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Barnes LL, Lem M, Patterson A, Segal R, Holland MC, Lentz R, Sbitany H, Piper M. Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction. Plast Reconstr Surg 2024; 153:553-566. [PMID: 37166039 DOI: 10.1097/prs.0000000000010621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase. METHODS The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point. RESULTS A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively. CONCLUSIONS Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Laura L Barnes
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Melinda Lem
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Anne Patterson
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | | | - Michael C Holland
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Rachel Lentz
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
- Division of Plastic and Reconstructive Surgery, University of Washington
| | - Hani Sbitany
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai
| | - Merisa Piper
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
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2
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Huang H, Lu Wang M, Chen Y, Chadab TM, Vernice NA, Otterburn DM. A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest. J Reconstr Microsurg 2024; 40:70-77. [PMID: 37040876 DOI: 10.1055/a-2071-3368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients. METHODS This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications. RESULTS Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87. CONCLUSION This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.
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Affiliation(s)
- Hao Huang
- NewYork-Presbyterian Hospital-Cornell and Columbia, New York, New York
| | - Marcos Lu Wang
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York
| | - Yunchan Chen
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York
| | - Tara M Chadab
- NewYork-Presbyterian Hospital-Cornell and Columbia, New York, New York
| | - Nicholas A Vernice
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York
| | - David M Otterburn
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York
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3
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Tokumoto H, Akita S, Kosaka K, Kubota Y, Mitsukawa N. Correlation between abdominal visceral volume measured by a simple procedure and bulging at the abdominal free flap donor site for breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:295-301. [PMID: 37385141 DOI: 10.1016/j.bjps.2023.06.008] [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: 07/17/2022] [Revised: 05/10/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Breast reconstructions using autologous abdominal tissue result in breasts with a natural shape and consistency. One of the major complications is abdominal bulging. Because of the increased abdominal wall tension, high visceral volume (not visceral fat alone) may increase the occurrence rate of abdominal bulging. A simple procedure involving CT imaging was used to assess this relationship in patients undergoing an abdominal free flap for unilateral breast reconstruction. METHODS A total of 278 patients were enrolled in this study. The patients' demographics, the thicknesses of visceral volume were compared (Bulging (+) vs. Bulging (-)). Visceral volume was investigated based on the horizontal thickness, which was measured at the thickest part at the level of the umbilical fossa between both sides under the transverse abdominis muscles. RESULTS Bulging (+) consisted of 39 patients (14.0%), whereas Bulging (-) included 239 patients. Patients with Bulging (+) were significantly older, had higher gestational history rate, and had thin rectus abdominis muscle. In terms of visceral volume, the Bulging (+) group had significantly higher horizontal thicknesses (median 233 mm vs. 219 mm, P < 0.001). No significant differences were observed with respect to other factors (age, BMI, history of laparotomy, and operative details). The multivariate logistic regression analysis revealed that the thickness of the rectus abdominis muscle, horizontal visceral volume, and gestational history were independently significant predictors. CONCLUSIONS Not only the patients with thin rectus abdominis muscle but also patients with a thick horizontal visceral volume may have a higher risk of abdominal bulging.
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Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan.
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
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4
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Löfstrand J, Paganini A, Lidén M, Hansson E. Donor-Site Satisfaction of DIEP and Latissimus Dorsi Flaps-A Comparative Cohort Study. J Reconstr Microsurg 2022. [PMID: 36379466 DOI: 10.1055/a-1978-9610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Understanding of donor-site morbidity and satisfaction after breast reconstruction is limited. There are few previous studies comparing satisfaction with different donor sites in breast reconstruction. This study aimed to examine the long-term patient-reported satisfaction with the donor site of latissimus dorsi (LD) flaps in comparison to the deep inferior epigastric artery perforator (DIEP) flaps. Further, a systematic review of previously published studies was conducted. METHODS In this retrospective cross-sectional study, all women who underwent breast reconstructions with either LD or DIEP flap following mastectomy and radiotherapy between 2007 and 2017 were included; patient-reported satisfaction was assessed using the BREAST-Q reconstruction module. For the systematic review, studies examining patient-reported abdominal satisfaction and well-being, and meeting the PICO (Population, Intervention, Comparison, and Outcome) criteria were included. RESULTS Eligible and responding participants were divided into the LD (n = 135 patients) and DIEP (n = 118 patients) flap groups. Impairment due to muscular weakness of the donor site was more common in the LD group than that of the DIEP group. Bulging was common in the DIEP group and increased over time. Regarding the esthetic appearance of the donor site, the patients in the DIEP group were less satisfied than the LD group. The systematic review showed that most of the patients were dissatisfied with their abdomen after the operation. CONCLUSION Patients who have undergone DIEP flap for breast reconstruction are less satisfied with the donor-site esthetics than those who have undergone LD flap. Patient-reported abdominal bulging was common in the DIEP group and the number seemed to increase over time. Most patients were not satisfied with their abdominal scarring postoperatively, as per the systematic review. These results may indicate a need for more nuanced preoperative patient information, as well as improvements in the surgical management of the donor site, for DIEP flap reconstructions.
