Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset

The Role of Computed Tomography Angiography in Perforator Flap Planning

Preoperative computed tomography angiography (CTA) for perforator free flaps is accurate, precise, and reliable in mapping perforator anatomy that can be used in the intraoperative domain. CTA holds important clinical value as a tool in surgical decision making and surgical innovation, enabling reconstructive surgeons to tailor complex flap designs for extensive defects. Integration into existing infrastructure for virtual surgical planning is feasible, and future efforts to characterize the association of preoperative CTA with postoperative outcomes and cost-analyses for perforator flaps are warranted.

Risk of Bleeding Versus Venous Thromboembolism After Surgery for Breast Cancer: A National Surgical Quality Improvement Program Analysis

INTRODUCTION

Patients who undergo surgery for breast cancer are at risk for venous thromboembolism (VTE) and bleeding, which can lead to significant consequences on outcomes. This study examined factors related to VTE and bleeding risk in breast cancer surgery, with and without reconstruction. We also investigated the relationship between operative time and resident involvement on bleeding and VTE risk.

METHODS

Using the ACS-NSQIP database, patients who underwent mastectomy, implant, pedicled, or free flap reconstruction from 2005 to 2021 were identified. Resident involvement was available from 2007 to 2010. We fitted two logistic regressions to model the log odds of bleeding occurrence and VTE as linear functions of procedure type, controlling for age, body mass index, and comorbidities.

RESULTS

Implant reconstruction had significantly reduced 30-d incidence of bleeding, compared to those who underwent transverse rectus abdominus muscle flap (P < 0.001). Free flap was associated with a significant increase in bleeding but not VTE risk (P < 0.001; P = 0.132). Increase in operative time significantly increased the risk of bleeding and VTE (P < 0.001). For surgeries with resident involvement coded, there was no significantly increased risk of bleeding or VTE (P = 0.600; P = 0.766).

CONCLUSIONS

Implant reconstruction remains the procedure with the lowest risk of both bleeding and VTE. Free flap reconstruction did not show a significantly increased risk of VTE, potentially expanding reconstruction options for patients previously excluded from autologous reconstruction. Surgeons should be mindful of operative time, with re-evaluation of risk factors with each additional hour of surgery, irrespective of reconstruction type. Resident involvement in surgeries should continue to be encouraged by faculty.

Endoscopic Primary Breast Augmentation With Loco-Regional Anesthesia: Preliminary Experience of 200 Consecutive Patients

Background

Breast augmentation with implants recorded over 1.6 billion procedures globally in 2022. To reduce surgical trauma and complications and facilitate a fast recovery, we employ an ultrasound-guided local-regional anesthesia technique, the creation of a partial submuscular implant pocket by direct endoscopic visualization and minimal skin access on the mammary fold.

Objectives

The aim in this study is to evaluate whether breast augmentation performed in endoscopy under local-regional anesthesia reduces postoperative recovery time, reduces complications, and increases patient satisfaction.

Methods

Patients provided their consent through a signed form. We set strict inclusion and exclusion criteria. We prospectively evaluated postoperative pain and recovery times, the rate of complications, and patient satisfaction at 12 months postsurgery.

Results

Between January 2021 and September 2022, 200 patients met the inclusion criteria. The average operation time was 54.2 min. Patients were discharged from the hospital within 2 to 3 h. Eighty-nine percent of patients expressed great satisfaction with the result. None of the patients experienced postsurgical complications.

Conclusions

In our initial study, we showed that endoscopic breast augmentation conducted under localized anesthesia is safe. It allows for quick recovery postsurgery and swift resumption of everyday activities. The overall complication risk is less than what has been reported in scientific studies for the classic dual-plane technique. Moreover, this approach yields excellent patient satisfaction. Additional prospective and randomized studies will be required to enhance the scientific validity of this technique. Moreover, a larger patient cohort will be essential to stratify the risks associated with varying prosthetic volumes.

Level of Evidence 4

Prolonged operative time is a risk factor for adverse postoperative outcomes in the unilateral deep inferior epigastric perforator (DIEP) flap surgery: A retrospective cohort study

BACKGROUND

Currently, one published study documented operative time (OT) as a predictor for postoperative outcomes in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstructions. No literature has investigated this in unilateral DIEP flaps. We aimed to determine the relationship between unilateral OT, postoperative complications, unplanned reoperations (UR), and extended length-of-stay (eLOS).

