The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients

The Effects of Body Mass Index on Postoperative Complications in Patients Undergoing Autologous Free Flap Breast Reconstruction

BACKGROUND

 The prevalence of obesity in the United States exceeds 40%, yet perioperative effects of higher body mass index (BMI) in autologous breast reconstruction remain poorly studied. The purpose of this study was to investigate BMI's impact on postop complications in abdominal and gluteal-based autologous breast reconstruction.

METHODS

 We conducted a retrospective study using TriNetX, a health care database containing de-identified data from more than 250 million patients. Patients undergoing autologous breast reconstruction were identified by Current Procedural Terminology codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and 35 to 39.99 kg/m2. Outcomes of interest were defined by International Classification of Diseases, Tenth Revision (ICD-10) codes. A two-sample t-test was performed to compare incidence of postoperative complications between cohorts within 3 months of surgery. Patients with a BMI < 24.99 kg/m2 served as the control. Cohorts were balanced on age, race, and ethnicity.

RESULTS

 We identified 8,791 patients who underwent autologous breast reconstruction. Of those, 1,143 had a BMI < 24.99 kg/m2, 1,867 had a BMI of 25 to 29.99 kg/m2, 1,396 had a BMI of 30 to 34.99 kg/m2, and 559 had a BMI of 35 to 39.99 kg/m2. Patients with a BMI of 25 to 29.99 kg/m2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to 34.99 and 35 to 39.99 kg/m2 had a significantly increased risk of cellulitis, surgical site infection, need for debridement, wound dehiscence, and flap failure.

CONCLUSION

 Our study illustrates that there is an increased risk of postoperative complications associated with higher BMI classes. Understanding these data are imperative for providers to adequately stratify patients and guide the procedural decision-making.

The Effect of Body Mass Index on Free Flap Breast Reconstruction

BACKGROUND

 Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class.

METHODS

 Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time.

RESULTS

 Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001).

CONCLUSION

 This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

BACKGROUND

Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps.

METHODS

Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups.

RESULTS

Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications.

CONCLUSION

In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

Relationship between rib cartilage resection and postoperative chest recession deformity in breast reconstruction

AIM

The most versatile recipient vessels for breast reconstruction are the internal mammary artery and vein. For microvascular anastomosis, one or two costal cartilages are often dissected to increase the length of the vessel and the degree of freedom. In some cases, the resection of the rib cartilage causes long-term depression at the dissected site, compromising its cosmetic appearance.

PATIENTS AND METHODS

A total of 101 patients were examined, with 111 sides in which the internal mammary artery and vein were used as the recipient vessels. The patients were followed up for at least 6 months.

RESULTS

A total of 37 of 38 patients with complete rib cartilage preservation had no depression, and 1 patient had a slight depression. In the case of partial resection of the rib cartilage, 37 of the 46 sides had no depression, 8 sides had mild depression, and 1 side had an obvious depression. When more than one rib cartilage was removed, 11 of the 27 sides had no depression, 11 had mild depression, and 5 had an obvious depression. The Spearman rank correlation coefficient was 0.4911936.

CONCLUSION

This study reported the relationship between rib cartilage resection and postoperative concave deformity in breast reconstruction surgery using free flap transfer and the internal mammary artery and vein as the recipient vessels. A strong correlation was found between the extent of rib cartilage resected and the degree of depression. Minimizing rib cartilage resection when using the internal mammary artery and veins may minimize postoperative chest recession deformity and provide a well-dressed breast reconstruction.

Risk Stratification of Surgical Site Outcomes by BMI & Flap Type in Autologous Breast Reconstruction

INTRODUCTION

Afflicting 2 million lives annually worldwide, breast cancer remains devastating. This study utilized a continuously updated network of electronic medical records (TriNetX Inc, Cambridge, MA) for analysis of 90-day postoperative outcomes of autologous breast reconstruction by increasing body mass index (BMI).

METHODS

The deidentified electronic medical records (EMRs) of 29,453,000 females, age 18-99 years, were retrospectively screened from 45 healthcare organizations. A combined cohort of 7136 patients undergoing autologous breast reconstruction via transverse rectus abdominus muscle (TRAM), deep inferior epigastric perforator (DIEP), or latissimus flap was categorized by BMI into 5 subgroups: normal (n = 3568), overweight (n = 1239), class I (n = 1166), class II (n = 807), and class III (n = 356) obesity. The normal BMI cohort was then compared with each elevated BMI cohort. BMI strata were analyzed for risk of surgical-site occurrences within 90 days of surgery using CPT codes. Stringent propensity score matching was performed.

RESULTS

For the combined group (N = 7136), significant linear increases in risk were observed with increasing BMI for infection (risk ratio [RR] 1.39-2.91,p < 0.05) and dehiscence (RR 2.65-5.17, p < 0.05). Similar linear increases were observed for the abdominally based group (N = 5454) for infection (RR 1.45-2.47, p < 0.05) and dehiscence (RR 2.54-4.77, p < 0.05). For DIEP (N = 4874), near-linear increases were observed for infection (RR 1.60-2.79, p < 0.05) and dehiscence (RR 1.57-5.59, p < 0.05). For TRAM (N = 714), significant increases were observed for seroma, infection, dehiscence, deep vein thrombosis (DVT), sepsis, and PE while increased risks of seroma, DVT, PE, and hernia were observed for latissimus (N = 1380).

CONCLUSIONS

Regardless of flap type, our analysis suggests that a BMI> 39.9 is the inflection point beyond which it may be beneficial not to perform autologous breast reconstruction. Limitations include this study's retrospective nature; thus, future prospective studies would be beneficial.

"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."

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.

The effect of sarcopenic obesity and muscle quality on complications after DIEP-flap breast reconstruction

Introduction

The aim of this study was to evaluate whether sarcopenic obesity and muscle quality as expressed by skeletal muscle radiodensity (SMD) are associated to postoperative complications in women undergoing DIEP-flap breast reconstruction (BR).

