"DIEP Flap vs PAP Flap vs LAP Flap: A Propensity Matched Analysis of Aesthetic Outcomes, Complications, and Satisfaction".

INTRODUCTION: As free breast reconstruction options evolve, a patient and body centric approach can distinguish refined aesthetic outcomes. While DIEP, PAP, and LAP flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these three flaps has not been performed. We aim to compare these three flaps based on outcomes, BREAST-Q, and aesthetic results. METHODS: After IRB approval, a retrospective review in a REDCap database guided analysis of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Post-operative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population. RESULTS: Overall patient post-operative breast satisfaction was insignificantly different across the three flap groups(p>0.05). Associations were seen with LAP flap donor site seromas, PAP flap donor site infections and wounds, and DIEP flap breast wounds and flap necrosis(p<0.05). DIEP flaps had a higher raw score average on crowdsourcing survey, although LAP flaps were rated significantly higher aesthetically than DIEP and PAP flaps when undergoing a matched head-to-head analysis(p<0.05). CONCLUSION: DIEP, PAP, and LAP flaps all have favorable outcomes with insignificantly different long-term satisfaction, with comparable complication profiles. While DIEP flaps may initially score higher, LAP flaps score higher frequently when analyzed in a head-to-head analysis. For these reasons, tailoring breast reconstruction to the patient's anatomy and morphology provides optimal outcomes.

Head-to-Head Analysis of Vertical vs Horizontal Incision Patterns in Breast Reconstruction: Surgical Outcomes and Aesthetic Implications.

BACKGROUND: Modern aesthetically optimized breast reconstruction requires collaboration between the patient, breast surgeon, and plastic surgeon. To optimize both surgical outcome and aesthetic results, incision patterns must be carefully planned. OBJECTIVES: We aimed to determine whether vertical or horizontal orientation of mastectomy incision was preferred in the general population and to analyze corresponding complication profiles. METHODS: A retrospective review was performed of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 to November 2022. Postoperative complications of the 2 incision patterns were analyzed. Additionally, crowdsourcing was utilized to assess aesthetic implications of horizontal and vertical incision patterns on postoperative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess differences in scoring based on voter characteristics. RESULTS: There were no significant differences in postoperative breast complications between patients with horizontal or vertical incisions when considering wound, infection, seroma, hematoma, fat necrosis, or overall complications (P > .05). Crowdsourcing showed that, regardless of voter demographics, vertical incisions were preferred over horizontal incisions (P < .001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (P < .001). CONCLUSIONS: Although there are no significant differences in complication profiles between vertical and horizontal incisions in autologous breast reconstruction patients, vertical incision patterns are preferred aesthetically by the general population.

Reduction in Seroma Rate Following Deep Inferior Epigastric Perforator Flap with Umbilectomy Utilizing Progressive Tension Sutures.

BACKGROUND: Umbilectomy has been implemented in both abdominoplasties and deep inferior epigastric perforator (DIEP) flaps to improve abdominal wound healing and better control the location of the neoumbilicus; however, seroma rates are increased. The objective of this study is to compare the seroma rate following DIEP flap reconstruction with umbilectomy when progressive tension sutures (PTS) are implemented. METHODS: A retrospective chart review was performed to evaluate postoperative seroma rates in patients undergoing DIEP flap breast reconstruction at a single academic institution between January 2015 and September 2022. All procedures were performed by two senior surgeons. Patients were included if their umbilicus was removed intraoperatively. PTS were utilized in all abdominal closures beginning in late February 2022. Demographics, comorbidities, and postoperative complications were evaluated. RESULTS: A total of 241 patients underwent DIEP flap breast reconstruction with intraoperative umbilectomy. Forty-three consecutive patients received PTS. Overall complications were significantly lower in those who received PTS (p = 0.007). There were no abdominal seromas (0%) in patients who received PTS, whereas 14 (7.1%) occurred without PTS. The use of PTS conferred a decreased likelihood of abdominal seroma (5.687× lower risk, p = 0.017). Additionally, wound formation was significantly lower in those who received PTS (p = 0.031). CONCLUSION: The use of PTS in the abdominal closure during DIEP flap reconstruction addresses the previously seen rise in seroma rates when concomitant umbilectomy is performed. Decrease in both donor-site wounds and now seroma rates reaffirm the efficacy of removing the umbilicus to improve patient outcomes.

"Categorizing Patient Selection, Outcomes, and Indications in a Decade of 405 PAP Flaps".