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Affiliation(s)
- Jonas Löfstrand
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Lidén
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma Hansson
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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5
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Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis. Plast Reconstr Surg Glob Open 2022; 10:e4693. [PMID: 36583164 PMCID: PMC9750533 DOI: 10.1097/gox.0000000000004693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/06/2022] [Indexed: 12/15/2022]
Abstract
Breast reconstruction (BR) is a unique surgical procedure that provides patients undergoing mastectomy with significant psychosocial and aesthetic benefits and has also become a crucial part of the treatment pathway for women with breast cancer. Due to methodological inadequacies and the absence of substantial risk factor analysis, no conclusion can be drawn about the correlation between risk variables and post-surgical complications in BR surgery. We aim to identify the potential risk factors associated with postoperative complications. Methods We queried MEDLINE and Cochrane CENTRAL from their inception to March 2022, for published randomized controlled trials and observational studies that assessed complications post-reconstruction procedure in breast cancer patients following mastectomy or evaluated at least one of the following outcomes of major or reoperative complications. The results from the studies were presented as odds ratios with 95% confidence intervals and were pooled using a random-effects model. Results Our pooled analysis demonstrated a significant correlation with BR postoperative complications and risk factors such as diabetes, hypertension, and obesity. Diabetes and the development of seroma were found to have a significant relationship. Risk variables such as age, radiotherapy, COPD, and smoking had no significant connection with 0-to-30-day readmission and 30-to-90-day readmission. Conclusion This meta-analysis shows that risk factors like age, smoking history, high blood pressure, and body mass index (BMI) have a big effect on complications after BR, and patients with risk factors have a high rate of developing infection.
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6
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Ogilvie WA, Shakir Z, Whinery LD, Puthoff JS, Chow GS, Lim RB, Khorgami Z. Effect of obesity on outcomes after breast reconstruction surgery, an analysis of national surgical quality improvement program. J Plast Reconstr Aesthet Surg 2022; 75:4496-4512. [PMID: 36280442 DOI: 10.1016/j.bjps.2022.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 07/20/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Obesity is a risk factor for breast cancer and may affect the incidence, and outcomes of surgical treatment for breast cancer, including breast reconstruction. OBJECTIVE This study aimed to evaluate outcomes of breast reconstruction in patients with obesity. METHODS In a retrospective review of the NSQIP 2013-2018, adult patients who underwent breast reconstruction were included. Procedures were categorized to with or without an implant. Obesity was considered as body mass index(BMI)≥30 kg/m2. We made composite variables for 30-day any complication, wound complications, and major complications. Regression analysis was used to identify the independent effect of obesity on outcomes. RESULTS A total of 46,042 patients were included(mean age 51.4 ± 11.1 years, 99.8% female). There were 3134(6.8%) patients with any complication, 2429(5.3%) with major, and 2772(6%) with wound complications, 2795 patients(6.1%) with unplanned re-operation, and 3 deaths. Obesity was an independent predictor of any complication, major complications, and wound complications(OR:1.83-1.87), and unplanned re-operation(OR:1.52). Wound complication was lower in the implant group(3.7% vs 10.9%) but obesity had a higher odds of wound complications in the implant group(2 vs 1.4). There was an increase in the odds of complications as BMI rises. CONCLUSION Patients with a BMI>30 kg/m2 have a significantly higher risk of developing surgical complications following breast reconstruction with both implant and tissue reconstruction. Weight loss strategies should be considered in patients who need breast reconstruction surgeries and this may decrease the risk of postoperative wound complication and the need for reoperation.
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Affiliation(s)
- William A Ogilvie
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Zakiya Shakir
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
| | - Lacie D Whinery
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Justin S Puthoff
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Geoffrey S Chow
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Robert B Lim
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA; Harold Hamm Diabetes Center, University of Oklahoma, Ok, USA.
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7
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Shaffrey EC, Ly N, Seitz AJ, Ziemlewicz TJ, Poore SO, Michelotti BF. Evaluation of Morphometric Measurements on Preoperative CT Angiograms to Determine Risk of Abdominal Donor Site Complications—A Retrospective Review of 174 Patients. Plast Surg (Oakv) 2022. [DOI: 10.1177/22925503221128987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection ( P = .005), epidermolysis ( P = .031), and seroma ( P = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity ( P = .024), history of smoking ( P = .049), and the number of perforators harvested ( P = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks.
