2010. The comparison of quality scores between the two time periods showed a shift toward higher scores in the period 2008 to 2010. The DIEP technique was investigated more frequently between 2008 and 2010 than between 1970 and 2007, whereas the percentage of articles focusing on the TRAM flap decreased. The percentage of articles investigating the LADO and SGAP/IGAP techniques remained constant across the time periods. CONCLUSIONS Results relating to the methodological quality of articles on breast reconstruction with autologous tissue show that the quality of publications has improved with time, whereas research interests concerning the type of surgical technique investigated have changed in focus.
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Affiliation(s)
- Stefanie Schülein
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, Georg-Brauchle-Ring 56, 80992 Munich, Germany
| | - Katherine J Taylor
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University, Obere Zahlbacher Strasse 69, 55131 Mainz, Germany
| | - Bettina Braun
- Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Building D3, 48149 Münster, Germany
| | - Volker Heyl
- Mic.ma.mainz, Center of Medicine for Minimally Invasive Surgery, Senology and Oncology, Rheinstrasse 4, 55116 Mainz, Germany
| | - Hermann Zoche
- Gynecology Clinic, Regiomed-Clinic, Ketschendorfer Strasse 33, 96450 Coburg, Germany
| | - Alberto Peek
- Group Practice for Plastic Surgery, Oeder Weg 2-4, 60318 Frankfurt am Main, Germany
| | - Christine Solbach
- Senology and Breast Center, Clinic for Gynecology and Obstetrics, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Sarah Schott
- University Women's Clinic, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany; German Cancer Consortium (DKTK), NCT Heidelberg and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University, Obere Zahlbacher Strasse 69, 55131 Mainz, Germany
| | - Stefanie J Klug
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, Georg-Brauchle-Ring 56, 80992 Munich, Germany.
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Slump J, Hofer SOP, Ferguson PC, Wunder JS, Griffin AM, Hoekstra HJ, Bastiaannet E, O'Neill AC. Flap reconstruction does not increase complication rates following surgical resection of extremity soft tissue sarcoma. Eur J Surg Oncol 2017; 44:251-259. [PMID: 29275911 DOI: 10.1016/j.ejso.2017.11.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/09/2017] [Accepted: 11/19/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Flap reconstruction plays an essential role in the surgical management of extremity soft tissue sarcoma (ESTS) for many patients. But flaps increase the duration and complexity of the surgery and their contribution to overall morbidity is unclear. This study directly compares the complication rates in patients with ESTS undergoing either flap reconstruction or primary wound closure and explores contributing factors. METHODS Eight hundred and ninety-seven patients who underwent ESTS resection followed by primary closure (631) or flap reconstruction (266) were included in this study. Data on patient, tumour and treatment variables and post-operative medical and surgical complications were collected. Univariate and multivariate regression analyses were performed to identify independent predictors of complications. RESULTS Post-operative complications occurred in 33% of patients. Flap patients were significantly older, had more advanced disease and were more likely to require neoadjuvant chemo- and radiotherapy. There was no significant difference in complication rates following flap reconstruction compared to primary closure on multivariate analysis (38 vs 30.9% OR 1.12, CI 0.77-1.64, p = 0.53). Pre-operative radiation and distal lower extremity tumour location were significant risk factors in patients who underwent primary wound closure but not in those who had flap reconstruction. Patients with comorbidities, increased BMI and systemic disease were at increased risk of complications following flap reconstruction. CONCLUSIONS Flap reconstruction is not associated with increased post-operative complications following ESTS resection. Flaps may mitigate the effects of some risk factors in selected patients.
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Affiliation(s)
- Jelena Slump
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada; Department of Surgical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - Harald J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Esther Bastiaannet
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada.