Methods

All patients who underwent DIEP-flap BR at our tertiary center between 2010 and 2018 were asked to sign informed consent for the use of their electronic medical records and images. By outlining anatomical skeletal muscle contours on the preoperative abdominal CT-scan at lumbar level L3, SMD and skeletal muscle indices (SMI) were measured by two observers independently. Using logistic regression analyses, the association between sarcopenic obesity (BMI >25 & SMI <39), low SMD (<40HU), and Clavien-Dindo (CD) grade ≥ II complications was evaluated. In this way odds ratios (OR) and adjusted odds ratios (OR_adjusted) were provided.

Results

Out of the 103 patients included in this study, 36% had CD grade ≥ II complications within 30 days of surgery. Twenty patients (19%) suffered from sarcopenic obesity of whom eleven patients (55%) had CD grade ≥ II complications (OR = 2.7, p = 0.05). In a multivariate analysis, sarcopenic obesity was not significantly related to a higher complication rate (OR_adjusted = 2.2, p = 0.14) but women with SMD below average and those with prior radiotherapy had a higher risk for grade ≥ II complications (OR_adjusted = 2.9, p = 0.02 and OR_adjusted = 2.7, p = 0.02 respectively).

Conclusion

Below average SMD (<40HU) was found to be associated with the development of postoperative CD grade ≥ II complications in women undergoing DIEP-flap BR. Future research should evaluate whether improving SMD reduces the complication incidence in this patient group.

The role of psychosocial factors in patients' recollections of breast reconstruction options discussed with their surgeons

A patient's comprehension and memory of conversations with their providers plays an important role in their healthcare. Adult breast cancer patients whose legal sex was female and who underwent treatment at the Center for Reconstructive Surgery at The University of Texas MD Anderson Cancer Center were asked to indicate which breast reconstruction procedures they discussed with their surgeon. We focused on the three most frequent responses: (a) participants who remembered discussing implant-based, tissue-based, and combination procedures; (b) participants who remembered only an implant-based option being discussed; and (c) participants who remember only a tissue-based option being discussed. We used multinomial logistic regression models to explore the psychosocial factors associated with patients' recollections of their breast reconstruction options after discussions with their reconstructive surgeons, controlling for medical factors that impact surgical decision-making. Our analyses identified body mass index, body image investment, and body image as statistically significantly associated with the reconstructive options that a participant recalls discussing with their surgeon. Our findings highlight body image investment and body image as important psychological factors that may influence what patients remember from consultations about breast reconstruction options.

Autologous Versus Alloplastic Reconstruction for Patients with Obesity: A Systematic Review and Meta-analysis

BACKGROUND

Autologous flaps may have superior outcomes when compared to implant breast reconstruction in patients with obesity. To date, no published review has illustrated the superiority of autologous to implant-based reconstruction in this study group in terms of aesthetics outcomes and surgical complications.

METHODS

A systematic search was conducted on PubMed, Cochrane, Google Scholar, and Embase from inception to December 31, 2020. Studies comparing the outcomes (patient satisfaction and complications) of autologous versus implant-based reconstruction in patients with BMI > 30 were selected.

RESULTS

The search yielded 1633 articles, of which 76 were assessed in full text. A total of 12 articles fit inclusion for qualitative review; of them, 7 were meta-analyzed. Autologous reconstruction had a lower incidence of infection (OR 0.74 [95% CI 0.59, 0.92]), hematoma/seroma formation (OR 0.34 [95% CI 0.23, 0.49]), and reconstructive failure (OR 0.47 [95% CI 0.36, 0.62]), but not skin necrosis (OR 0.95 [95% CI 0.73, 1.25]) or wound dehiscence (OR 1.03 [95% CI 0.72, 1.49]) when compared to implant-based reconstruction. Deep vein thrombosis (DVT) and pulmonary embolism occurred more frequently with autologous versus alloplastic reconstruction (OR 2.21 [95% CI 1.09, 4.49] for DVT and OR 2.49 [95% CI 1.13, 5.48] for PE). BREASTQ scores were higher for the autologous breast reconstruction when compared to implant-based group, but failed to reach significance (p value >0.05).

CONCLUSION

The current evidence in the literature suggests that autologous breast reconstruction has lower surgical complication rate when compared to implant-based reconstruction at the expense of higher risk of thrombotic complications for patients with BMI > 30.

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 .

Impact of Body Mass Index on Surgical Outcomes in Oncologic Microvascular Head and Neck Reconstruction

BACKGROUND

Despite increasing recognition, obesity continues to represent a major health issue for millions of people in the USA and worldwide. There is a paucity in the literature regarding the effect of body mass index (BMI) on microsurgical head and neck reconstruction. The present study hypothesized that high BMI is predictive of postoperative recipient- and donor-site complications with longer operative times.

PATIENTS AND METHODS

Retrospective review of patients who underwent free flap surgery for head and neck reconstruction was performed between January 2005 and December 2018. Patients were categorized into four groups based on BMI: < 20 kg/m², 20-30 kg/m², 30-40 kg/m², and ≥ 40 kg/m². Patient characteristics and surgical outcomes were compared between the four groups.

RESULTS

Overall, 4000 free flap surgeries were included in the present study, performed on 3753 patients, of whom 9.9% had a BMI < 20 kg/m², 64.9% had a BMI between 20 and 30 kg/m², 21.6% had a BMI between 30 and 40 kg/m², and 3.6% had a BMI ≥ 40 kg/m². After adjusting for potential confounders, multivariate analysis showed no association between BMI and any complication, major recipient complications, or total flap loss. However, multivariate linear regression model showed BMI 30-40 kg/m² and BMI ≥ 40 kg/m² to be independently associated with longer operative times compared with BMI < 20 kg/m².

CONCLUSION

Obesity and high BMI increase operative times; however, with meticulous surgical technique and diligent postoperative care, microvascular head and neck reconstructions can be performed safely and reliably in the majority of patients regardless of BMI with similar overall, recipient-site, and donor-site complications.