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Affiliation(s)
- Ellen C. Shaffrey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Nancy Ly
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Allison J. Seitz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Timothy J. Ziemlewicz
- Department of Radiology, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Samuel O. Poore
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Brett F. Michelotti
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
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8
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Zehnpfennig L, Ritter M, Montagna G, Handschin TM, Ling BM, Oberhauser I, Lévy J, Schaefer KM, Maggi N, Soysal SD, López LC, Müller MM, Schwab FD, Haug M, Weber WP, Kurzeder C, Kappos EA. The Impact of Delayed Wound Healing on Patient-Reported Outcomes After Breast Cancer Surgery. J Plast Reconstr Aesthet Surg 2022; 75:4125-4132. [DOI: 10.1016/j.bjps.2022.06.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 04/14/2022] [Accepted: 06/07/2022] [Indexed: 10/31/2022]
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9
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Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction. Plast Reconstr Surg 2022; 149:568-577. [PMID: 35196669 DOI: 10.1097/prs.0000000000008825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Psychological factors are broadly understood to contribute to overall health, but their contribution to wound healing is less well defined. Limited data exist on the association of preoperative psychological factors such as body image and postoperative complications. The present study analyzed the association between preoperative body image factors and postoperative complications following breast reconstruction. METHODS This was a prospective cohort study of 302 breast cancer patients undergoing breast reconstruction from 2011 to 2015. All patients completed the BREAST-Q; demographics, surgical details, and postoperative complications were recorded. The association of body image factors by means of the BREAST-Q and postoperative complications was analyzed. RESULTS On univariate analysis, patients who reported lower preoperative satisfaction with how they appeared in the mirror unclothed, or felt less self-confident or attractive, were significantly more likely to develop an infection postoperatively. Preoperative satisfaction scores were not associated with complications when analyzed in a multivariate fashion. On binomial logistic regression analysis, after controlling for age, body mass index, reconstruction technique, and use of radiotherapy, patients who reported less preoperative satisfaction with how comfortably bras fit or how they appeared in a mirror unclothed were at an increased risk for delayed wound healing. CONCLUSIONS Patients with lower preoperative body satisfaction were found to have an increased incidence of infections and delayed wound healing. Although postoperative outcomes are multifactorial, the data suggest that baseline psychological factors such as body image may play a role in postoperative outcomes. Broader use of prehabilitative therapies, targeted at psychosocial factors, may warrant further investigation to optimize postoperative outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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10
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Zhang X, Hou A, Cao J, Liu Y, Lou J, Li H, Ma Y, Song Y, Mi W, Liu J. Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review. Front Endocrinol (Lausanne) 2022; 13:841256. [PMID: 35721703 PMCID: PMC9204286 DOI: 10.3389/fendo.2022.841256] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/12/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery. METHODS We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery. RESULTS This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]). CONCLUSIONS DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Weidong Mi
- *Correspondence: Jing Liu, ; Weidong Mi,
| | - Jing Liu
- *Correspondence: Jing Liu, ; Weidong Mi,
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11
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Patterson CW, Palines PA, Bartow MJ, Womac DJ, Zampell JC, Dupin CL, St Hilaire H, Stalder MW. Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity. J Reconstr Microsurg 2021; 38:1-9. [PMID: 33853129 DOI: 10.1055/s-0041-1727202] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. RESULTS When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications. CONCLUSION DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.
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Affiliation(s)
- Charles W Patterson
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Patrick A Palines
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Matthew J Bartow
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Daniel J Womac
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | | | - Charles L Dupin
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | - Hugo St Hilaire
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | - Mark W Stalder
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
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12
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Morris TM, Marlborough FJ, Montgomery RJ, Allison KP, Eardley WGP. Smoking and the patient with a complex lower limb injury. Injury 2021; 52:814-824. [PMID: 33495022 DOI: 10.1016/j.injury.2020.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/11/2020] [Accepted: 12/23/2020] [Indexed: 02/02/2023]
Abstract
Smoking is known to increase the risk of peri-operative complications in Orthoplastic surgery by impairing bone and wound healing. The effects of nicotine replacement therapies (NRTs) and electronic cigarettes (e-cigarettes) has been less well established. Previous reviews have examined the relationship between smoking and bone and wound healing separately. This review provides surgeons with a comprehensive and contemporaneous account of how smoking in all forms interacts with all aspects of complex lower limb trauma. We provide a guide for surgeons to refer to during the consent process to enable them to tailor information towards smokers in such a way that the patient may understand the risks involved with their surgical treatment. We update the literature with recently discovered methods of monitoring and treating the troublesome complications that occur more commonly in smokers effected by trauma.