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Li N, Zheng Z, Li J, Fan J, Wang T, Zhang J, Wang H, Chen J, Lv Y, Yi J, Huang M, Ling R. Immediate breast reconstruction with omental flap for luminal breast cancer patients: Ten clinical case reports. Medicine (Baltimore) 2017; 96:e7797. [PMID: 28816969 PMCID: PMC5571706 DOI: 10.1097/md.0000000000007797] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RATIONALE Luminal subtype breast cancer, accounting for 70 to 80% of all breast cancers, has been reported to be associated with good prognosis. However, for the patients with large mass or worse mass position, omental flap transplantation may provide a new option for breast reconstruction. PATIENT CONCERNS Ten patients (6 luminal B1, 2 luminal B2, 2 luminal A), were enrolled into the study, between January 23, 2015 and August 22, 2016. The mean age was 34.6 ± 6.96 (24-44) years old. Immunohistochemistry demonstrated that the tumor cells were positive for estrogen receptor and progestrone receptor. DIAGNOSES According to the clinicopathological features, diagnosis of breast cancer patients were made. INTERVENTIONS Breast-conserving surgery, laparoscopic greater omentum harvest and vascular anas-tomosis were carried out orderly. Postoperative operative results, cosmetic outcomes, complications, as well as blood supply were investigated for surgery evaluation. Reasonable chemotherapy and irradia-tion were adopted to patients according to the pathological condition. OUTCOMES We successfully accomplished breast reconstruction by omental flap transplantation, ex-cept one failed case because of the necrosis of omentum and changed to fat transplantation. The volumes and symmetry of breasts were all satisfied. The blood supply was detected to be fluent. Only one case of slight hematoma and another case of one distant metastasis were observed during fol-low-up period. No arm mordities or arm movement restriction occurred after surgery. Moreover, radia-tion therapy and chemotherapy had no clear effects on the reconstructed breast. LESSONS Immediate breast reconstruction surgery by transplanting omental flap for luminal breast cancer patients can be considered successful based on the excellent clinic outcome.
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Affiliation(s)
- Nanlin Li
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Zhao Zheng
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University
| | - Jipeng Li
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Jing Fan
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Ting Wang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Juliang Zhang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Hui Wang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Jianghao Chen
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Yonggang Lv
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Jun Yi
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Meiling Huang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Fourth Military Medical University
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Bauder AR, Samra F, Kanchwala SK, Serletti JM, Kovach SJ, Wu LC. Autologous breast reconstruction in the postbariatric patient population. Microsurgery 2017; 38:134-142. [PMID: 28467614 DOI: 10.1002/micr.30184] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 03/21/2017] [Accepted: 04/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution. METHODS Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts. RESULTS Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00). CONCLUSIONS As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.
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Affiliation(s)
- Andrew R Bauder
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fares Samra
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suhail K Kanchwala
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liza C Wu
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Nelson JA, Fischer JP, Grover R, Nelson P, Au A, Serletti JM, Wu LC. Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction. J Plast Surg Hand Surg 2017; 51:336-341. [DOI: 10.1080/2000656x.2016.1269777] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John P. Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ritwik Grover
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Priscilla Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology, Lankenau Medical Center, Wynnewood, PA, USA
| | - Alex Au
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M. Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C. Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Post-mastectomy breast reconstruction and its subsequent complications: a comparison between obese and non-obese women with breast cancer. Breast Cancer Res Treat 2016; 157:373-383. [PMID: 27178333 DOI: 10.1007/s10549-016-3832-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
To compare the utilization pattern of breast reconstruction between obese and non-obese patients and assess the association between obesity and postoperative complications as well as healthcare costs. Using MarketScan databases, we identified 2558 breast cancer patients who underwent mastectomy between 2009 and 2012. Temporal trends in breast reconstruction were assessed using the Cochran-Armitage test. Logistic regression models were performed to determine the association between obesity and the occurrence of postoperative complications. Healthcare costs were compared using a generalized linear model. Among 2558 patients treated with mastectomy, the breast reconstruction rate of non-obese patients (76.2 %) was significantly higher than patients in obese class I and class II&III (63.3 and 60.2 %, respectively; P < 0.001). Compared with non-obese patients, obese patients had significantly higher rates of infection (OR 1.53, for obese class I, and OR 1.60, for obese class II&III, both P < 0.01), wound (OR 1.51, P = 0.01 for obese class I, and OR 1.98, P < 0.001 for obese class II&III), and perfusion complications (OR 1.73, P = 0.01 for obese class I, and OR 2.21, P < 0.01 for obese class II&III). The mean postoperative complication cost for non-obese patients ($4684) was significantly lower than those for obese class I patients ($6250) and obese class II&III patients ($7868; P < 0.001). Our analysis demonstrated a significant gap in breast reconstruction between obese and non-obese patients, and our finding underscores the need for careful preoperative assessment of obese patients and call for additional research to minimize the risk of complications.