A Bayesian Network Meta-Analysis of Complications Related to Breast Reconstruction Using Different Skin Flaps After Breast Cancer Surgery

BACKGROUND AND OBJECTIVES

As the incidence of breast cancer rises, the number of mastectomy surgeries surges, so does the importance of postoperative breast reconstruction. The implementation of autologous flap restoration methods is becoming prevalent, although which is the best flap remains controversial. As a result, we performed a Bayesian network meta-analysis to compare the eight most common flap in the reconstruction processor of breast cancer surgery. Our findings may help surgeons decide which skin flaps to use for breast reconstruction.

METHODS

We searched PubMed, Medline, Embase, and the Cochrane library for relevant literature. For our Bayesian network meta-analysis, we scrutinized 37 papers and evaluated the postoperative complications of eight commonly used breast reconstruction procedures. We also registered this study on PROSPERO, with the number CRD42021251989.

RESULTS

A total of 21,184 patients were included in this Bayesian network meta-analysis from 37 different studies. The results demonstrate that TRAM flaps are more prone to complications such as hernias in the abdominal wall and blood flow problems. Hematoma and seroma are more likely to follow LDP flaps. Combining LDP flaps with a prosthetic or autologous adipose tissue does not enhance the risk of postoperative problems appreciably. Fat liquefaction are relatively common in DIEP.

CONCLUSIONS

After breast reconstruction, several skin flaps can be employed as clinical choices. TRAM flaps are not recommended for patients with a weak abdominal wall structure, although LDP flaps or SIEA flaps can be considered instead. We do not advocate LDP flaps for patients who have had breast surgery because of the higher risk of hematoma or seroma, but DIEP flaps or LAP flaps can be utilized instead. We do not propose DIEP flaps for individuals who are at a higher risk of postoperative fat liquefaction, but LDP flaps or SIEA flaps can be used instead. However, this Bayesian network meta-analysis has limitations, and further randomized controlled trials are needed to confirm its findings.

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 .

BMI Specific Complications Following Implant-Based Breast Reconstruction after Mastectomy

Background: Breast reconstruction has a positive impact on body image and quality of life for women after experiencing the physically and psychologically demanding process of mastectomy. Previous studies have presented body mass index (BMI) as a predictor for postoperative complications after breast reconstruction, however, study results vary. This retrospective study aimed to investigate the impact of patients’ BMI on postoperative complications following implant-based breast reconstruction. Methods: All implant-based breast reconstructions performed at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Vienna from January 2001 to March 2018 were evaluated. A total of 196 reconstructed breasts among 134 patients met eligibility criteria. Demographic data, surgical techniques, as well as major and minor complications within a one-year follow-up period were analyzed. Results: Patients’ BMI did not show a significant impact on complication rates. The overall incidence of postoperative complications was 30.5% (40/131) of which 17.6% required reoperation. Impaired wound healing (18.3%), seroma (6.1%), hematoma (4.6%), capsular contraction (4.6%) and infection (3.8%) were the most common complications. Conclusion: In our study cohort, BMI was not associated with a significantly higher risk of complications. However, postoperative complications significantly increased with a longer operative time and resulted in an extended length of hospital stay.

Superficial Thinning of the DIEP Flap: A Safe Option to Achieve an Aesthetic Reconstructed Breast in the Obese Patient

BACKGROUND

Abdominal flap-based breast reconstruction is challenging in the overweight and obese population not only because of increased donor-site complications, but also because excessive flap thickness makes inset cumbersome, requiring thinning and remodeling that frequently result in aesthetically poor outcomes.

METHODS

The authors started by studying 10 deep inferior epigastric artery perforator flaps with angiographic computed tomography. Then, they prospectively performed 21 breast reconstructions using a superficial thinning technique reliant on a constant suprafascial vessel as the pedicle for the remaining deep fat and compared the rate of complications with their previous experience using traditional flap thinning techniques.

RESULTS

All samples studied showed a suprafascial division of the main perforator. Two constant branches were identified, one coursing over the Scarpa fascia and displaying a robust network of linking vessels with the subcutaneous and subdermal plexuses. That anatomical insight was used to develop a flap-thinning technique tested on 21 consecutive high-body mass index patients. A 7-year retrospective analysis (n = 164) showed no significant correlation between body mass index and incidence of complications except for a long-term upper pole step deformity that was associated with increasing body mass index (p = 0.001). No statistically significant difference in complications was found comparing high-body mass index patients from the retrospective group (n = 72) with the superficial thinning group, but a highly suggestive difference (p = 0.061) was found regarding the avoidance of the step deformity using the superficial thinning technique.

CONCLUSION

The presence of a constant suprafascial perforator branch makes superficial DIEP thinning a safe technique that facilitates inset and improves the reconstructed breast contour of obese patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Higher body mass index is a more important risk factor than sarcopenia for complications in deep inferior epigastric perforator reconstruction

BACKGROUND

In recent years, breast reconstruction using autologous tissue after breast cancer surgery has become a common procedure. This study investigated the association between the occurrence of complications in breast reconstruction using deep inferior epigastric perforator (DIEP) flaps and patient risk factors among Asian women.

METHODS

This study included cases of breast reconstruction using DIEP flaps performed at our institution. We retrospectively investigated the relationship between preoperative and operative patient factors and postoperative complications by collecting data from medical records. Sarcopenia was also evaluated by calculating psoas muscle index from the area of the iliopsoas muscle at the level of the third lumbar vertebra using images from preoperative computed tomography. Postoperative complications were compared between a low-body mass index (BMI) group and a high-BMI group, defined using BMI values of <25 kg/m² and ≥25 kg/m², respectively.

RESULTS

A total of 129 cases of breast reconstruction using DIEP flaps were included in this analysis. The frequency of postoperative complications was significantly higher in the high-BMI group, including for skin flap necrosis of the breast (p = 0.03), recipient-site infection (p = 0.03), and donor-site seroma (p = 0.003). Moreover, abdominal circumference correlated significantly with recipient-site infection (p = 0.01) and donor-site seroma (p = 0.002). Sarcopenia did not show significant correlations with any complications.