METHODS

Patients who underwent elective unilateral DIEP reconstruction from 2018 to 2023 at a tertiary centre in London, United Kingdom, were retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive covariates, including procedural complexity, was recorded and used in univariable and multivariable regression models.

RESULTS

The final cohort contained 173 patients. After risk-adjustment, ≥421-minute operations led to a significantly higher overall complication rate (HR: 2.14, 95% CI: 1.26, 3.64, p = 0.005) relative to <421 min. Significantly higher odds of eLOS were observed in the ≥460-minute group (OR: 2.07, 95% CI: 1.07, 3.99, p = 0.03) compared to <460 min. There was no significant effect on the rate of postoperative UR across any OT group.

CONCLUSIONS

We confirmed OT was an independent predictor for postoperative outcomes in the DIEP flap, and demonstrated this in unilateral reconstructions. A clinical maximum threshold of 7 h was derived based on this cohort to help guide future surgical practice. Efficiency can be achieved by meticulous preoperative planning and process standardisation, multiple senior surgeons working per flap, and smooth teamwork between specialities and intraoperative staff.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Risk factors associated with venous thromboembolism in laparoscopic surgery in non-obese patients with benign disease

INTRODUCTION

Few studies have focused on intraoperative positioning as a risk factor for venous thromboembolism (VTE). Positioning that places the legs in a dependent position may be a risk factor. We theorized that the reverse-Trendelenburg position specifically would increase the risk of postoperative VTE.

METHODS AND PROCEDURES

374,017 subjects undergoing laparoscopic surgery in the 2015-2018 NSQIP database were included. Diagnosis of cancer and BMI ≥ 30 were excluded. Subjects were grouped based on positioning: reverse-Trendelenburg (RT), supine (S), and Trendelenburg (T).

RESULTS

The RT, S, and T groups consisted of 117,887, 66,511, and 189,619 subjects, respectively. Overall median BMI was 25.7, and 82.8% of subjects were non-smokers. VTE within 30 days postoperative was seen in 0.25% RT, 0.23% S, and 0.4% T (p < 0.0001); 30-day mortality was 0.34% RT, 0.25% S, and 0.19% T (p < 0.0001). After adjusting for potential confounders and other risk factors, RT position was associated with a lower risk of VTE compared to S (OR 1.49 with 95% CI 1.16, 1.93) and T (OR 1.34 with 95% CI 1.15, 1.56) positions. VTE risk was significantly different across the three groups (p = 0.0001). Inpatient procedures had a higher VTE risk vs outpatient (OR 2.49 with 95% CI 2.10, 2.95). Increasing operative time was associated with higher VTE risk [4th (> 106 min) vs 1st (≤ 40 min) quartiles (OR 3.54 with 95% CI 2.79, 4.48)].

CONCLUSIONS

Among other risk factors, inpatient procedures and longer operative times are associated with higher VTE risk in laparoscopic surgery performed for benign disease in non-obese patients. The risk was significantly different across the three positioning groups with lowest risk in the RT group and highest risk in the S group.

Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

The deep inferior epigastric perforator flap for breast reconstruction is associated with lengthy operative times that remain an issue for plastic surgeons today. The main objective of this study was to determine if a 2-stage deep inferior epigastric perforator flap reconstruction resulted in a shorter total plastic surgeon operative time compared with an immediate reconstruction.

Methods

A retrospective chart review was conducted on all patients who underwent deep inferior epigastric perforator flap breast reconstruction from February 2013 to July 2020 by the senior author. Patient demographics, medical comorbidities, mastectomy characteristics, expander placement, reconstructive procedures, operative time, and complications were tabulated.

Results

The study included a total of 128 patients. For immediate/1-stage flap reconstruction, average operative times for the plastic surgeon were 427.0 minutes for unilateral procedures, and 506.3 minutes for bilateral procedures. For delayed/2-stage reconstruction, average combined plastic surgeon operative times were 351.1 minutes for unilateral expander followed by flap reconstruction (75.9 minutes shorter than immediate unilateral, P = 0.007), and 464.8 minutes for bilateral reconstruction (41.5 minutes shorter than immediate bilateral, P = 0.04). Total patient time under anesthesia was longer for 2-staged bilateral reconstruction (P = 0.0001), but did not differ significantly for unilateral reconstruction. Complications between immediate and delayed groups were not significantly different.

