Autologous Options for Postmastectomy Breast Reconstruction: A Comparison of Outcomes Based on the American College of Surgeons National Surgical Quality Improvement Program

Reduce Flap Necrosis After Autologous Breast Reconstruction: A Systematic Review

BACKGROUND

Autologous breast reconstruction provides substantial benefits in terms of aesthetics and longevity. However, the risk of flap necrosis poses potential challenges to patients' appearance and psychological well-being, while also escalating health care costs. Consequently, examining the risk factors, assessment techniques, and therapeutic approaches for flap necrosis is critically important.

METHOD

The authors conducted a comprehensive search for relevant studies from January 2010 to August 2024 using PubMed, Web of Science, and the Cochrane Library. The search terms included "autologous breast reconstruction", "flap necrosis", "risk factor", "assessment", and "treatment". The authors initially screened titles and abstracts, followed by a detailed review by 3 investigators to determine the studies that met the inclusion criteria.

RESULT

A total of 68 studies were ultimately selected for analysis. Identified risk factors for flap necrosis include smoking, advanced age, obesity, diabetes, large breast volume, previous radiotherapy, and abdominal surgery. Various assessment methods (e.g., preoperative imaging, intraoperative blood flow monitoring, and postoperative evaluations) can enhance flap survival. The review also covered surgical treatment strategies and non-surgical interventions, including local wound care, hyperbaric oxygen therapy, and pharmacological treatments.

CONCLUSION

This review highlights the critical role of thorough planning and management in minimizing the risk of flap necrosis after autologous breast reconstruction. Effective preoperative assessments, perioperative monitoring, and specific postoperative interventions can significantly lower the incidence of flap necrosis.

Prophylactic Antibiotics for Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Comparison between Three Different Duration Approaches

There is no consensus on the duration of prophylactic antibiotic use for autologous breast reconstruction after mastectomy. We attempted to standardize the use of prophylactic antibiotics after mastectomy using a deep inferior epigastric perforator flap for the breast reconstruction procedure.

Methods

This retrospective case series included 108 patients who underwent immediate breast reconstruction with a deep inferior epigastric perforator flap at the Ditmanson Medical Foundation Chia-Yi Christian Hospital between 2012 and 2019. Patients were divided into three groups based on the duration of prophylactic antibiotic administration (1, 3, and >7 days) for patients with drains. Data were analyzed between January and April 2021.

Results

The prevalence of surgical site infection in the breast was 0.93% (1/108), and in the abdomen it was 0%. The patient groups did not differ by age, body mass index, smoking status, or neoadjuvant chemotherapy. Only one patient experienced surgical site infection in the breast after half-deep necrosis of the inferior epigastric perforator flap. There were no significant differences in surgical site infection based on the duration of prophylactic antibiotic use. The operation time, methods of breast surgery, volume of fluid drainage in the first 3 days of the abdominal and breast drains, and day of removal of the abdominal and breast drains did not affect surgical site infection.

Conclusion

Based on these data, we do not recommend extending prophylactic antibiotics beyond 24 hours in deep inferior epigastric perforator reconstruction.

"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 modified 5-item frailty index is a predictor of perioperative risk in breast reconstruction: An analysis of 40,415 cases

BACKGROUND

The aging population has presented surgeons with new challenges as they increasingly must operate on greater numbers of frail patients. The modified frailty index 5 (mFI-5) is a concise comorbidity-based scale that has been shown to accurately predict adverse surgical outcomes. In this study, we sought to evaluate the ability of the mFI-5 to predict the risk of postoperative outcomes in breast reconstruction patients.

METHODS

Utilizing the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified 40,415 patients who underwent breast reconstruction, of which 29,562 were implant-based reconstructions and 10,853 were autologous breast reconstructions. Demographic and preoperative variables as well as 30-day postoperative outcomes, including mortality, operation duration, length of hospital stay, medical and surgical complications, and discharge destination, were extracted.

RESULTS

Increases in the mFI score correlated with higher rates of reoperation (mFI≥3: 13.5% vs. mFI=0: 5.9%), unplanned readmission (mFI≥3: 10.8% vs. mFI=0: 3.6%), surgical (mFI≥3: 12.2% vs. mFI=0: 4.3%) and medical complications (mFI≥3: 6.8% vs. mFI=0: 1.2%), and lower rates of home discharge (mFI≥3: 96% vs. mFI=0: 99.5%). Multivariate analysis to control for confounders verified significantly higher rates of reoperation (OR=0.01, 95%CI 0.005-0.016), unplanned readmission (OR=0.009, 95%CI 0.005-0.014), and occurrence of surgical complications (OR=0.014, 95%CI 0.009-0.019) and medical complications (OR=0.005, 95%CI 0.002-0.008). Stratification by age showed that the mFI-5 was a stronger risk predictor in younger patients who are frail. Stratification by type of reconstruction showed that increased mFI scores significantly correlated with complications in both autologous and implant-based reconstruction, but the correlation was greater in autologous procedures.