CONCLUSION

BMI was identified as a risk factor for the occurrence of postoperative complications in breast reconstruction using the DIEP flap, but sarcopenia was not.

Effect of Radiation Therapy on Microsurgical Deep Inferior Epigastric Perforator Flap Breast Reconstructions: A Matched Cohort Analysis of 4577 Cases

INTRODUCTION

Breast reconstruction with autologous tissue is a state-of-the art procedure. Several patient-related factors have been identified with regard to the safety and efficacy of these reconstructions. The presented study investigates the impact of prereconstruction radiation on outcomes of deep inferior epigastric perforator (DIEP) free-flap breast reconstructions using largest database available in Europe.

MATERIALS AND METHODS

Between 2011 and 2019, 3926 female patients underwent 4577 DIEP flap breast reconstructions in 22 different German breast cancer centers. The cases were divided into a no-radiation (NR) and a radiation (R) group, according to radiation status before reconstruction. Groups were compared with regard to surgical complications and free-flap outcome.

RESULTS

Overall, there was no significant difference between the groups regarding the rate of total flap loss [1.9% (NR) vs 2.1% (R), P = 0.743], partial flap loss [0.9% (NR) vs 1.5 (R), P = 0.069], and revision surgery [vascular revision: 4.4% (NR) vs 4.1% (R), P = 0.686; wound revision: 7.6% (NR) vs 9.4% (R), P = 0.122]. However, the patients had a significantly higher risk of developing wound healing disturbances at the recipient site [1.2% (NR) vs 2.1% (R), P = 0.035] and showed significantly longer hospitalization {8 [SD, 8.4 (NR)] vs 9 [SD, 15.4 {R}] days, P = 0.006} after prereconstruction radiation.

CONCLUSIONS

Our findings suggest that DIEP flap reconstruction after radiation therapy is feasible. Women with a history of radiation therapy should, however, be informed in detail about the higher risk for wound healing disturbances at the recipient site.

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

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.

Breast Reconstruction Completion in the Obese: Does Reconstruction Technique Make a Difference in Its Achievement?

BACKGROUND

 Breast mound and nipple creation are the goals of the reconstructive process. Unlike in normal body mass index (BMI) women, breast reconstruction in the obese is associated with increased risk of perioperative complications. Our aim was to determine if reconstruction technique and the incidence of perioperative complications affect the achievement of reconstruction completion in the obese female.

METHODS

 Consecutive obese women (BMI ≥30) who underwent mastectomy and implant or autologous reconstruction were evaluated for the completion of breast reconstruction.

RESULTS

 Two hundred twenty-five women with 352 reconstructions were included. Seventy-four women underwent 111 autologous reconstructions and 151 women underwent 241 implant-based reconstructions. Chemotherapy, radiation, and delayed reconstruction timing was more common in the autologous patients. Major perioperative complications (requiring hospital readmission or unplanned surgery) occurred more frequently in the implant group (p ≤ 0.0001). Breast mounds were completed in >98% of autologous cases compared with 76% of implant cases (p ≤ 0.001). Nipple areolar complex (NAC) creation was completed in 57% of autologous patients and 33% of implant patients (p = 0.0009). The rate of successfully completing the breast mound and the NAC was higher in the autologous patient group (Mound odds ratio or OR 3.32, 95% confidence interval or CI 1.36-5.28 and NAC OR 2.7, 95% CI 1.50-4.69).

CONCLUSION

 Occurrence of a major complication in the implant group decreased the rate of reconstruction completion. Obese women who undergo autologous breast reconstruction are more likely to achieve breast reconstruction completion when compared with obese women who undergo implant-based breast reconstruction.

Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study

INTRODUCTION

Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI).

PATIENTS AND METHODS

A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m²), normal weight/ control group (BMI: 18.5-24.9 kg/m²), overweight group (BMI: 25-29.9 kg/m²), moderately obese group (BMI: 30-34.9 kg/m²), and severely obese group (BMI ≥ 35 kg/m²). Surgical complications were accounted for and the five BMI groups were then compared.

RESULTS

Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01).

CONCLUSION

Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.

Breast reconstruction in the high-risk population: current review of the literature and practice guidelines

Breast reconstruction is an important part of the cancer treatment paradigm and the psychosocial benefits are well described in the literature. Notably, breast reconstruction restores both the functional and emotional losses patients experience due to tumor resection. Post-cancer quality of life is an important benchmark of successful treatment; therefore, breast reconstruction is an essential component that should be offered whenever possible. Over time, reconstructive techniques and outcomes have improved dramatically resulting in better patient safety and decreased operative morbidity. When counseling a patient for surgery, the provider must consider all aspects of a patient's health. Ideally, breast cancer patients should be physically, emotionally, and oncologically appropriate candidates for reconstruction. However, in concerted effort to provide opportunities for as many patients as possible, the definition of who is a good candidate for reconstruction has evolved to include higher risk patients. These patients include those with advanced age, nicotine use, obesity, and significant ptosis. With improvements in surgical procedures and perioperative care, this population may also benefit from restorative surgery. However, the exact risk of complications and necessary counseling has gone largely undefined in this population. This article examines particular "high-risk" groups that may be challenging for extirpative and reconstructive surgeons and offers current guidelines for practice.

A short-term comparison of expander prosthesis and DIEP flap in breast reconstructions: A prospective randomized study

BACKGROUND

There is yet no clear consensus on which method is preferable in secondary breast reconstructions, prosthesis, or autologous tissue.

METHODS

In this first prospective randomized study, 29 women underwent reconstruction with expander prosthesis (EP) and 44 with deep inferior epigastric perforator (DIEP) flap. Inclusion started in 2012 and ended in 2018. Demographic data, complications, surgery time, hospital days, and consulting visits were recorded. Patient satisfaction was evaluated pre- and postoperatively using the BREAST-Q questionnaire. Health care costs were calculated based on rates from the financial year 2018. Here, we report the results related to the surgery and the first 30 postoperative days.