Conclusions

We found that staged reconstruction over 2 procedures resulted in a significant reduction in operative time for the plastic surgeon for both unilateral and bilateral reconstruction. With amenable breast surgeons and patients, the advantages of controlling scheduling and the operating room may encourage plastic surgeons to consider performing free flap reconstruction in a delayed fashion.

Mastopexy with Autologous Augmentation in Women After Massive Weight Loss: A Randomized Clinical Trial

BACKGROUND

Breast reshaping or mastopexy following massive weight loss can be challenging. The LOPOSAM (lower pole subglandular advancement mastoplasty) technique has shown promising results for correction of ptotic, wide, lateralized and deflated breasts following massive weight loss.

MATERIALS AND METHODS

We compared the LOPOSAM technique to the mastopexy technique after massive weight loss described by Rubin JP, in a randomized trial. The main outcome measure was the total operative time. Secondary outcomes measures were socio-economic factors; length of hospital stay, numbers of sutures used, secondary corrective procedures, post-operative sick leave and surgeon- and patient-reported appearance of the breasts.

RESULTS

We included 22 women: 11 operated on by the LOPOSAM technique and 11 by the technique described by Rubin JP. The total operative time was 84.8 (SD 12.2) minutes in the LOPOSAM group and 99.1 (SD 23.5) in the Rubin JP group (p = 0.074). There were no differences related to days with drains, length of hospital stay or sick leave between the two groups. The surgeon- and the patient-reported appearance of the breasts changed significantly between the pre-operative and the 12-month post-operative assessments.

CONCLUSION

The LOPOSAM technique is a safe and quick surgical procedure for correction of ptotic, wide, lateralized and deflated breasts following massive weight loss and seems to provide results comparable to the better-known Rubin JP's technique. There was a trend that the LOPOSAM technique was faster to perform, however, not significant. The breast appearance improved significantly using both techniques when assessed by both surgeons and patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of Cross-Sex Hormone Therapy on Venous Thromboembolism Risk in Male-to-Female Gender-Affirming Surgery

Individuals with gender dysphoria often seek medical interventions, such as hormone treatment and surgery, to live as their identified gender. Cross-sex hormone therapy typically consists of various estrogen formulations which confer varying risks of venous thromboembolism (VTE). Currently, there is no standard practice by surgeons regarding the preoperative gender-affirming surgery (GAS) hormone regimen of male-to-female (MTF) patients to minimize thromboembolic postoperative complications. The aim of this review is to examine the current literature on VTE occurring in MTF transgender patients on cross-sex hormone therapy (CSHT) when undergoing various gender-affirming surgeries-facial feminization surgery (FFS), top surgery (TS), and bottom surgery (BS)-to understand how evidence-based recommendations regarding perioperative hormone regimens can be established to improve clinical outcomes. Within the past 25 years, 7 published studies have examined the incidence of VTE in MTF patients undergoing GAS procedures. Two of these articles examined MTF patients undergoing FFS, 1 article reported a patient who had undergone BS and FFS during the same hospitalization, and the remaining 4 articles investigated VTE risk in BS. Our review supports that plastic surgeons who perform GAS are divided on their preferred CSHT protocols, with some requiring patients to suspend their CSHT weeks before surgery and others allowing patients to continue CSHT through the day of surgery. Three of the 7 studies detailed a CSHT perioperative regimen which instructed patients to suspend CSHT sometime before surgery; 1 study tapered CSHT to lower levels before surgery; the remaining 3 studies did not specify a CSHT perioperative regimen. This review highlights the paucity of data failing to support that continuing CSHT through GAS elevates VTE risk. We conclude that in the absence of definitive VTE risk factors (e.g., smoking, clotting disorders, or malignancy), surgeons may engage MTF patients in joint decision-making process to determine the most optimal perioperative CSHT management plan on a case-by-case basis. Future studies are warranted to evaluate VTE risk based on patient age, type of surgery, operating time, prophylactic measures, follow-up time, and CSHT perioperative regimens.

Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes

BACKGROUND

Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane.

METHODS

An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286).

RESULTS

A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01).