CONCLUSION

The mFI-5 is identified as a powerful risk predictor in breast reconstruction. The application of this easily accessible tool in the preoperative risk stratification of patients undergoing breast reconstruction can enhance treatment planning and support, optimizing patient counseling, informed consent, and decision-making.

Big data analysis of the risk factors and rates of perioperative transfusion in immediate autologous breast reconstruction

Patients undergoing autologous breast reconstruction (ABR) are more likely to require perioperative transfusions due to the increased intraoperative bleeding. In addition to the mastectomy site, further incisions and muscle dissection are performed at the donor sites, including the back or abdomen, increasing the possibility of transfusion. The purpose of this study was to evaluate perioperative transfusion rates and risk factors according to the type of ABR through analysis of big data. Patients who underwent total mastectomy for breast cancer between 2014 and 2019 were identified. The patients were divided into mastectomy only and immediate ABR groups. The transfusion rate was 14-fold higher in the immediate ABR group (16.1%) compared to the mastectomy only group (1.2%). The transfusion rate was highest with the pedicled transverse rectus abdominis myocutaneous flap (24.2%). Performance of the operation in medical institutions located in the provinces and coronary artery disease (CAD) were significant risk factors for the need for transfusion. The perioperative transfusion risk among patients undergoing immediate ABR was related to the flap type, location of medical institution, and CAD. Based on the higher transfusion rate in this study (16.1%) compared to previous studies, the risk factors for the need for transfusion should be determined and evidence-based guidelines should be developed to reduce the transfusion rates.

Nipple-sparing Mastectomy: What the Radiologist Should Know

Nipple-sparing mastectomy (NSM) is increasingly offered to patients undergoing treatment of breast cancer and prophylaxis treatment for reduction of breast cancer risk. NSM is considered oncologically safe for appropriately selected patients and is associated with improved cosmetic outcomes and quality of life. Accepted indications for NSM have expanded in recent years, and currently only inflammatory breast cancer or malignancy involving the nipple is considered an absolute contraindication. Neoplasms close to and involving the nipple areolar complex are common, and cancer of the lactiferous ducts can spread to the nipple. Therefore, accurate determination of nipple involvement at imaging examinations is critical to identifying appropriate candidates for NSM and preventing local recurrence. Multiple imaging features have been described as predictors of nipple involvement, with tumor to nipple distance, enhancement between the index malignancy and the nipple, and nipple retraction demonstrating the highest predictive values. These features can be assessed at multimodality breast imaging, particularly at breast MRI, which demonstrates high specificity and negative predictive value for determining nipple involvement in malignancy. Online supplemental material is available for this article. ^©RSNA, 2022.

Autologous Reconstruction after Mastectomy for Breast Cancer

Background

Women undergoing autologous reconstruction (AR) after mastectomy for breast cancer and their surgeons must make decisions regarding timing of the AR and choose among various flap types. We conducted a systematic review to evaluate the comparative benefits and harms of (1) timing of AR relative to chemotherapy and radiation therapy, and (2) various flap types for AR.

Methods

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.

Results

We screened 15,936 citations. Twelve mostly high risk of bias studies, including three randomized controlled trials and nine nonrandomized comparative studies met criteria (total N = 31,833 patients). No studies addressed timing of AR relative to chemotherapy or radiation therapy. Six flap types were compared, but conclusions were feasible for only the comparison between transverse rectus abdominus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. The choice of either flap may result in comparable patient satisfaction with breasts and comparable risk of necrosis (low SoE for both outcomes), but TRAM flaps probably pose a greater risk of harm to the area of flap harvest (abdominal bulge/hernia and need for surgical repair) (moderate SoE).

Conclusions

Evidence regarding details for AR is mostly of low SoE. New high-quality research among diverse populations of women is needed for the issue of timing of AR and for comparisons among flap types.

Chest Feminization in Male-to-Female Transgender Patients: A Review of Options

Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.

Destination Design msTRAM: For Greater Reconstructive Certainty

Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction.

Predicted versus actual complications in Australian women undergoing post-mastectomy breast reconstruction: a retrospective cohort study using the BRA Score tool

INTRODUCTION

The Breast Reconstruction Risk Assessment (BRA) Score tool is a risk calculator developed to predict the risk of complications in individual patients undergoing breast reconstruction. It was developed in a North American population exclusively undergoing immediate breast reconstruction. This study sought to assess the predictions of the BRA Score tool against the measured outcomes of surgery for an Australian public hospital population, including both immediate and delayed reconstructions.