RESULTS

The two groups were comparable regarding demographics and clinical characteristics. Satisfaction with breasts, measured with BREAST-Q, was significantly higher in patients who had undergone reconstruction with DIEP flap compared with EP. Within 30 days after breast reconstruction, significantly fewer women (n = 2) in the EP group suffered complications compared to the DIEP flap group (n = 16; p < 0.01). The health care cost was also significantly higher in the DIEP flap group relative to the EP group (p < 0.01).

DISCUSSION

This patient cohort will be studied systematically over time, and results concerning the need for complementary surgery, costs, esthetics, and the patient-reported outcome (PRO) will be reported in future work. In this short-term report, EP seems to be preferable in regard to cost and complications, and DIEP flap is to choose from the patient's perspective.

Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer

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.

Disparities in Access to Autologous Breast Reconstruction

Background and objectives: This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. Materials and methods: This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ2 test and logistic regression in this analysis. Results: On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58-0.78, p < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72-0.93, p = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33-1.86, p < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51-0.74, p < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Conclusions: Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.

An Evaluation of the Utility of the Breast Reconstruction Risk Assessment Score Risk Model in Prepectoral Tissue Expander Breast Reconstruction

INTRODUCTION

Individualized postsurgical risk assessment models provide surgeons and patients with information that is vital to the surgical decision-making process. One such tool, the Breast Reconstruction Risk Assessment (BRA) score, uses a limited selection of patient-specific factors to predict 30-day postsurgical risk of surgical site infection, seroma, dehiscence, reoperation and explantation associated with immediate submuscular tissue expander breast reconstruction. This model's performance in prepectoral tissue expander reconstruction has not been previously reported. Here, we evaluate the performance of the BRA score model in a population of patients who underwent immediate prepectoral tissue expander breast reconstruction.

MATERIALS AND METHODS

A retrospective chart review was conducted of prepectoral breast reconstructions performed in 2 institutions between January 2017 and December 2018. Complications occurring within 30 days postoperatively were documented and compared with the BRA score predicted risk for each patient.

RESULTS

Overall 247 patients (average age, 49.2 years) were included in the study. The mean BRA score predicted 30-day risk of a complication was 13.0% (7.5-41.5%). The observed rate of 30-day postoperative complications was 31.2% (77 patients), though only 36 (14.6%) patients had complications included in the model. The remaining patients experienced skin necrosis or hematoma as their only early complication. The 30-day BRA score model demonstrated good fit for the overall occurrence of any of the BRA score predicted complications (Hosmer-Lemeshow 0.7167), though the model discrimination was poor (C statistic <0.60). Notably, half of the 30-day postsurgical complications observed in this study were due to skin necrosis, a complication not currently included in the 30-day BRA score model.

CONCLUSIONS

Our results indicate that the current 30-day BRA score model may have poor predictive value in prepectoral breast reconstruction. The most common early complication observed, skin necrosis, is not currently included in the model, suggesting that caution should be applied when using this risk predictive calculator as an adjunct to patient evaluation and counseling.

Effect of Body Mass Index on Outcomes after Prepectoral Breast Reconstruction

BACKGROUND

Body mass index has been shown to be a predictor of outcomes after subpectoral expander/implant reconstruction, with every unit increase in body mass index increasing the risk of complications by approximately 6 percent. The effect of body mass index on complications after prepectoral reconstruction has not yet been evaluated and is the purpose of this study.

METHODS

A total of 366 reconstructed breasts from 197 patients were stratified into five body mass index groups (normal; overweight; and class I, class II, and class III, obese) and postoperative complications were compared across the groups. Additional analyses were performed using broad classifications of body mass index into nonobese and obese in addition to normal, overweight, and obese. Body mass index as an independent predictor of complications was assessed using multivariate logistic regression analysis.

RESULTS

Complication rates did not differ significantly across body mass index groups when using the broad classifications. With five-group stratification, significantly higher rates of return to operating room, expander/implant loss, skin necrosis, wound dehiscence, and overall complications were seen in class II and/or class III obese versus overweight patients. However, on multivariate logistic regression analyses, body mass index, as a continuous variable, did not independently predict any complication. Diabetes and smoking emerged as significant predictors of any complication, indicating that these factors, rather than body mass index, were driving the increased rates of complications seen in the high-body mass index groups.

CONCLUSION

Body mass index alone is not a predictor of outcomes after prepectoral expander/implant breast reconstruction and should not be used to estimate risk of postoperative complications or exclude patients for prepectoral reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Increasing abdominal wall thickness predicts complications in abdominally based breast reconstruction: A review of 106 consecutive patients

BACKGROUND

Body mass index (BMI) has long been the proxy for patient selection in obese patients presenting for abdominally based breast reconstruction. BMI, however, fails to accurately reflect the distribution of abdominal adipose tissue. This study aims to quantify the effect of abdominal wall thickness on the incidence of post-operative complications and contrast abdominal wall thickness and BMI as predictors of post-operative morbidity.

METHODS

We performed a retrospective review of 106 consecutive patients who underwent abdominally based breast reconstruction. Abdominal wall thickness was quantified using preoperative CT angiograms. Primary outcomes included delayed wound healing (abdomen and/or breast), flap fat necrosis, return to OR in 30 days, infection, and flap loss.

RESULTS

Patients experiencing delayed abdominal wound healing (n=38), delayed breast wound healing (n=27), and flap fat necrosis (n=24) had significantly thicker abdominal wall measurements (p<0.0015). Of the 24 patients with palpable fat necrosis, 11 required excision. Increasing abdominal wall thickness significantly increased the odds of delayed abdominal wound healing (p=0.0005), delayed breast wound healing (p=0.0009), flap fat necrosis (p=0.0028), and infection (p=0.0198). Compared to BMI, abdominal wall thickness proved to be a more accurate predictor of delayed breast wound healing, any delayed wound healing, flap fat necrosis, and infection.