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Affiliation(s)
- Timothy M Morris
- Orthoplastic Surgery Department, James Cook University Hospital, Marton Road, Middlesbrough, England, TS4 3BW.
| | - Fergal J Marlborough
- Orthoplastic Surgery Department, James Cook University Hospital, Marton Road, Middlesbrough, England, TS4 3BW
| | - Richard J Montgomery
- Orthoplastic Surgery Department, James Cook University Hospital, Marton Road, Middlesbrough, England, TS4 3BW
| | - Keith P Allison
- Orthoplastic Surgery Department, James Cook University Hospital, Marton Road, Middlesbrough, England, TS4 3BW
| | - William G P Eardley
- Orthoplastic Surgery Department, James Cook University Hospital, Marton Road, Middlesbrough, England, TS4 3BW
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Shin HD, Rodriguez AM, Abraham JT, Cargile JC, Brown CN, Altman AM, Saint-Cyr MH. “Does ERAS benefit higher BMI patients? A single institutional review”. J Plast Reconstr Aesthet Surg 2021; 74:475-479. [DOI: 10.1016/j.bjps.2020.08.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/02/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022]
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Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3099. [PMID: 33133950 PMCID: PMC7544316 DOI: 10.1097/gox.0000000000003099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
Background: Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience. Methods: An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications. Results: No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes’ incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified. Conclusions: Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.
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Allan J, Locke M, Wagener J. Ethnic variability in
post‐mastectomy
breast reconstruction in Counties Manukau District Health Board in 2017: a retrospective review. ANZ J Surg 2020; 90:1402-1407. [DOI: 10.1111/ans.15894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 03/17/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jessica Allan
- Faculty of Medicine and Health ScienceThe University of Auckland Auckland New Zealand
| | - Michelle Locke
- Faculty of Medicine and Health ScienceThe University of Auckland Auckland New Zealand
- Department of Plastic and Reconstructive SurgeryMiddlemore Hospital Auckland New Zealand
| | - Jenny Wagener
- Department of General SurgeryMiddlemore Hospital Auckland New Zealand
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Munder B, Andree C, Witzel C, Fertsch S, Stambera P, Schulz T, Fleischer O, Hagouan M, Grüter L, Aufmesser B, Staemmler K, Kornetka J, Aldeeri M, Seidenstücker K, Abu-Ghazaleh A, Wolter A. The DIEP Flap as Well-established Method of Choice for Autologous Breast Reconstruction with a Low Complication Rate - Retrospective Single-centre 10-Year Experience. Geburtshilfe Frauenheilkd 2020; 80:628-638. [PMID: 32565553 PMCID: PMC7299686 DOI: 10.1055/a-1116-2102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background
Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications.
Patients and Methods
Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months.
Results
A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates.
Conclusion
DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.
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Affiliation(s)
- Beatrix Munder
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Christoph Andree
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Christian Witzel
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Sonia Fertsch
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Peter Stambera
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Tino Schulz
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Olaf Fleischer
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Mazen Hagouan
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Lukas Grüter
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Birgit Aufmesser
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Katinka Staemmler
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Julia Kornetka
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Mohammed Aldeeri
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Katrin Seidenstücker
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Alina Abu-Ghazaleh
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany
| | - Andreas Wolter
- Klinik für Plastische und Ästhetische Chirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Germany.,Universität Witten-Herdecke, Fakultät für Gesundheit, Witten, Germany
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Sacher M, Kapalschinski RN, Wallner C, Wagner JM, Dadras M, Hirsch T, Heute C, Nicolas V, Lehnhardt M, Behr B. Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction. J Plast Reconstr Aesthet Surg 2019; 73:494-500. [PMID: 31883690 DOI: 10.1016/j.bjps.2019.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/15/2019] [Accepted: 10/05/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA). PATIENTS AND METHODS We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI. RESULTS Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41). CONCLUSION We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.
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Affiliation(s)
- Maxi Sacher
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany.
| | - Roman N Kapalschinski
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Christoph Wallner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Johannes Maximilian Wagner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Mehran Dadras
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Tobias Hirsch
- Department of Plastic- and Reconstructive Surgery, Fachklinik Hornheide, Münster, Germany
| | - Christoph Heute
- Department of Adult and Pediatric Diagnostic, Interventional Radiology, Nuclear Medicine, BG University Hospital Bergmannsheil Bochum, Germany
| | - Volkmar Nicolas
- Department of Adult and Pediatric Diagnostic, Interventional Radiology, Nuclear Medicine, BG University Hospital Bergmannsheil Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Björn Behr
- Department of Plastic Surgery, BG University Hospital Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany.
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