Evolution of Bilateral Free Flap Breast Reconstruction over 10 Years: Optimizing Outcomes and Comparison to Unilateral Reconstruction

Timing of Autologous Tissue Breast Reconstruction Does Not Affect Free Flap Failure

ABSTRACT

This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction.

Free Tissue Transfer for Reconstruction After Bilateral Skin Sparing Mastectomy-A Systematic Review

BACKGROUND

Breast cancer is the most commonly diagnosed malignant neoplasia in females worldwide. Overall survival and patients' choice for bilateral mastectomy have increased. It is therefore important to offer breast reconstructive procedures to improve patient quality of life and self-esteem. The aim of this systematic literature review is to quantify the outcome and sustainability of bilateral breast reconstruction using autologous, vascularized free tissue transfer.

METHODS

A systematic literature review of PubMed, Cochrane, and the Web of Science databases was performed. A total of 5879 citations were identified, and 12 studies met the inclusion criteria.

RESULTS

A total of 1316 patients were included, with a mean age of 47.2 years. Overall, 32.5% of patients experienced a complication after breast reconstruction. If reported, 7.45% of patients experienced major complications, while 20.7% had minor complications.The following flaps were used for breast reconstruction, in order of reducing frequency: DIEP (45.45%), TRAM (22.73%), SIEA (9.09%), SGAP (9.09%), TUG (4.55%), TMG (4.55%), and LD/MLD (4.55%).

CONCLUSIONS

Current studies indicate that bilateral breast reconstruction using autologous, vascularized free tissue transfer is a safe procedure for postmastectomy reconstruction and offers stable long-term results. This is particularly in comparison to implant-based breast reconstruction.

Abdominal-Based Microsurgical Breast Reconstruction: How to Inset the Flap to Maximize the Aesthetic Result-A Systematic Review

Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

The Utility of the 5-Factor Modified Frailty Index to Predict Postoperative Risk in Microsurgical Reconstruction

BACKGROUND

Microsurgical reconstruction is an integral part of plastic surgery. The 5-factor modified frailty index (5-mFI) is an effective tool to predict postoperative complications across multiple subspecialties. We aimed to determine if frailty scores using the 5-mFI can predict postoperative complications specifically in microvascular reconstruction.

STUDY DESIGN

Frailty scores were retrospectively assessed in microsurgical reconstruction patients (2012-2016) using the American College of Surgeons National Quality Improvement Program base. The 5 variables that comprise the 5-mFI are history of chronic obstructive pulmonary disease, history of congestive heart failure, functional status, hypertension requiring medication and diabetes. The data were analyzed using the Goodman test, χ2 test, and a logistic regression model. The congruence was also compared between the 5-mFI and the American Society of Anesthesiology (ASA) classification in predicting complications.

RESULTS

Of 5894 patients, the highest 5-mFI value was "3." Analyses show an increase in postoperative complications requiring ICU care. Further models indicate an association between readmission with hypertension and chronic obstructive pulmonary disease (P < 0.05). There was an increased risk of a failure to wean from ventilator with a history of chronic obstructive pulmonary disease and diabetes and an increased risk of readmission with a history of hypertension and chronic obstructive pulmonary disease. The 5-mFI and ASA were incongruent in predicting postoperative complications.

CONCLUSIONS

The 5-mFI predicts postoperative complications in the microsurgical reconstruction population. Although the 5-mFI and ASA predict different complications, their use provides insight into the potential adjustable risks before surgery.

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.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

BACKGROUND

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

METHODS

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

RESULTS

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

CONCLUSIONS

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Ethnic Disparities in Thrombotic and Bleeding Diatheses Revisited: A Systematic Review of Microsurgical Breast Reconstruction across the East and West

BACKGROUND

 Ethnicity has been shown to play a role in disparate coagulative responses between East Asian and Caucasian patients undergoing nonmicrovascular surgery. In this study, we sought to further investigate this hematologic phenomenon between the two ethnic groups within the field of microsurgical breast reconstruction.

METHODS

 A systematic review examining the reported incidence of microvascular thrombosis and all-site bleeding among breast free flaps in East Asians and Westerners was performed. Statistical analysis was performed using the chi-square test.

RESULTS

 Ten East Asian studies with 581 flaps and 99 Western studies with 30,767 flaps were included. A statistically significant higher rate of thrombotic complications was found in Westerners compared with East Asians (4.2 vs. 2.2%, p = 0.02). Conversely, bleeding events were more common in East Asians compared with Westerners (2.6 vs. 1.2%, p = 0.002).