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Klasson S, Nyman J, Svensson H, Velander P. Smoking increases donor site complications in breast reconstruction with DIEP flap. J Plast Surg Hand Surg 2016; 50:331-335. [DOI: 10.1080/2000656x.2016.1175357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Satteson ES, Reynolds MF, Bond AM, Pestana IA. An Analysis of Complication Risk Factors in 641 Nipple Reconstructions. Breast J 2016; 22:379-83. [PMID: 27038175 DOI: 10.1111/tbj.12591] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Nipple-areola reconstruction represents the completion of the breast restorative process and is associated with significant positive psychological implications. While factors such as medical comorbidities, smoking status, and radiation therapy have been shown to be associated with an increase in complications following breast reconstruction, their impact on nipple reconstruction remains largely unaddressed in the literature. An IRB-approved, retrospective review of 472 patients who underwent nipple reconstruction at Wake Forest University over a 15-year period was completed. Demographic and surgical characteristics were assessed including age, body mass index, medical comorbidities, smoking status, need for radiation, breast reconstruction type, and nipple flap used. Four hundred and seventy-two patients with 641 nipple reconstructions were included with an average follow-up of 56.5 months. Radiation prior to nipple reconstruction was required in 146 breasts (22.8%). Overall, postoperative nipple projection problems occurred in 7.6% of reconstructions with a 4.1% rate of other complications, including nipple necrosis, tip loss, wound infection and wound breakdown. Implant-based reconstruction and radiation were associated with significantly more nipple projection problems (p = 0.009 and 0.05, respectively). Higher rates of complications and nipple projection problems were seen with skate flap reconstruction compared to a star flap (p = 0.046 and 0.001, respectively). Implant-based breast reconstruction and radiotherapy are associated with higher rates of nipple reconstruction problems. Identification of patient and surgical variables associated with increased risk of poor outcomes preoperatively could help in patient counseling and selection of the most appropriate method of breast and nipple reconstruction.
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Affiliation(s)
- Ellen S Satteson
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Michael F Reynolds
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Austin M Bond
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ivo A Pestana
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Nahabedian MY, Patel K. Autologous flap breast reconstruction: Surgical algorithm and patient selection. J Surg Oncol 2016; 113:865-74. [DOI: 10.1002/jso.24208] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Maurice Y. Nahabedian
- Department of Plastic Surgery; Georgetown University Hospital; Washington District of Columbia
| | - Ketan Patel
- Department of Plastic Surgery; University of Southern California; Los Angeles California
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Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, Rosa JH, Taub PJ. Flap Failure and Wound Complications in Autologous Breast Reconstruction: A National Perspective. Aesthetic Plast Surg 2015; 39:902-9. [PMID: 26487657 DOI: 10.1007/s00266-015-0575-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/01/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE There are many options for breast reconstruction following a mastectomy, and data on outcomes are greatly needed for both the patient and the care provider. This study aims to identify the prevalence and predictors of adverse outcomes in autologous breast reconstruction in order to better inform patients and surgeons when choosing a surgical technique. METHODS This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified each autologous breast reconstruction performed between 2005 and 2012. Of the 6855 autologous breast reconstructions, there were 2085 latissimus dorsi (LD) flap procedures, 2464 pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedures, and 2306 free flap procedures that met the inclusion criteria. The prevalence of complications in each of the three procedures was calculated and compared using χ(2) analysis for binomial categorical variables. Univariate and multivariate logistic regression analyses identified independent risk factors for adverse outcomes in autologous reconstruction as a whole. RESULTS The prevalence of general complications was 10.8% in LD flaps, 20.6% in TRAM flaps, and 26.1% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of wound complications was 4.3% in LD flaps, 8.1% in TRAM flaps, and 6.2% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of flap failure was 1.1 % in LD flaps, 2.7% in TRAM flaps, and 2.4% in free flaps for autologous breast reconstruction (p < 0.001). Multivariate regression analysis showed that obesity [odds ratio (OR) 1.495, p = 0.024], hypertension (OR 1.633, p = 0.008), recent surgery (OR 3.431, p < 0.001), and prolonged operative times (OR 1.944, p < 0.001) were independently associated with flap failure in autologous breast reconstruction procedures. When controlling for confounding variables, TRAM flaps were twice as likely (OR 2.279, p = 0.001) and free flaps were three times as likely (OR 3.172, p < 0.001) to experience flap failure when compared to LD flaps. CONCLUSIONS Latissimus dorsi flaps are associated with the fewest short-term general complications and free flaps are associated with the most short-term general complications in autologous breast reconstruction. Free flaps are the most likely to experience flap failure, though there is no significant difference when compared to pedicled TRAM flaps. Free and TRAM flaps remain as the widely acceptable forms of breast reconstruction in the patient without many risk factors for flap failure or wound complications. The identified risk factors will aid in surgical planning and risk adjustment for both the patient and the care provider. Though many other factors will be taken into consideration with surgical planning of autologous breast reconstruction, the presence of these identified risk factors may encourage the use of a surgical technique associated with fewer adverse outcomes, like the LD flap. 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.
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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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