CONCLUSIONS

Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Perforator mapping may be performed prior to deep inferior epigastric perforator (DIEP) flap breast reconstruction to guide perforator selection. However, the accuracy of different imaging modalities remains unknown. This review aimed to evaluate the accuracy of different modalities for locating perforators for unipedicled DIEP flap breast reconstruction.

METHODS

MEDLINE and EMBASE were searched from inception to 24th September 2019 for studies concerning adult women undergoing DIEP flap breast reconstruction with preoperative perforator mapping. The index test was pre-operative imaging and the reference standard was intraoperative identification.

RESULTS

21 articles with 1146 women were included. Six methods were described; handheld doppler, colour doppler (duplex) ultrasonography, computed tomography angiography, magnetic resonance angiography (MRA), direct infrared thermography with and without doppler. Meta-analysis revealed 94% (95% CI 88-99%) of DIEPs identified as the 'dominant perforator' on imaging were chosen as dominant perforators intraoperatively. Colour doppler (Duplex) ultrasonography had the lowest agreement (mean 74% [95% CI 67-81%]) whilst MRA had the highest agreement (mean 97% [95% CI 86-100%]). There was no statistically significant difference in the performance of different tests. All studies were subject to bias as the operators had knowledge of the index test prior to conducting the reference standard.

CONCLUSIONS

Based upon limited evidence, cross sectional (CT/MR) imaging modalities for preoperative DIEP mapping appear to have similar accuracy and perform better than ultrasound.

The Posterior Arm Flap for Reshaping the Postbariatric Breast

Postbariatric surgery, either by itself or in association with other procedures, tries to correct physical defects and body deformities. Because of the intrinsic complexity of massive weight loss (MWL) patients, more than a single procedure is, most of the time, required. We report a combined surgical method able to improve arms' and breasts' contour that aims to obtain a satisfying functional and aesthetic result by reducing surgical times and costs.

Methods

A female MWL patient with proper body mass index was clinically evaluated and considered suitable for surgery. While authors performed a modified Pascal-Le Louarn brachioplasty for the upper arm, a standard McKissock mastopexy followed by a Wise pattern skin closure was selected to obtain the breast lift. By sparing the proximal pedicle, the fasciocutaneous flaps were harvested on both posteromedial sides of the arms. The posterior arm flaps (PAF) were tunneled and transposed below the subcutaneous skin bridge across the axilla and finally used to increase the breast mound.

Results

In the immediate postoperative follow-up, no complications were reported. After the 6-month and 1-year follow-up, both arms' silhouette was documented as healthy and symmetric. Breasts were soft, without any signs of ptosis and/or contracture. No skin disorders or scar hypertrophy or lymphedema were reported.

Conclusions

PAF in breast contouring procedures is an interesting surgical option, but more patients need to be treated to validate the effectiveness of the procedure. This technique should be considered when there is a need for simultaneously improving arm's contour and breast's volume and shape.

Increased Incidence of Symptomatic Venous Thromboembolism following Pedicled Lower Extremity Flap Harvest for Abdominal and Perineal Reconstruction in Patients Receiving Mechanical Prophylaxis and Chemoprophylaxis: A Case for Heightened Awareness

BACKGROUND

Postsurgical venous thromboembolism remains a leading cause of hospital morbidity. Data to support venous thromboembolism prophylaxis guidelines in lower extremity flap surgery are lacking. The purpose of this study was to explore the effect of pedicled lower extremity flap harvest on venous thromboembolism development in the setting of abdominal or perineal reconstruction.

METHODS

One hundred twenty-six patients undergoing unilateral lower extremity flap harvest for abdominal or perineal reconstruction were included. The contralateral leg served as an internal control. Sixty comorbidity-matched patients who underwent abdominal/perineal resection without flap reconstruction provided an external control. Bivariate analyses included chi-square and t tests; logistic regression adjusted for confounding variables on venous thromboembolism development.

RESULTS

All patients underwent flap reconstruction for an oncologic defect of the abdomen or perineum, with 80 percent undergoing perineal reconstruction. Most patients underwent anterolateral thigh (41 percent) or gracilis flap (40 percent) harvest. Eleven patients developed deep venous thromboses in one or more legs (9 percent): 10 of 11 (90.9 percent) in the donor extremity and five (45.5 percent) contralaterally (p = 0.022). Patients who underwent flap harvest had a 10-fold higher odds of venous thromboembolism formation when compared to comorbidity-matched controls without flap reconstruction (OR, 10.64; 95 percent CI, 1.11 to 102.34; p = 0.041).