METHOD

This was a retrospective cohort study of data from women at a single Australian public teaching hospital unit. Data from the Flinders Breast Reconstruction Database was retrieved and compared to BRA Scores calculated for each patient. Receiver operating curve area under the curve analysis was performed as well as Brier scores to compare predicted versus observed complications.

RESULTS

BRA Score predictions were reasonable or good (C-statistic >0.7, Brier score <0.09) for the complications of overall surgical complications, surgical site infection (SSI) and seroma at 30 days, and similarly accurate for prediction of the same complications for implant reconstructions at 12 months. There were similar findings between delayed and immediate reconstructions.

CONCLUSION

The BRA Score risk calculator is valid to detect some risks in both patients undergoing immediate and delayed breast reconstruction in an Australian public hospital setting. SSI is the best predicted complication and is well-predicted across both autologous and prosthetic reconstruction types.

Assessing Readability of Patient Education Materials on Breast Reconstruction by Major US Academic Hospitals as Compared With Nonacademic Sites

PURPOSE

Women undergoing postmastectomy breast reconstruction face many complex choices. A myriad of online patient education materials exist to assist in decision making. Understanding of these materials, termed health literacy, affects surgical decision making and outcomes. The National Institutes of Health recommends writing patient education materials at a sixth- to seventh-grade reading level. The primary goal of this study was to assess readability of online breast reconstruction materials.

METHODS AND MATERIALS

Resources were collected from every academic hospital with a plastic surgery residency program, 97 in total. These data were compared with the top nonacademic Web sites ranked by search engine results, 14 in total. Materials were analyzed using 3 validated readability assessment scales: Coleman-Liau Index, SMOG (Simplified Measure of Gobbledygook) Readability Formula, and Flesch-Kincaid Grade Level. Average readability was analyzed, and results were compared using a 1-way analysis of variance to assess for significance between the different tools and a 2-sided t test to assess for significance between academic and nonacademic readability results.

RESULTS

The mean readability scores across the academic programs were a Coleman-Liau Index of 13.38 (standard Deviation [SD] 2.81, 13th to 14th grade), Flesch-Kincaid Grade Level of 13.04 (SD = 3.9, 13th grade), and SMOG Readability of 13.64 (SD = 2.99, 13th to 14th grade). For the 14 nonacademic sites, results showed a Coleman-Liau Index of 11.93 (SD = 1.14, 12th grade), Flesch-Kincaid of 11.82 (SD = 2.33, 11th to 12th grade), and SMOG Readability of 10.91 (SD = 1.79, 11th grade). One-way analysis of variance demonstrated no significant differences in mean readability scores across the 3 readability tools used (academic F = 2.7804, P = 0.06; nonacademic F = 1.14, P = 0.33). Two-tailed t test results demonstrated that there was statistical significance between readability of the academic in comparison with nonacademic search engine results (t = 2.04, P = 0.04).

CONCLUSIONS

Average readability across all Web sites were much higher than the recommended reading level, at a 13th to 14th grade reading level for academic institutions, and an 11th to 12th grade for nonacademic Web sites. Plastic surgeons may contribute to improving patient understanding and perioperative outcomes through revising patient education materials.

The Assessment of Early Complications and Risk Factors Affecting Their Occurrence in Breast Reconstructive Procedures

The presence of postoperative complications may have a significant impact on the outcome of the breast reconstruction. The aim of this study was to investigate early postoperative complications and the risk factors for their occurrence. A prospective analysis was carried out to evaluate surgical outcomes after breast reconstructive surgeries performed over a 2-year period. Procedures included expander/implant (TE/IMP), pedicle transverse rectus abdominis musculocutaneous (pTRAM), and latissimus dorsi (LD) techniques. All adverse events which occurred within 6 weeks of surgery were ranked according to severity based on the contracted Accordion grading system. Outcomes were assessed for their association with surgical, demographic, and clinical variables. Sixty-one consecutive breast reconstruction procedures were analyzed. The overall complication rate was 60.7% (n = 37), and 8 patients (13.1%) required reoperation. The lowest complication rate was observed in implant-based reconstructions (TE/IMP, 18.8%; pTRAM, 72.7%; LD, 78.3%; p = 0.008). Mild complications occurred significantly more often after LD reconstructions (LD, 60.9%; pTRAM, 22.7%; TE/IMP, 12.5%; p = 0.031), while severe complications were significantly more frequent after the pTRAM procedures (pTRAM, 27.3%; TE/IMP, 6.2%; LD, 8.7%; p = 0.047). Severe complications were associated with higher rehospitalization rate (p = 0.010) and longer hospital stay. Study revealed a significant impact of the operative method on the incidence and severity of early complications after breast reconstruction procedures with little effect from other demographic and clinical factors.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Does Internal Mammary Node Irradiation for Breast Cancer Make a Significant Difference to the Diameter of the Internal Mammary Artery? Correlation with Computed Tomography

Objective

Lymphatic irradiation in breast cancer improves locoregional control and has been shown to decrease distant metastasis. However, irradiation also accelerates the formation of atherosclerosis and can cause stenosis, not only in the coronary arteries but also in the internal mammary artery (IMA). The aim of this study was to investigate the effects of radiation on IMAs via computed tomography (CT).