CONCLUSIONS

Our data indicate that as abdominal wall thickness increases, so does the risk of postoperative morbidity. Abdominal wall thickness outperformed BMI as a predictor of postoperative morbidity in several areas. This suggests that objective data obtained from preoperative CT scans may allow more accurate, individualized perioperative risk assessment.

Impact of Obesity on Quality of Life After Breast Reconstruction

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.

Surgical Site Infection after Breast Surgery: A Retrospective Analysis of 5-Year Postoperative Data from a Single Center in Poland

Background and Objectives: Surgical site infection (SSI) is a significant complication of non-reconstructive and reconstructive breast surgery. This study aimed to assess SSI after breast surgery over five years in a single center in Poland. The microorganisms responsible for SSI and their antibiotic susceptibilities were determined. Materials and Methods: Data from 2129 patients acquired over five years postoperatively by the Department of Surgical Oncology, Medical University of Gdansk in Poland were analyzed. Results: SSI was diagnosed in 132 patients (6.2%) and was an early infection in most cases (65.2%). The incidence of SSI was highest in patients who underwent subcutaneous amputation with simultaneous reconstruction using an artificial prosthesis (14.6%), and breast reconstruction via the transverse rectus abdominis muscle (TRAM) flap method (14.3%). Gram-positive bacteria were responsible for SSI in most cases (72.1%), and these were mainly Staphylococcus strains (53.6%). These strains were 100% susceptible to all beta-lactam antibiotics (except penicillin) but were less susceptible to macrolides and lincosamides. Conclusions: SSI is a serious problem, and attention should be focused on its prevention. Reconstruction using an artificial prosthesis or via the TRAM flap method is connected to increased SSI incidence. Further studies are required to prevent SSI following breast surgery.

Operative risk stratification in the obese female undergoing implant-based breast reconstruction

The prevalence of obesity is growing, and breast reconstruction in the obese patient is becoming the norm rather than the exception. Our aim was to evaluate implant reconstruction outcomes in the obese female in the presence of coincident surgical risk factors and identify potential risk-reducing interventions. A review of consecutive obese women (BMI ≥ 30) who underwent mastectomy and implant breast reconstruction was performed. Patient demographics, comorbidities, oncologic treatments, and reconstructive procedures and their complications were recorded. A total of 151 women (242 breast reconstructions) were included with mean follow-up of 28 months. Average BMI was 36. Eighty percent of cases were immediate and 20% delayed. ADMs were utilized in 58% of cases. About 25% of patients had diabetes with one-third achieving perioperative glycemic control. About 18% of women were active smokers, and 33% had radiotherapy. Major and minor complications occurred in 42% and 11% of patients, respectively. About 24% of reconstructed breasts required implant removal. Obese patients with prior radiation were three times as likely to develop infection (P = 0.008) and 2.5× as likely to undergo explantation (P = 0.002). Skin flap necrosis was three times as likely in obese smokers (P = 0.01). Increased rates of wound breakdown were identified in obese patients with increasing age (P = 0.005), smoking (P = 0.0035), and radiation (P = 0.023). In the obese radiated and smoking patient subgroups, surgical modifications (use of autologous tissue, delayed breast reconstruction timing, and no ADM) were associated with reduction in the relative risk for implant complications. While obesity alone increases implant breast reconstruction complication rates, the presence of additional risk factors compounds these rates. The use of surgical modifications may reduce the occurrence of perioperative complications in the obese female with coincident surgical risk factors undergoing implant breast reconstruction.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

Background

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

Methods

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

Results

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

Conclusion

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

The Effect of Smoking and Body Mass Index on The Complication Rate of Alloplastic Breast Reconstruction

BACKGROUND AND AIMS

The aim of this study was to evaluate the effect of smoking and body mass index on the occurrence of complications after alloplastic breast reconstruction.

MATERIALS AND METHODS

A consecutive series of 56 patients treated with immediate or delayed alloplastic breast reconstruction, including six cases combined with latissimus dorsi flap, at three hospitals between 2012 and 2018 were included. Complications were scored and defined according to Clavien-Dindo. To evaluate the impact of smoking, body mass index, and other potential risk factors on the occurrence of any and severe complications, univariate and multivariate logistic regression analyses were applied to estimate odds ratios and 95% confidence intervals.

RESULTS

In 56 patients, 22 patients had a complication. As much as 46% of smokers had severe complications compared to 18% of non-smokers. Of patients with body mass index ⩾ 25, 40% had severe complications compared to 10% with body mass index < 25. Smokers had eight times more chance of developing severe complications than non-smokers (OR_adjusted = 8.0, p = 0.02). Patients with body mass index ⩾ 25 had almost 10 times more severe complications compared to patients with body mass index ⩽ 25 (OR_adjusted = 9.9, p = 0.009). No other risk factors were significant.

CONCLUSION

Smoking and body mass index ⩾ 25 both increased the complication rate to such an extent that patients should be informed about their increased risk for complications following alloplastic breast reconstruction and on these grounds surgeons may delay alloplastic breast reconstruction. It is an ethical dilemma whether one should deny overweight and obese patients and those who smoke an immediate alloplastic breast reconstruction. For both life style interventions, adequate guidance should be made available.

Prospective Evaluation of Obese Patients Undergoing Autologous Abdominal Free Flap Breast Reconstruction

BACKGROUND

Obesity has been viewed as a relative contraindication against autologous free flap breast reconstruction because of increased risks of complications, including flap loss.

METHODS

The authors conducted a prospective analysis of obese patients undergoing autologous breast reconstruction.