CONCLUSIONS

The rate of venous thromboembolism is higher than previously appreciated for reconstructive procedures of the abdomen and/or perineum that use pedicled lower extremity flaps-particularly in the operative extremity. Additional research can clarify the role for further prophylaxis or screening.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The role of fat grafting in prepectoral breast reconstruction

Prepectoral breast reconstruction has reemerged as a promising alternative to submuscular implants, as they place the patient at lower risk for pain, muscular impairment, and animation deformity. However, the thinner amount of overlying tissue in prepectoral reconstruction presents its own unique set of challenges. A "rippling" deformity is seen in some prepectoral patients, which is typically corrected with fat grafting. This report details our recommended technique for fat grafting in the prepectorally implanted patient.

Is quicker better? A NSQIP analysis of anesthesia time and complications following tracheostomy placement

BACKGROUND

Increased anesthesia time may lead to respiratory complications in patients receiving tracheostomy, which contributes to patient morbidity.

METHODS

The American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases of planned tracheostomy (CPT 31600) from 2005 to 2012. Patients were stratified into quintiles based on anesthesia duration. Pearson's chi square, Fischer's exact test, one-way ANOVA, and multivariate regression were used to determine the association between patient characteristics with pneumonia and ventilator dependence.

RESULTS

Out of 752 patients, 83 patients experienced post-operative pneumonia, and 166 experienced ventilator dependence. Following multivariate regression analysis, anesthesia quintiles were not significantly associated with pneumonia or ventilator dependence. Age (OR 1.03, 95% CI 1.00-1.05, P = .032), dyspnea (OR 2.21, 95% CI 1.18-4.13; P = .013), pre-operative ventilator dependence (OR 3.08, 95% CI 1.19-7.98; P = .020), and sepsis (OR 6.68, 95% CI 3.19-14.0; P < .001) remained as significant predictors of post-operative ventilator dependence.

CONCLUSIONS

Faster may not be better-- prolonged anesthesia time does not increase the risk of post-operative pneumonia or ventilator dependence in patients receiving a planned tracheostomy in the operating room.

Demystifying the "July Effect" in Plastic Surgery: A Multi-Institutional Study

BACKGROUND

The "July Effect" refers to a theoretical increase in complications that may occur with the influx of inexperienced interns and residents at the beginning of each academic year in July.

OBJECTIVES

We endeavored to determine if a July Effect occurs in plastic surgery.

METHODS

Plastic surgery procedures were isolated from the National Surgical Quality Improvement Program registry. Cases involving residents were grouped as either having occurred within the first academic quarter (AQ1) or remaining year (AQ2-4). Groups were propensity matched using patient/operative factors and procedure type to account for baseline differences. Univariate and multivariate regression analyses assessed differences in overall complications, surgical and medical complications, individual complications, length of hospital stay, and operative time. A comparison group comprised of procedures without resident involvement was also analyzed.

RESULTS

There were 5967 cases with resident involvement, 5156 of which successfully matched. Both univariate and multivariate regression analyses revealed no significant differences between AQ1 and AQ2-4 in terms of overall, surgical, medical and individual complications, or length of hospital stay. There was a statistically significant, albeit not clinically significant, increase in operative time by 10 minutes per procedure during AQ1 in comparison to AQ2-4 (P = 0.001). For procedures lacking resident participation, there were no differences between AQ1 and AQ2-4 in terms of these outcomes.

CONCLUSIONS

A July Effect was not observed for plastic surgery procedures in our study, conceivably due to enhanced resident oversight and infrastructural safeguards. Patients electing to undergo plastic surgery early in the academic year can be reassured of their safety during this period.

Incidence and Predictors of Venous Thromboembolism in Abdominoplasty

BACKGROUND

The prevention of venous thromboembolism (VTE) is a high priority in aesthetic surgery. Abdominoplasty is the aesthetic procedure most commonly associated with VTE, yet the mechanisms for the development of VTE associated with this procedure are unclear.