Methods

We reviewed the data of 3,612 patients with breast cancer treated with radiotherapy (RT) between January 2010 and December 2016. We included 239 patients with appropriate imaging and nodal irradiation in the study. All patients were treated with lymphatic irradiation of 46-50 Gy, and a boost dose (6-10 Gy) to the involved internal mammary nodes (IMNs) when imaging studies demonstrated pathological enlargement. Bilateral IMA diameter and the presence of calcification were assessed via thin contrast-enhanced CT and those of ipsilateral irradiated IMAs were compared with those of contralateral nonirradiated IMAs.

Results

The mean diameter of irradiated IMAs was significantly shorter than that of nonirradiated IMAs, regardless of laterality. All vascular calcifications were determined on the irradiated side. A boost dose of radiation to the IMNs and radiation technique did not significantly affect the IMA diameter or the presence of calcification.

Conclusions

The diameter of the IMA is decreased due to RT regardless of laterality, radiation technique, and administration of a boost dose. Evaluation of vessels on CT before coronary artery bypass graft or flap reconstruction can help the surgeon select the most appropriate vessel.

Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients

BACKGROUND

Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage.

METHODS

By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.

RESULTS

We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001).

CONCLUSION

Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.

Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction

Purpose:

We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block.

Patients and methods:

This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block.

Results:

Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results (P ⩾ .2).

Conclusions:

Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.

The effect of sarcopenia on perioperative complications in abdominally based free-flap breast reconstruction

PURPOSE

The identification of patient-specific risk factors, which predict morbidity following abdominally based microvascular breast reconstruction is difficult. Sarcopenia is a proxy for patient frailty and is an independent predictor of complications in a myriad of surgical disciplines. We predict that sarcopenic patients will be at higher risk for surgical complications following abdominally based microvascular breast reconstruction.

METHODS

A retrospective study of all patients who underwent delayed abdominally based autologous breast reconstruction following postmastectomy radiation therapy from 2007 to 2013 at a single institution was conducted. Univariate and multiple logistic regression models were used to assess the effect of sarcopenia on postoperative outcomes.

RESULTS

Two hundred and eight patients met the inclusion criteria, of which 30 met criteria for sarcopenia (14.1%). There were no significant differences in demographics between groups. There were no significant differences in minor (36.7% vs 44.4%; P = .43) or major (16.7% vs 25.3%; P = .36) complications between groups as well as hospital length of stay. Multivariable logistic regression demonstrated that a staged reconstruction with the use of a tissue expander was the only consistent variable, which predicted major complications (OR, 2.24; 95% CI, 1.18-4.64; P = .015).

CONCLUSIONS

Sarcopenia does not predispose to minor or major surgical complications in patients who undergo abdominally based microsurgical breast reconstruction.

Volumetric change of the latissimus dorsi muscle after postoperative radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap

Background

This study aimed to determine the magnitude of volume reduction of the latissimus dorsi (LD) muscle after treatment using only postoperative radiotherapy (PORTx) in patients who underwent immediate breast reconstruction using an extended LD musculocutaneous (eLDMC) flap after partial mastectomy.

Methods

We retrospectively reviewed 28 patients who underwent partial mastectomy and an eLDMC flap, received only PORTx, and underwent chest computed tomography (CT) 7 to 10 days after surgery and 18±4 months after the end of radiotherapy, from March 2011 to June 2016. The motor nerve to the LD was resected in all patients. One plastic surgeon performed the procedures, and the follow-up period was at least 36 months (mean, 46.6 months). The author obtained LD measurements from axial CT views, and the measurements were verified by an experienced radiologist. The threshold for statistical significance was set at P<0.05.

Results

A statistically significant decrease in the LD volume was found after the end of PORTx (range, 61.19%–80.82%; mean, 69.04%) in comparison to the measurements obtained 7 to 10 days postoperatively (P<0.05). All cases were observed clinically for over 3 years.

Conclusions

The size of an eLDMC flap should be determined considering an average LD reduction of 69% after PORTx. Particular care should be taken in determining the size of an eLDMC flap if the LD is thick or if it occupies a large portion of the flap.

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.

Robotic Surgery: A Novel Approach for Breast Surgery and Reconstruction

Supplemental Digital Content is available in the text.

