Evaluation of Microvascular Autologous Breast Reconstruction in Patients Older Than 60 Years

Outcomes of free flap breast reconstruction in patients aged 70 years and over: A single-centre experience

BACKGROUND

Chronological age is an important factor in determining whether a patient can be offered reconstruction following breast cancer surgery. Free flap breast reconstruction is considered the gold standard but is seldom offered to older patients, as the risks are considered too high. This study aimed to examine the outcomes of free flap breast reconstruction in patients aged ≥70 years treated in our unit.

METHODS

We conducted a retrospective review examining the outcomes of consecutive patients aged ≥70 years undergoing free flap breast reconstruction at a single centre between January 2015 and December 2023. Logistic regression was used to determine the relationship between increasing age and comorbidities, and four primary outcome variables- all complications, readmission, return to theatre and length of stay.

RESULTS

We identified 71 patients with a mean age of 72.3 years (70-78 years). 63.4% had one or more comorbidities, with the most common being hypertension and hypercholesterolaemia. Most patients (90.1%) were American Society of Anesthesiologists (ASA) grade 1 or 2. The overall complication rate was 36.6%, most of which were minor wound healing complications (22.5%). There were no episodes of flap loss, either partial or complete. The rates of severe complications (14.1%), readmission (8.4%) and return to theatre (7.0%) were low and comparable to those previously published for our general patient cohort. There was no relationship between increasing age beyond 70 years and any of the four primary adverse outcome measures.

CONCLUSIONS

Free flap breast reconstruction in patients aged ≥70 years can be successful and safe. Therefore, it should be considered as an option for fit, surgically optimised patients, independent of age.

The impact of metabolic syndrome in breast reconstruction decision-making and postoperative outcomes: A nationwide analysis

BACKGROUND

Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities including hypertension, obesity, insulin resistance, and dyslipidemia. The safety profiles of patients with MetS undergoing breast reconstruction remain underreported. This study aims to evaluate the impact of MetS on the BR decision-making process and postoperative complication rates.

METHODS

The ACS-NSQIP database was utilized to identify women who underwent BR between 2012 and 2021. Baseline characteristics were compared based on the presence of MetS, defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Group differences were assessed using t tests and Fisher's exact tests. Multivariate logistic regression models evaluated postoperative complications between the groups.

RESULTS

A total of 160,115 patients underwent BR. A total of 4570 had a diagnosis of MetS compared to 155,545 without MetS. No statistically significant differences were observed in the type of BR patients received across cohorts. Logistic regression models demonstrated a higher likelihood of postoperative wound complications (OR 2.21; 95% CI 1.399, 3.478; p = 0.001), and readmission rates (OR 2.045; 95% CI 1.337, 3.128; p = 0.001) in the MetS group compared to the non-MetS patients. No significant differences were identified in other postoperative complications between groups.

CONCLUSIONS

Patients with MetS appear to have an increased risk of postoperative wound complications and readmission after breast reconstruction. The synergistic effects of these comorbidities on postoperative outcomes underscore the importance of addressing MetS as a holistic condition and considering choosing Delayed breast reconstruction over Immediate Breast Reconstruction in this population. Thus, integrating MetS management and patient counseling at various stages of BR may improve outcomes and facilitate patient decision-making.

Evaluating mesh use for abdominal donor site closure after deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Despite improvement in abdominal morbidity with deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to prior abdominally-based free flap breast reconstruction, abdominal bulge, and hernia rates have been cited anywhere from 2% to 33%. As a result, some surgeons utilize mesh or other reinforcement upon donor-site closure, but its benefit in preventing abdominal wall morbidity has not been well-defined for DIEP flaps. The purpose of this systematic review is to evaluate DIEP donor-site closure techniques and the impact of mesh type and plane on abdominal-wall morbidity including hernia and bulge, relative to primary fascial closure.

METHODS

MEDLINE, PubMED, Cochrane Library, and SCOPUS were systematically reviewed for studies evaluating DIEP flap breast reconstruction abdominal-donor site closure, where any mesh reinforcement or primary fascial closure was specified, and postoperative outcomes of hernia and/or abdominal bulge were reported. Analysis was performed in Review Manager (RevMan) evaluating mesh use, type, and plane relative to primary fascial closure, using the Mantel-Haenszel method to calculate odds ratios (ORs) of significance level p < .05, and a random effects model to account for inter-study heterogeneity.

RESULTS

Of the 2791 DIEP patients across 11 studies, 1901 patients underwent primary closure and 890 were repaired with mesh. When hernia and/or bulge were combined into a single complication, the use of any mesh did not significantly reduce its odds compared to primary closure (OR = 0.69, p = .20). Similarly, the use of any mesh did not significantly reduce the odds of bulge alone compared to primary closure (OR = 0.62, p = .43). However, the odds of hernia alone were significantly reduced by 72% with any mesh use (OR = 0.28, p = .03).

CONCLUSION

Mesh use was significantly associated with decreased odds of hernia alone with DIEP flap surgery, but there was no difference in bulge or combined hernia/bulge rates. As bulge is the more common abdominal morbidity after DIEP flap harvest in a patient with no prior abdominal surgery or risk factor for hernia, mesh use is not indicated in abdominal closure of all DIEP patients. Future prospective studies are warranted to characterize the specific indications for mesh use in the setting of DIEP flap surgery.