CONCLUSION

 There appears to be an ethnicity-based propensity for thrombosis in Westerners and, conversely, for bleeding in East Asians, as evident by the current systematic review of microvascular breast reconstruction data. It is therefore advisable to consider ethnicity in the comprehensive evaluation of patients undergoing microsurgical procedures.

Latest Advancements in Autologous Breast Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses.

SUMMARY

Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.

Risk of Pneumothorax With Internal Mammary Vessel Utilization in Autologous Breast Reconstruction

BACKGROUND

Complications associated with autologous breast reconstruction are well reported in the literature. Regardless of the type of free flap harvested, the anastomosis is most commonly performed to the recipient internal mammary vessels. Although pneumothorax is a known possible complication of breast surgery, incidence of pneumothorax in breast reconstruction involving the use of the internal mammary vessels is rarely discussed. The aim of our study was to determine the incidence of pneumothorax in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

A single-institution review was performed examining the incidence of pneumothorax in cases of DIEP flap breast reconstruction with anastomosis to the internal mammary vessels over a 4-year period. Intraoperative irrigation was used to visually assess for evidence of pneumothorax during recipient vessel dissection and anastomosis. Anteroposterior chest radiographs were obtained on the first postoperative day to assess for pneumothorax. Additional variables analyzed included type of retractor used during recipient vessel dissection and history of radiation.

RESULTS

A total of 180 patients underwent autologous DIEP breast reconstruction at our institution. The overall incidence of pneumothorax was 1.4 per 100 recipient vessel dissections and 2.2 per 100 patients undergoing breast reconstruction. There was a total of 4 cases of pneumothorax. Three were attributed to unknown causes, and 1 was due to direct injury to the parietal pleura via electrocautery.

CONCLUSION

The use of the internal mammary artery and vein as recipient vessels continues to be the most common and reliable recipient for autologous breast reconstruction. Based on our data, pneumothorax does not seem to be a common complication of this procedure. If concern for iatrogenic injury to the pleura arises intraoperatively, we suggest the use of a saline bubble test to investigate the possible injury. Routine postoperative radiographs are not indicated unless the patient develops symptoms suggestive of pneumothorax.

Predictive risk factors of complications in different breast reconstruction methods

PURPOSE

Women with different BMI, age and comorbidities seek for breast reconstruction. It is critical to understand the risk associated with each technique to ensure the most appropriate method and timing is used. Outcome after reconstructions have been studied, but consensus is lacking regarding predictive risk factors of complications. The authors present their experience of different autologous and alloplastic reconstructions with an emphasis on predictors of complications.

METHODS

Prospectively maintained reconstruction database from 2008 to 2019 was reviewed. Factors associated with complications were identified using logistic regression, multinomial logistic regression and risk factor score to determine predictors of complications.

RESULTS

A total of 850 breast reconstructions were performed in 793 women, including 447 DIEP, 283 LD, 12 TMG and 51 implant reconstructions. Complications included minor (n = 231, 29%), re-surgery requiring (n = 142, 18%) and medical complications (n = 7, 1%). Multivariable analysis showed that complications were associated independently with BMI > 30 (OR 1.59; 95% CI 1.05-2.39, p = 0.027), LD technique (OR 4.05; 95% CI 2.10-7.81, p < 0.001), asthma or chronic obstructive pulmonary disease (OR 2.77; 95% CI 1.50-5.12, p = 0.001) and immediate operation (OR 0.69; 95% CI 0.44-1.07, p = 0.099). Each factor contributed 1 point in the creation of a risk-scoring system. The overall complication rate was increased as the risk score increased (35%, 61%, 76% and 100% for 1, 2, 3 and 4 risk scores, respectively, p < 0.001).

CONCLUSIONS

The rate of complication can be predicted by a risk-scoring system. In increasing trend of patients with medical problems undergoing breast reconstruction, tailoring of preventive measures to patients' risk factors and careful consideration of the best timing of reconstruction is mandatory to prevent complications and costs.

Incidence of Complications in Delayed Abdominal-Based Flap Breast Reconstruction Using a Drainless Recipient Site: A Case Series

BACKGROUND

Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site.

METHODS

A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications.

RESULTS

Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5).