RESULTS

Overall, 72 patients (average age, 48.5 years; average body mass index, 35.7 kg/m) underwent abdominal free flap breast reconstruction. There were 43 bilateral reconstructions and the remainder were unilateral (n = 115 flaps). There were 67 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps (58.3 percent), 44 deep inferior epigastric perforator (DIEP) flaps (38.2 percent), two free bipedicle DIEP flaps, one superficial inferior epigastric perforator flap, and one free TRAM flap. Forty-two patients (58.3 percent) had prior radiation, and 51 (70.8 percent) had prior chemotherapy. Forty-three patients (59.7 percent) underwent delayed reconstruction and 21 (29.2 percent) underwent immediate reconstruction. Eight patients (11.1 percent) had bilateral reconstruction, with one breast reconstructed in an immediate and the other in a delayed fashion. Half of the patients (n = 36) had mesh placed in an underlay fashion to reinforce the donor site. Regarding breast complications, there were 11 wound dehiscences, one hematoma, one infection, and two patients with mastectomy skin flap necrosis. Twelve patients had donor-site wound healing complications, there were four infections, and three patients developed a bulge/hernia. There were no flap losses. Comparison to historic controls demonstrated no significant differences in overall flap loss rates (p = 0.061) or donor-site bulge/hernia (p = 0.86).

CONCLUSION

Autologous abdominal free flaps can be performed safely in obese patients without increased risks for donor-site bulge/hernia or flap loss compared to nonobese patients; however, patients should be counseled carefully regarding the potential risks of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Medial Arm Flap: An Unexplored Option for Autologous Breast Reconstruction in the Setting of Morbid Obesity

Currently, deep inferior epigastric perforator flap is undoubtedly the first choice for autologous breast reconstruction for most surgeons; however, there are instances where lower abdominal tissue is unavailable for microvascular transfer. In these cases, most surgeons choose gluteal or lower-extremity territories as donor sites.In the setting of morbid obesity, there is an increased risk of flap and donor site complications, as well as increased blood loss, surgical time, and risk of deep venous thrombosis, not to mention a more challenging surgical technique. Added to these problems, Tamoxifen intake and delayed or limited ambulation due to pain or surgical wounds increases deep venous thrombosis risk even further.The use of the upper arm as donor site for microvascular transfer avoids most of these problems and allows for immediate, comfortable ambulation. On the other hand, upper arm flaps have smaller caliber vessels for microanastomosis, shorter pedicles, and a limited amount of skin which makes them a viable option for only a select group of patients with redundant upper arm skin. We provide a previously undocumented proof-of-concept case report of a delayed breast reconstruction using the medial arm free flap that resulted in an uneventful postoperatory follow-up with a naturally textured and shaped reconstructed breast.

Spontaneous rupture of abdominal wall after breast reconstruction using deep inferior epigastric perforator flap following mastectomy for breast cancer

BACKGROUND

The demand for breast reconstruction after mastectomy is rising. The use of deep inferior epigastric perforator (DIEP) flap in autologous reconstruction is a popular approach. There were some reports about abdominal complications after breast reconstruction. However, there was no report about spontaneous rupture of abdominal wall.

CASE PRESENTATION

A 46-year-old female patient was diagnosed with left breast cancer. Left mastectomy with sentinel lymph node biopsy was performed, and the breast was reconstructed using DIEP flap simultaneously. She suffered heavy abdominal pain and vomiting at postoperative day 4. Computed tomography showed bowel herniation into the subcutaneous tissue caused by left abdominal wall rupture. The abdominal wall was sutured and repaired using mesh by emergency surgery.

CONCLUSIONS

To the best of our knowledge, this is the first case about spontaneous rupture of abdominal wall after breast reconstruction using DIEP flap to be reported in the English literature. DIEP flap on breast reconstructive surgery may cause spontaneous rupture of abdominal wall.

Impact of Body Mass Index on Operative Outcomes in Head and Neck Free Flap Surgery

Objective

Analyze the risk for perioperative complications associated with body mass index (BMI) class in patients undergoing head and neck free flap reconstruction.

Study Design and Setting

Retrospective cohort study.

Subjects and Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried for all cases of head and neck free flaps between 2005 and 2014 (N = 2187). This population was stratified into underweight, normal-weight, overweight, and obese BMI cohorts. Groups were compared for demographics, comorbidities, and procedure-related variables. Rates of postoperative complications were compared between groups using χ2 and binary logistic regression analyses.

Results

Underweight patients (n = 160) had significantly higher rates of numerous comorbidities, including disseminated cancer, preoperative chemotherapy, and anemia, while obese patients (n = 447) had higher rates of diabetes and hypertension. Rates of overall surgical complications, medical complications, and flap loss were insignificantly different between BMI groups. Following regression, obese BMI was protective for perioperative transfusion requirement (odds ratio [OR] = 0.63, P = .001), while underweight status conferred increased risk (OR = 2.43, P < .001). Recent weight loss was found to be an independent predictor of perioperative cardiac arrest (OR = 3.16, P = .006) while underweight BMI was not (OR = 1.21, P = .763). However, both weight loss and underweight status were associated with significantly increased risk for 30-day mortality (OR = 4.48, P = .032; OR = 4.02, P = .010, respectively).

Conclusion

Obesity does not increase the risk for postoperative complications in head and neck free flap surgery and may be protective in some cases. When assessing a patient’s fitness for surgery, underweight status or recent weight loss may suggest a reduced ability to tolerate extensive free flap reconstruction.

Goldilocks Mastectomy with Bilateral In Situ Nipple Preservation Via Dermal Pedicle

Patients who don't want or can't have formal breast reconstruction after mastectomy surgery can be considered for a Goldilocks mastectomy, where the breast fullness is recreated from what is left behind after the gland tissue is removed from underneath the skin in a breast reduction pattern. A Goldilocks mastectomy does not require the use of implants or tissue transfer from other parts of the body and may be completed in a single surgery. This is best suited for larger breasted women who are willing to have much smaller breasts as a result. Previously, it was a challenge to be able to preserve the nipples when this operation was performed; however, this article describes a patient who had a bilateral Goldilocks mastectomy for right breast cancer who was able to save her nipples by keeping the blood flow in place from the surrounding skin. Conventional breast reconstruction after mastectomy is a challenge for larger breasted women. The Goldilocks mastectomy technique was designed to make best use of the redundant lower pole skin and subcutaneous fat to recreate a breast mound without a prosthetic implant or autologous tissue transfer. In its original description, the Goldilocks mastectomy did not include a means for nipple preservation. In this report, we describe the further refinement of the Goldilocks procedure that preserves the nipple areolar complex using a dermal pedicle. A patient with large pendulous breasts and right breast carcinoma underwent a bilateral Goldilocks nipple-sparing mastectomy and immediate reconstruction without an implant or flap.