Background:

Breast cancer is the most prevalent cancer and second leading cause of cancer-related deaths in both the US and UK female population, a prominent cause of morbidity and cost to both health services. All surgically fit patients are offered breast reconstruction following the initial surgery, and this is traditionally an open approach: either implant-based or an autologous tissue flap. Both lead to scarring that is difficult to conceal. This paper aims to evaluate the novel minimally invasive technique of robotic-assisted surgery.

Methods:

A systematic review was conducted using Medline (OvidSP) and Embase (OvidSP) to evaluate the current application of robotic-assisted surgery in breast surgery and reconstruction.

Results:

Twenty-one articles were identified and discussed, composing of level 4 and 5 evidence comparing different surgeons' experiences, techniques, and outcomes. To date, the robotic system has been utilized to harvest the latissimus dorsi muscle for use as a tissue flap (total harvest time of 92 minutes), to perform nipple-sparing mastectomy with immediate breast reconstruction (total operation time 85 minutes) and lately to harvest a deep inferior epigastric perforator flap via an intraabdominal approach.

Conclusions:

Robotic-assisted surgery can successfully and reproducibly perform a nipple-sparing mastectomy with breast reconstruction. It can minimize the size of scarring and is superior to the laparoscopic technique, with improved 3-dimensional visualization, dexterity, and range of motion able to guide around the curvature of the breast. The main limiting factors are the lack of the US Food and Drug Administration approval, cost of the robot, and specialized skills required.

Breast Reconstruction with a Tissue Engineering and Regenerative Medicine Approach (Systematic Review)

Current techniques for breast reconstruction include an autologous-tissue flap or an implant-based procedure, although both can impose further morbidity. This systematic review aims to explore the existing literature on breast reconstruction using a tissue engineering approach; conducted with the databases Medline and Embase. A total of 28 articles were included, mainly comprising of level-5 evidence with in vitro and animal studies focusing on utilizing scaffolds to support the migration and growth of new tissue; scaffolds can be either biological or synthetic. Biological scaffolds were composed of collagen or a decellularized tissue matrix scaffold. Synthetic scaffolds were primarily composed of polymers with customisable designs, adjusting the internal morphology and pore size. Implanting cells, including adipose-derived stem cells, with combined use of basic fibroblast growth factor has been studied in an attempt to enhance tissue regeneration. Lately, a level-4 evidence human case series was reported; successfully regenerating 210 mL of tissue using an arterio-venous pedicled fat flap within a tissue engineering chamber implanted on the chest wall. Further research is required to evaluate whether the use of cells and other growth factors could adjust the composition of regenerated tissue and improve vascularity; the latter a major limiting factor for creating larger volumes of tissue.

Risk factors associated with the development of sepsis after reconstructive flap surgery. J Plast Surg Hand Surg 2019;53:328-334. [PMID: 31204583 DOI: 10.1080/2000656x.2019.1626738]

Sepsis is a serious and potentially life-threatening condition. Risk factors that are associated with the development of sepsis may differ as it relates to reconstructive flap surgery. The purpose of this study is to identify the incidence and predictors for sepsis in patients undergoing reconstructive flap surgery. The ACS-NSQIP database was queried from 2005 to 2016 for factors related to sepsis in patients undergoing reconstructive flap surgery. CPT codes were used to identify patient cohorts. A sepsis group was compared to a control group that underwent the same procedures without the postoperative manifestations of sepsis. Statistical analyses were performed to ascertain risk factors associated with the development of sepsis. 24,257 patients who underwent flap reconstruction were included in this study. Of these, 511 developed sepsis postoperatively (2.1%). Multivariate analysis showed that male gender (p < .001), African-American race (p < .001), hypertension requiring medication (p < .001), smoking (p < .001), a higher Charlson comorbidity Index score (p < .001), evidence of preoperative wound infection (p < .001), chronic steroid use (p < .001), and prolonged operative time (p < .001) all significantly were associated with the development of sepsis. Sepsis resulted in a higher chance of 30-day mortality (p < .001) and increased the risk of developing septic shock (OR: 2.578, CI: 1.241-5.354) This study shows that postoperative sepsis is a serious complication of reconstructive flap surgery. Risk reduction and prevention of potentially life-threatening complications is always a priority. Awareness of the risk factors contributing to the development of sepsis is crucial for early intervention and treatment.

Non-narcotic Perioperative Pain Management in Prosthetic Breast Reconstruction During an Opioid Crisis: A Systematic Review of Paravertebral Blocks

Background:

Alternatives to postoperative, narcotic pain management following implant-based, postmastectomy breast reconstruction (IBR) must be a focus for plastic surgeons and anesthesiologists, especially with the current opioid epidemic. Paravertebral blocks (PVBs) are a regional technique that has demonstrated efficacy in patients undergoing a variety of breast cancer–related surgeries. However, a specific understanding of PVB’s efficacy in pain management in patients who undergo IBR is lacking.