CONCLUSIONS

In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Assessing the Relationship between Anxiety and Revision Surgery following Autologous Breast Reconstruction

BACKGROUND

Revision procedures address contour irregularities and aesthetic concerns following autologous breast reconstruction. Mental health diagnoses are known to influence patient satisfaction with reconstruction. The authors aimed to identify oncologic, reconstructive, and demographic factors, including mental health diagnoses, associated with the number of revisions after autologous breast reconstruction.

METHODS

The medical records of all adult women undergoing abdominal free flap-based breast reconstruction at a major academic institution between 2011 and 2016 were reviewed. Multivariate logistic regression was used to identify factors associated with receipt of revisions. Negative binomial regression was used to identify characteristics associated with number of revisions received.

RESULTS

Of 272 patients identified, 55.2 percent received one revision, 23.2 percent received two revisions, and 10.3 percent received three or more revisions after autologous breast reconstruction (median, one; range, zero to five). After adjustment on multivariate analysis, anxiety (OR, 4.34; p = 0.016) and bilateral reconstruction (OR, 3.10; p = 0.017) were associated with receipt of any revisions; other oncologic and reconstructive factors including breast cancer stage, receipt of radiation therapy, and type or timing of free flap reconstruction were not associated with revisions. Using univariate negative binomial regression, anxiety (incidence rate ratio, 1.34; p = 0.006), Caucasian race (incidence rate ratio, 1.24; p = 0.02), and bilateral reconstruction (incidence rate ratio, 1.39; p = 0.04) were predictive of increased numbers of revisions received. After stepwise selection on multivariate analysis, anxiety remained the only significant predictor of increased numbers of revisions.

CONCLUSIONS

Preoperative anxiety significantly influences the number of revisions after autologous breast reconstruction. Further research is necessary to better understand the interplay among mental health, patient preference, and outcomes in breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap

BACKGROUND

Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs.

OBJECTIVES

The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap.

METHODS

Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed.

RESULTS

The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q.

CONCLUSIONS

Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis.

LEVEL OF EVIDENCE: 4

Patient-Reported Satisfaction after Prophylactic Operations of the Breast

Background

Prophylactic mastectomies in carriers of mutations in BRCA1 or BRCA2 are becoming increasingly more accepted. We investigated the outcome after prophylactic mastectomy, especially regarding satisfaction with the procedure, in a monocenter study.

Methods

BRCA1/2 mutation carriers and non-carriers with elevated pedigree-based cancer risk were followed prospectively in a structured surveillance program between 2000 and 2017. A retrospective telephone survey was conducted among all patients with documented prophylactic mastectomy. Complications and satisfaction with the decision for prophylactic mastectomy were recorded.

Results

39 patients who opted for a prophylactic mastectomy (38 BRCA1/2 mutation carriers and 1 non-carrier) were interviewed. Mostly nipple-sparing mastectomy with reconstruction was performed (87%). Half of the patients (22/39; 56.4%) had a history of unilateral breast cancer. The median time since prophylactic mastectomy was 5.6 years. While 61.5% did not report any complications, flap loss was seen in 15% (3/20) and moderate limitations in everyday life were present in 20% (7/35). An improvement in quality of life was noticed by 82% after prophylactic mastectomy and no patient expressed regret with regard to the decision.

Conclusions

Prophylactic mastectomy is a procedure with risk for long-term complications in some cases. Our results confirm high satisfaction with the decision and improved quality of life.

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.

Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions

Purpose

As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions.

Methods

For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded.

Results

A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59–5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14–11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27–3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052).

Conclusions

This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4695-0) contains supplementary material, which is available to authorized users.

Association of High-Volume Surgeons Working in High-Volume Hospitals with Cost of Free Flap Surgeries

Background

We examined the associations of surgeon and hospital volume with total cost, length of stay (LOS), and cost per day for free tissue transfer (FTT) surgeries. Evidence demonstrates a higher likelihood of success for FTT in higher volume hospitals. Little, however, is known about volume-outcome associations for surgical costs and LOS. We hypothesized that higher provider volume is associated with lower cost and shorter LOS.

Methods

Using Taiwan's national data (2001-2012), we conducted a retrospective cohort study of all adults 18-64 years of age who underwent FTT during the study period. We used hierarchical regression modeling for our analyses. Our 3 outcome variables were total cost of FTT surgery, LOS in hospital, and cost per day.