OBJECTIVES

The purpose of this study was to analyze the incidence and predictors of VTE in patients undergoing abdominoplasty procedures in outpatient surgery centers using data from the Internet Based Quality Assurance Program (IBQAP).

METHODS

IBQAP data from 2001 to 2011 were queried retrospectively to identify abdominoplasty cases and VTE cases. Patient- and procedure-specific variables were analyzed to identify potential predictors of VTE in abdominoplasty.

RESULTS

Among all outpatient aesthetic surgery cases entered from 2001 to 2011, 414 resulted in VTE, representing a VTE incidence of 0.02%. Of these, 240 (58%) occurred in abdominoplasty cases. Predictors of VTE were age greater than 40 years and BMI greater than 25 kg/m2. Patient sex, duration of anesthesia and surgery, type of anesthesia, type of additional procedure, and number of procedures did not appear to influence the risk of VTE. Importantly, 95.5% of the VTEs identified for this study occurred in patients whose Caprini risk assessment model score was between 2 and 8, which would not be an indication for chemoprophylaxis according to current recommendations.

CONCLUSIONS

Many factors must be considered when determining the true incidence of VTE in abdominoplasty. Research is needed to discover the reason abdominoplasty carries a greater risk compared with other aesthetic surgery procedures so that appropriate steps can be taken to prevent its occurrence and improve the safety of the procedure.

Perforator mapping reduces the operative time of DIEP flap breast reconstruction: A systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography

BACKGROUND

Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) reduces the risk of flap failure. This review aimed to investigate the additional potential benefit of a reduction in operating time.

METHODS

We systematically searched the literature for studies concerning adult women undergoing DIEP flap breast reconstruction, which directly compared the operating times and adverse outcomes for those with and without preoperative perforator mapping by ultrasound, CTA or MRA. Outcomes were extracted, data meta-analysed and the quality of the evidence appraised.

RESULTS

Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p < 0.001) and was associated with a lower risk of partial flap failure (RR 0.15 [95% CI 0.04, 0.6], p = 0.007). All studies were at risk of methodological bias and the quality of the evidence was very low.

CONCLUSIONS

The quality of research regarding perforator mapping prior to DIEP flap breast reconstruction is poor and although preoperative angiography appears to save operative time, reduce morbidity and confer cost savings, higher quality research is needed.

REGISTRATION

PROSPERO ID CRD42017065012.

Anesthesia Duration as an Independent Risk Factor for Early Postoperative Complications in Adults Undergoing Elective ACDF

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine the presence of any potential associations between anesthesia time with postoperative outcome and complications following elective anterior cervical discectomy and fusion (ACDF).

METHODS

Patients who underwent elective ACDF were identified in the American College of Surgeons National Quality Improvement Program database. Patient demographics, medical comorbidities, and perioperative and postoperative complications up to 30 days were analyzed by univariate and multivariate analysis.

RESULTS

A total of 3801 patients undergoing elective ACDF were identified. Patients were subdivided into quintiles of anesthesia time: Group 1, 48 to 129 minutes (n = 761, 20%); Group 2, 129 to 156 minutes (n = 760, 20%); Group 3, 156 to 190 minutes (n = 760, 20%); Group 4, 190 to 245 minutes (n = 760, 20%); and Group 5, 245 to 1025 minutes (n = 760, 20%). Univariate analysis showed significantly higher rates of any complication (P < .0001), pulmonary complication (P < .0001), intra-/postoperative blood transfusions (P < .0001), sepsis (P = .017), wound complications (P = .002), total length of stay >5 days (P < .0001), and return to operating room (P = .006) in the highest quintile compared to those of other groups. Multivariate regression analysis revealed that prolonged anesthesia was an independent factor for increased odds of overall complications (odds ratio [OR] = 2.71, P = .012), venous thromboembolism (OR = 2.69, P = .011), and return to the operating room (OR = 2.92, P = .004). The 2 groups with the longest anesthesia durations (quintiles 4 and 5) had increased total length of stay more than 5 days (for quintile 4, OR = 3.10, P = .0004; for quintile 5, OR = 3.61, P < .0001).

CONCLUSION

Prolonged anesthesia duration is associated with increased odds of complication, venous thromboembolism, increased length of stay, and return to the operating room.