Methods:

A systematic search of PubMed, EMBASE, and Cochrane Library electronic database was conducted to examine PVB administration in mastectomy patients undergoing IBR. Data were abstracted regarding: authors, publication year, study design, patient demographics, tumor laterality, tumor stage, type, and timing of reconstruction. The primary outcome was PVB efficacy, represented as patient-reported pain scores. Secondary outcomes of interest include narcotic consumption, postoperative nausea and vomiting, antiemetic use, and length of stay.

Results:

The search resulted in 1,516 unique articles. After title and abstract screening, 29 articles met the inclusion criteria for full-text review. Only 7 studies were included. Of those, 2 studies were randomized control trials and 5 were retrospective cohort studies. Heterogeneity of included studies precluded a meta-analysis. Overall, PVB patients had improved pain control, and less opioid consumption.

Conclusion:

PVBs are a regional anesthesia technique which may aid in pain management in the breast reconstructive setting. Evidence suggests that PVBs aid in controlling acute postoperative pain, reduce opioid consumption, and improve patient length of stay. However, some conflicting findings demonstrate a need for continued research in this area of pain control.

Free Tissue Breast Reconstruction

Free tissue transfer serves as a modern workhorse for breast reconstruction. Advancements in microsurgical technique have allowed for the development of free flap procedures that produce an aesthetic breast while minimizing donor site morbidity. Here, the authors review the use of different free flap procedures for breast reconstruction with a focus on the preferred and most commonly used flap, the deep inferior epigastric perforator flap. Each flap has its advantages and drawbacks, and certain patient risk factors increase postoperative complications. Other techniques of breast reconstruction including pedicled flaps and adjunctive fat grafting are also briefly discussed.

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.

[Current situation of breast reconstruction after breast cancer in Reunion Island]

OBJECTIVES

The aim of this study is to describe the current trends of breast reconstruction (BR) and breast oncoplasty (BO) for breast cancer patients in Reunion Island.

METHODS

This is a multicenter retrospective descriptive study of all BR and BO surgeries in 2016. We studied the first stage of BR that corresponds to the choice of surgical technique. Patient's age, care center, technique and duration of surgery, complications and their risk factors were reviewed. Patient satisfaction was assessed using the modified BREAST-Q^©.

RESULTS

In 2016, BR rate over total mastectomy was 47.6% and BO rate was 6.3% over partial mastectomy. Among the 92 patients included, 25 immediate BR were performed (84% in private institution) and 44 delayed BR (67% in public hospital). Although prosthetic techniques were the most used, satisfaction seems to be better with autologous techniques.

CONCLUSIONS

The ratio of BR is high in Reunion Island with a wide range of techniques but uneven practice. Conversely, BO's ratio is low and improvement is needed.

Comparison of Wound Complications After Immediate, Delayed, and Secondary Breast Reconstruction Procedures

Importance

Few data are available concerning surgical site infection (SSI) and noninfectious wound complications (NIWCs) after delayed (DR) and secondary reconstruction (SR) compared with immediate reconstruction (IR) procedures in the breast.

Objective

To compare the incidence of SSI and NIWCs after implant and autologous IR, DR, and SR breast procedures after mastectomy.

Design, Setting, and Participants

This retrospective cohort study included women aged 18 to 64 years undergoing mastectomy from January 1, 2004, through December 31, 2011. Data were abstracted from a commercial insurer claims database in 12 states and analyzed from January 1, 2015, through February 7, 2017.

Exposures

Reconstruction within 7 days of mastectomy was considered immediate. Reconstruction more than 7 days after mastectomy was considered delayed if the mastectomy did not include IR or secondary if the mastectomy included IR.

Main Outcomes and Measures

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI and NIWCs.

Results

Mastectomy was performed in 17 293 women (mean [SD] age, 50.4 [8.5] years); 61.4% of women had IR or DR. Among patients undergoing implant reconstruction, the incidence of SSI was 8.9% (685 of 7655 women) for IR, 5.7% (21 of 369) for DR, and 3.2% (167 of 5150) for SR. Similar results were found for NIWCs. In contrast, the incidence of SSI was similar after autologous IR (9.8% [177 of 1799]), DR (13.9% [19 of 137]), and SR (11.6% [11 of 95]) procedures. Compared with women without an SSI after implant IR, women with an SSI after implant IR were significantly more likely to have another SSI (47 of 412 [11.4%] vs 131 of 4791 [2.7%]) and an NIWC (24 of 412 [5.8%] vs 120 of 4791 [2.5%]) after SR. The incidence of SSI (24 of 379 [6.3%] vs 152 of 5286 [2.9%]) and NIWC (22 of 379 [5.8%] vs 129 of 5286 [2.4%]) after implant SR was higher in women who had received adjuvant radiotherapy. Wound complications after IR were associated with significantly more breast surgical procedures (mean of 1.92 procedures [range, 0-9] after implant IR and 1.11 [range, 0-6] after autologous IR) compared with women who did not have a complication (mean of 1.37 procedures [range, 0-8] after implant IR and 0.87 [range, 0-6] after autologous IR).