Expander/Implant Removal After Breast Reconstruction: Analysis of Risk Factors and Timeline

INTRODUCTION

Removal of tissue expanders (TE) or implants is a dire consequence of breast reconstruction, and has the potential to halt the reconstructive efforts. Our goals were to characterize a cohort of patients with TE/implant removal, to perform a time-based analysis, and to review the bacteriology associated with explanted devices.

MATERIALS AND METHODS

Review of a prospectively maintained database was performed to identify patients who underwent TE/implant removal. Patient characteristics, surgical technique, adjuvant therapies, indications, complications, culture results were obtained. Data were analyzed according to timing of explantation.

RESULTS

A total of 55 TE and implants were removed in 43 patients. Reasons for explantation were infection (58%), patient request (22%), and wound-related complications (20%). The majority of explantations occurred after 30 days (62%), and after Stage I (81%). Median days to explantation was 62. Patients of older age (p = 0.01) and higher BMI (p = 0.02) were more likely to undergo explantation after Stage I. The most commonly cultured organisms were S. epidermidis (10.9%), S. aureus (10.9%) and P. aeruginosa (10.9%). Antibiotic resistance was commonly encountered for ampicillin, cefazolin, penicillin, and erythromycin.

CONCLUSION

Infection is the most common reason for explantation after prosthetic breast reconstruction. Patients should be carefully monitored for a prolonged period of time after Stage I, as the majority of explantations occur in this stage but beyond 30 days. For oral treatment, fluoroquinolones and trimethoprim-sulfamethoxazole and for IV treatment a combination of vancomycin or daptomycin with piperacillin-tazobactam or imipenems/carbapenems appear to be appropriate choices according to our culture results.

LEVEL OF EVIDENCE IV

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 .

Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes

BACKGROUND

In women who require postmastectomy radiation therapy, immediate autologous breast reconstruction is often discouraged. The authors prospectively evaluated postoperative morbidity and satisfaction reported by women undergoing delayed or immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy.

METHODS

Patients enrolled in the Mastectomy Reconstruction Outcomes Consortium study, who received postmastectomy radiotherapy and underwent immediate or delayed free abdominally based autologous breast reconstruction, were identified. Postoperative complications at 1 and 2 years after reconstruction were assessed. Patient-reported outcomes were evaluated using the BREAST-Q questionnaire preoperatively and at 1 and 2 years postoperatively. Bivariate analyses and mixed-effects regression models were used to compare outcomes.

RESULTS

A total of 175 patients met the authors' inclusion criteria. Immediate reconstructions were performed in 108 patients and delayed reconstructions in 67 patients; 93.5 percent of immediate reconstructions were performed at a single center. Overall complication rates were similar based on reconstructive timing (25.9 percent immediate and 26.9 percent delayed at 1 year; p = 0.54). Patients with delayed reconstruction reported significantly lower prereconstruction scores (p < 0.0001) for Satisfaction with Breasts and Psychosocial and Sexual Well-being than did patients with immediate reconstruction. At 1 and 2 years postoperatively, both groups reported comparable levels of satisfaction in assessed BREAST-Q domains.

CONCLUSIONS

From this prospective cohort, immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy appears to be a safe option that may be considered in select patients and centers. Breast aesthetics and quality of life, evaluated from the patient's perspective, were not compromised by flap exposure to radiation therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Patient determinants as independent risk factors for postoperative complications of breast reconstruction

BACKGROUND

Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling.

METHODS

We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications.

RESULTS

Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially.

CONCLUSIONS

Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.

Late Surgical-Site Infection in Immediate Implant-Based Breast Reconstruction

BACKGROUND

Surgical-site infection causes devastating reconstructive failure in implant-based breast reconstructions. Large national database studies offer insights into complication rates, but only capture outcomes within 30 days postoperatively. This study evaluates both early and late surgical-site infection in immediate implant-based reconstruction and identifies predictors.

METHODS

As part of the Mastectomy Reconstruction Outcomes Consortium Study, 1662 implant-based breast reconstructions in 1024 patients were evaluated for early versus late surgical-site infection. Early surgical-site infection was defined as infection occurring within 30 days postoperatively; late surgical-site infection was defined as infection occurring 31 days to 1 year postoperatively. Minor infection required oral antibiotics only, and major infection required hospitalization and/or surgical treatment. Direct-to-implant patients had 1-year follow-up, and tissue expander patients had 1-year post-exchange follow-up.

RESULTS

Among 1491 tissue expander and 171 direct-to-implant reconstructions, overall surgical-site infection rate for tissue expander was 5.7 percent (85 of 1491) after first-stage, 2.5 percent (31 of 1266) after second-stage, and 9.9 percent (17 of 171) for direct-to-implant reconstruction. Over 47 to 71 percent of surgical-site infection complications were late surgical-site infection. Multivariate analysis identified radiotherapy and increasing body mass index as significant predictors of late surgical-site infection. No significant difference between the direct-to-implant and tissue expander groups in the occurrence of early, late, or overall surgical-site infection was found.

CONCLUSIONS

The majority of surgical-site infection complications in immediate implant-based breast reconstructions occur more than 30 days after both first-stage and second-stage procedures. Radiotherapy and obesity are significantly associated with late-onset surgical-site infection. Current studies limited to early complications do not present a complete assessment of infection associated with implant-based breast reconstructions or their long-term clinical outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.