Predictors of adverse events after neck dissection: An analysis of the 2006-2011 National Surgical Quality Improvement Program (NSQIP) Database

While neck dissection is an important primary and adjunctive procedure in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed to identify factors associated with adverse events (AEs) in patients undergoing neck dissection. A total of 619 patients were identified, using CPT codes specific to neck dissection. Of the 619 patients undergoing neck dissection, 142 (22.9%) experienced an AE within 30 days of the surgical procedure. Risk factors on multivariate regression analysis associated with increased AEs included dyspnea (odds ratio [OR] 2.57; 95% confidence interval [CI] 1.06 to 6.22; p = 0.037), previous cardiac surgery (OR 3.38; 95% CI 1.08 to 10.52; p = 0.036), increasing anesthesia time (OR 1.005; 95% CI 1 to 1.009; p = 0.036), and increasing total work relative value units (OR 1.09; CI 1.04 to 1.13; p < 0.001). The current study is the largest, most robust analysis to identify specific risk factors associated with AEs after neck dissection. This information will assist with preoperative optimization, patient counseling, and appropriate risk stratification, and it can serve as benchmarking for institutions comparing surgical outcomes.

External validation of the breast reconstruction risk assessment calculator

INTRODUCTION

The Breast reconstruction Risk Assessment (BRA) Score estimates patient-specific risk for postsurgical complications using an individual's unique combination of preoperative variables. In this report, we externally validate the BRA Score models for surgical site infection, seroma, and explantation in a large sample of intra-institutional patients who underwent prosthetic breast reconstruction.

METHODS

We reviewed all initiated tissue expander/implant reconstructions by the senior authors from January 2004 to December 2015. BRA Score risk estimates were computed for each patient and compared against observed rates of complications. Hosmer-Lemeshow goodness-of-fit test, concordance statistic, and Brier score were used to assess the calibration, discrimination, and accuracy of the models, respectively.

RESULTS

Of the 1152 patients (1743 breasts) reviewed, 855 patients (1333 breasts) had complete data for BRA-score calculations and were included for analysis. Hosmer-Lemeshow tests for calibration demonstrated a good agreement between observed and predicted outcomes for surgical site infection (SSI) and seroma models (P-values of 0.33 and 0.16, respectively). In contrast, predicted rates of explantation deviated from observed rates (Hosmer-Lemeshow P-value of 0.04). C statistics demonstrated good discrimination for SSI, seroma, and explantation (0.73, 0.69, and 0.78, respectively).

CONCLUSIONS

In this external validation study, the BRA Score tissue expander/implant reconstruction models performed with generally good calibration, discrimination, and accuracy. Some weaknesses in certain models were identified as targets for future improvement. Taken together, these analyses validate the clinical utility of the BRA score risk models in predicting 30-day outcomes.

Impact of operative length on post-operative complications in meningioma surgery: a NSQIP analysis

Many studies have implicated operative length as a predictor of post-operative complications, including venous thromboembolism [deep vein thrombosis (DVT) and pulmonary embolism (PE)]. We analyzed the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2014, to evaluate whether length of operation had a statistically significant effect on post-operative complications in patients undergoing surgical resection of meningioma. Patients were included for this study if they had a post-operative diagnosis of meningioma. Patient demographics, pre-operative comorbidities, and post-operative 30-day complications were analyzed. Of 3743 patients undergoing craniotomy for meningioma, 13.6 % experienced any complication. The most common complications and their median time to occurrence were urinary tract infection (2.6 %) at 10 days postoperatively (IQR 7-15), unplanned intubation (2.5 %) at 3 days (IQR 1-7), failure to wean from ventilator (2.4 %) at 2.0 days (IQR 2-4), and DVT (2.4 %) at 6 days (IQR 11-19). Postoperatively, 3.6 % developed VTE; 2.4 % developed DVT and 1.7 % developed PE. Multivariable analysis identified older age (third and upper quartile), obesity, preoperative ventilator dependence, preoperative steroid use, anemia, and longer operative time as significant risk factors for VTE. Separate multivariable logistic regression models demonstrated longer operative time as a significant risk factor for VTE, all complications, major complications, and minor complications. Meningioma resection is associated with various post-operative complications that increase patient morbidity and mortality risk. this large, multi-institutional patient sample, longer operative length was associated with increased risk for postoperative venous thromboembolisms, as well as major and minor complications.