Conclusions and Relevance

The incidence of SSI and NIWCs was slightly higher for implant IR compared with delayed or secondary implant reconstruction. Women who had an SSI or NIWC after implant IR had a higher risk for subsequent complications after SR and more breast operations. The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy.

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.

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications

INTRODUCTION

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.

METHODS

Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.

RESULTS

Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).

CONCLUSION

Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.

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 A3 online Instructions to Authors. www.springer.com/00266 .

Preoperative Paravertebral Block Improves Postoperative Pain Control and Reduces Hospital Length of Stay in Patients Undergoing Autologous Breast Reconstruction after Mastectomy for Breast Cancer

BACKGROUND

Postoperative pain is a major challenge for patients undergoing breast reconstruction after surgical treatment of breast cancer, resulting in prolonged hospitalizations and additional resource utilization. Evidence on the efficacy of techniques to minimize postoperative pain in autologous breast reconstruction is lacking. We sought to determine whether preoperative paravertebral block (PVB), a regional anesthetic technique, affects postoperative pain control and hospital length of stay (LOS) in patients undergoing autologous breast reconstruction.

METHODS

Consecutive patients undergoing postmastectomy autologous breast reconstruction between 2012 and 2015 were identified from a prospectively collected database to compare those who received PVB to those who did not. Primary outcomes included self-reported pain score, time to oral-only narcotic usage (TTON), and LOS. Sample differences were compared using Wilcoxon rank-sum and Chi square tests for continuous and categorical variables. Kaplan-Meier analysis was used to evaluate TTON and LOS, with Mantel-Cox test used to compare groups.

RESULTS

Of 78 patients, 39 received PVB and 39 did not. Study groups did not differ regarding age, body mass index, American Society of Anesthesiologists class, mastectomy type, flap type, or cancer stage (p > 0.05). Patients in the PVB group reported significantly lower postoperative pain at 2 (p < 0.01) and 24 h (p < 0.01) and shorter median TTON (66 vs. 76 h, p < 0.01). Importantly, median LOS was reduced for patients receiving a PVB in both hours (95 vs. 116, p < 0.01) and hospital nights (4 vs. 5, p = 0.05).

CONCLUSIONS

Preoperative PVB is associated with improved postoperative pain control and shorter hospitalizations for patients with breast cancer undergoing postmastectomy autologous reconstruction.

Development of a Risk Prediction Model to Individualize Risk Factors for Surgical Site Infection After Mastectomy

BACKGROUND

Little data are available regarding individual patients' risk of surgical site infection (SSI) following mastectomy with or without immediate reconstruction. Our objective was to develop a risk prediction model for mastectomy-related SSI.

METHODS

Using commercial claims data, we established a cohort of women <65 years of age who underwent a mastectomy from 1 January 2004-31 December 2011. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify SSI within 180 days after surgery. SSI risk factors were determined with multivariable logistic regression using derivation data from 2004-2008 and validated with 2009-2011 data using discrimination and calibration measures.

RESULTS

In the derivation cohort, 595 SSIs were identified in 7607 (7.8 %) women, and 396 SSIs were coded in 4366 (9.1 %) women in the validation cohort. Independent risk factors for SSIs included rural residence, rheumatologic disease, depression, diabetes, hypertension, liver disease, obesity, pre-existing pneumonia or urinary tract infection, tobacco use disorder, smoking-related diseases, bilateral mastectomy, and immediate reconstruction. Receipt of home healthcare was associated with lower risk. The model performed equally in the validation cohort per discrimination (C-statistics 0.657 and 0.649) and calibration (Hosmer-Lemeshow p = 0.091 and 0.462 for derivation and validation, respectively). Three risk strata were created based on predicted SSI risk, which demonstrated good correlation with the proportion of observed infections in the strata.

CONCLUSIONS

We developed and internally validated an SSI risk prediction model that can be used to counsel women with regard to their individual risk of SSI post-mastectomy. Immediate reconstruction, diabetes, and smoking-related diseases were important risk factors for SSI in this non-elderly population of women undergoing mastectomy.