Results

Except for functional muscle flap, in which LOS was 12 days shorter in high-volume compared with low-volume hospitals (P = 0.017), no association between hospital volume and LOS was found. Contrary to our hypothesis, our results for all FTT cases demonstrate positive associations of medium-volume hospitals (OR = 1.31; CI, 1.11-1.55) and high-volume surgeons (OR = 1.16; CI,1.03-1.32) with total cost and cost per day, respectively. The interactions of hospital volume and surgeon volume show that in medium- and high-volume hospitals, surgeons with the highest volume had the lowest predicted cost per day among hospitals in that category; but all differences in cost were small.

Conclusions

There were no substantial variations based on different hospital or surgeon volume in LOS, total cost, or cost per day for FTT operations performed in Taiwan.

Associations of Surgeon and Hospital Volumes with Outcome for Free Tissue Transfer by Using the National Taiwan Population Health Care Data from 2001 to 2012

BACKGROUND

Greater hospital case volumes are associated with improved outcomes for high-risk procedures. The hospital-outcome association for complex but low-mortality procedures and the association between surgeon versus hospital case volume and surgical outcomes have been less explored. The authors examined the association between surgeon and hospital volume and the success for free tissue transfer (free flap) surgery. The authors hypothesized that there would be positive associations between hospital and surgeon volume and the success of free flap surgery.

METHODS

The study design was a cross-sectional analysis of adults aged 18 to 64 years who underwent free flap surgery. The authors used 100 percent of all free flap operations between 2001 and 2012 using Taiwan's national data that cover the entire population of 23 million in the country. The authors applied hierarchical regression modeling to analyze volume-outcome associations.

RESULTS

The association between hospital volume and free flap success was small but positive (OR, 1.007; 95 percent CI, 1.00 to 1.01). For surgeons, their years of experience had a positive association with success of the operation (OR, 1.04; 95 percent CI, 1.02 to 1.06) rather than their annual case volume. Compared with low-volume surgeons (<11 annual cases) working in low-volume hospitals (<95 annual cases), high-volume surgeons (>25 annual cases) working in high-volume hospitals (>156 annual cases) showed greater odds of operation success (OR, 2.97; 95 percent CI, 1.21 to 7.29).

CONCLUSIONS

Higher volume hospitals and more experienced surgeons, regardless of their annual volume, showed better outcomes. Increasing demand for high-quality care and Taiwan's national policies toward centralization of complex surgical procedures have increased competition among hospitals.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Impact of different type of cancer treatment on the effectiveness of breast reconstruction

For women undergoing mastectomy as part of their breast cancer treatment, breast reconstruction is an important part of therapy. However, neoadjuvant, adjuvant treatments as well as other patient-related factors can compromise the results of breast reconstruction techniques. In this article we have reviewed current approaches to the management of complications and risks that neoadjuvant and adjuvant therapies pose on breast reconstruction after mastectomy for breast cancer. Non-treatment related factors influencing reconstruction techniques were reviewed as well.

Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: A multicentre study

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is the first choice for autologous breast reconstruction. The aim of this retrospective cohort study was to analyse the recipient- and donor-site complications and compare them between unilateral and bilateral DIEP flap breast reconstructions.

METHODS

Between January 2010 and December 2014, 530 DIEP flap reconstructions were performed in 426 consecutive patients in three Dutch hospitals. Major and minor complications were categorised into recipient- and donor-site complications. Post-operative flap re-explorations were recorded.

RESULTS

Of the total 530 DIEP flap reconstructions performed (322 unilateral, 104 bilateral), recipient-site complications were major in 9.8% and minor in 20.2%. The patients developed fat necrosis (unilateral 14.0% vs. bilateral 7.7%; OR 1.950; 95% CI 1.071-3.550; p = 0.027) and infection (unilateral 5.6% vs. bilateral 1.9%; OR 3.020; 95% CI 1.007-9.052; p = 0.039) at the recipient site significantly more frequently in the unilateral DIEP flap reconstructions. The donor-site complications were major in 0.9% and minor in 19.5% of the cases. Body mass index (BMI) was significantly associated with complications (donor site: OR 1.137; 95% CI 1.075-1.201; p < 0.001, recipient site: OR 1.073; 95% CI 1.009-1.142; p = 0.026). Flap re-explorations were performed in 5.7% (n = 30) of the cases. Total flap loss occurred in 3.0% (n = 16) of the cases.

CONCLUSIONS

Bilateral DIEP flap breast reconstructions can be performed with the same percentage of complications and re-explorations as unilateral reconstructions and even result in less fat necrosis and infection at the recipient site. Higher BMIs are significantly associated with recipient- and donor-site complications.