Post-mastectomy breast reconstruction and its subsequent complications: a comparison between obese and non-obese women with breast cancer

To compare the utilization pattern of breast reconstruction between obese and non-obese patients and assess the association between obesity and postoperative complications as well as healthcare costs. Using MarketScan databases, we identified 2558 breast cancer patients who underwent mastectomy between 2009 and 2012. Temporal trends in breast reconstruction were assessed using the Cochran-Armitage test. Logistic regression models were performed to determine the association between obesity and the occurrence of postoperative complications. Healthcare costs were compared using a generalized linear model. Among 2558 patients treated with mastectomy, the breast reconstruction rate of non-obese patients (76.2 %) was significantly higher than patients in obese class I and class II&III (63.3 and 60.2 %, respectively; P < 0.001). Compared with non-obese patients, obese patients had significantly higher rates of infection (OR 1.53, for obese class I, and OR 1.60, for obese class II&III, both P < 0.01), wound (OR 1.51, P = 0.01 for obese class I, and OR 1.98, P < 0.001 for obese class II&III), and perfusion complications (OR 1.73, P = 0.01 for obese class I, and OR 2.21, P < 0.01 for obese class II&III). The mean postoperative complication cost for non-obese patients ($4684) was significantly lower than those for obese class I patients ($6250) and obese class II&III patients ($7868; P < 0.001). Our analysis demonstrated a significant gap in breast reconstruction between obese and non-obese patients, and our finding underscores the need for careful preoperative assessment of obese patients and call for additional research to minimize the risk of complications.

A case report of total breast reconstruction using an inframammary adipofascial flap with an implant

INTRODUCTION

Prosthetic-based breast reconstruction can be used in combination with autologous flaps such as a latissimus dorsi (LD) flap or a thoracodorsal artery perforator (TDAP) flap to achieve symmetry. However, the LD and TDAP flaps require a different skin incision from that which is used for the mastectomy. As a new autologous flap for use in combination with prosthetic-based breast reconstruction after nipple-sparing mastectomy (NSM), we used an inframammary adipofascial flap.

PRESENTATION OF CASE

The patient was a 27-year-old female with moderate ptotic breasts, who had ductal carcinoma in situ in the lower outer quadrant of her left breast. After NSM through the inframammary fold (IMF) incision, the subcutaneous fat of the intended inframammary area was undermined, and the tongue shaped adipofascial flap was pulled up in the intended area. After inserting a tissue expander under the major pectoral muscle, this adipofascial flap was reflected back to the inferior portion of the breast area. After modeling the breast mound with this flap, the inframammary skin incision was sutured. Eleven months later, the patient underwent surgery to replace the expander with a permanent implant. Eight months after the replacement with an implant, the cosmetic result is good.

DISCUSSION

This procedure can be performed through the same skin incision on the IMF as NSM. Total breast reconstruction using the inframammary adipofascial flap with an implant can be an alternative approach to achieving symmetry in some patients.

CONCLUSION

This method is useful for breast reconstruction after NSM for young patients with moderate-ptotic breasts.

Optimizing Efficiency in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

The process of harvesting and performing microsurgical anastomosis in a deep inferior epigastric perforator (DIEP) flap for breast reconstruction can be a lengthy procedure, which could affect outcomes and patient safety. We hypothesize that the implementation of a high volume center, preoperative planning, and the adaptation of key intraoperative components will optimize the efficiency of perforator flap surgery for breast reconstruction.

METHODS

A retrospective review of 68 consecutive patients who underwent 104 DIEP flaps for immediate or delayed breast reconstruction was performed. Standardized preoperative planning, including computed tomography/magnetic resonance imaging angiogram, operating room setup, and operative technique, was followed. The times of flap harvest, internal mammary vessel harvest, microsurgical anastomosis, flap inset, wound closure, and total length of procedure were reviewed as well as patient outcomes.

RESULTS

The average length of surgery for a unilateral DIEP was 3 hours and 21 minutes and for a bilateral DIEP was 5 hours and 46 minutes. In bilateral DIEP flaps, a significantly longer operative time was noted in immediate (363 ± 14 minutes) compared to delayed (296 ± 17 minutes) (P < 0.05) reconstruction and between procedures performed by 1 surgeon (400 ± 29 minutes) versus 2 surgeons (326 ± 11 minutes) (P < 0.05). Interestingly, no significant difference in operative time was seen in DIEP flaps performed on patients with a body mass index (BMI) less than 30 (193 ± 7.6, 352 ± 17 minutes) versus a BMI greater than 30 (213 ± 11, 333 ± 14 minutes) in both unilateral and bilateral procedures, respectively.

CONCLUSIONS

Efficiency is optimized by preoperative planning with computed tomography/magnetic resonance imaging angiogram, a dedicated operating room team, including 2 microsurgeons and a systematic approach for surgery. The BMI may not significantly affect the duration of surgery.