INTRODUCTION: Autologous tissue is the only permanent option for breast reconstruction. While abdominal tissue remains popular, considering alternative donor sites ensures comprehensive care tailored to a patient. The thigh has been established as an excellent choice in autologous reconstruction. We present a ten-year experience with 405 profunda artery perforator flaps (PAP flaps). METHODS: An IRB approved ten-year retrospective review of all patients treated with PAP flaps for breast reconstruction was performed. Procedures were carried out by two surgeons at the same institution. PAP flaps were divided into four consecutive groups with approximately 100 flaps in each group. Demographics, indications, intraoperative data, post-operative complications, revisions, and patient reported outcomes were recorded and analyzed. RESULTS: 207 patients (405 PAP flaps) were included. This accounted for 17.2% of all breast reconstruction flaps. 55% of patients underwent a multi-flap procedure. The average flap weight was 354.3 g (+/- 117.2), which significantly decreased over time (p<0.001). Rates of major complications were 9.6% wounds, 4.4% seromas, 4.7% hematomas, and 3.5% infections. Total flap loss was 2%, 67% of which were in stacked patients. Satisfaction routinely improved from pre-operative to post-operative. CONCLUSIONS: As available flap donor sites continue to evolve, tailoring breast reconstruction to the individual patient is standard in centers of excellence. The PAP flap has emerged as an excellent choice for autologous-based breast reconstruction through utilization of proper patient selection and surgical technique.

The Effects of High Deductible Health Plans on Breast Cancer Treatment and Reconstruction.

BACKGROUND: High-deductible health plans (HDHP) have expanded rapidly creating the potential for substantially increased out-of-pocket (OOP) costs. The associated financial strain has been associated with the decision to forego care, but the impact on patients undergoing breast cancer reconstruction is not known. We examined the impact of HDHPs vs. LDHPs and OOP maximums on breast reconstruction. METHODS: Between January 2014 and 2020, patients who had breast reconstruction by the 2 senior authors were retrospectively evaluated. Information on patient's insurance contract was collected. Criteria for HDHP and LDHP were defined following section 223(c)(2)(A) of the Internal Revenue Code. All aspects of cancer diagnosis, cancer treatment, and surgical procedures were reviewed. RESULTS: About 507 patients (262 in LDHPs and 245 in HDHPs) were reviewed. Patients treated with neoadjuvant chemotherapy were more likely to be enrolled in HDHPs (25.7% vs. 36.8%, P < .01). There was no significant difference in total operations, number of revisions, or length of reconstruction in days or calendar years. Additionally, no difference existed in the choice of autologous implant reconstruction. CONCLUSION: The cost-sharing burden of HDHPs creates the potential for patients to forego care, and thus, effort should be directed toward increasing patient education concerning health plan benefits. Utilization of postdeductible spending, as well as resources of health savings accounts, may limit the adverse effects of HDHPs. This study also emphasizes the importance for providers to increase cost transparency.

Bilateral LAP Flaps for Breast Reconstruction: A Perforator Classification System.

BACKGROUND: Autologous breast reconstruction is continually evolving with focus on the ideal donor site. This study presents 108 consecutive simultaneous LAP flaps and a perforator classification system. METHODS: An IRB approved retrospective review of all LAP flaps was completed and appropriate data recorded. All simultaneous bilateral LAP flaps were included, and perforator patterns were assessed using CTA. RESULTS: Fifty-four patients (108 flaps) were included in the final review. Mean age was 50.7 and mean BMI was 26.6. Mean ischemia times for all flaps and grafts were 130 +/- 64.5 and 300.6 +/- 97.3 minutes, respectively. Pedicle lengths averaged 4.6 +/- 1.5 cm and composite graft lengths averaged 6.2 +/- 1.7 cm. Donor site complications consisted of seromas (10 patients, 19%), hematomas (six patients, 11%), procedural wounds (four patients, 8% ), and infections (two patients, 4%). Total flap loss rate was 2.8%. Perforators were classified into categories based on pedicle pattern, lumbar spine level, and clusters, all in relation to posterior iliac bone as seen per CTA. Vascular pedicle patterns were categorized as type one (43.9%), two (45.6%), three (8.8%), and four (1.8%). Perforators were dissected at lumbar spine level L3 in 51.8% of patients, L4 in 46.5%, and L5 in 1.8%. CONCLUSIONS: We present a CTA directed, anatomical perforator classification system to assist in pre-operative planning, guide in dissection and choosing composite graft suited best for particular perforator pattern or calibers. Simultaneous LAP flaps can be successfully performed with excellent outcomes in patients unsuitable for other flaps.

Physiologic and pharmacologic considerations in morbid obesity and bariatric anesthesia.

Obesity is a growing worldwide health hazard that is characterized by excess malnutrition. Excess food intake leads to dysregulated energy homeostasis and increased adiposity, activating pro-inflammatory physiologic pathways that can contribute to the chronic inflammatory state associated with many chronic illnesses. Obesity is a preventable illness, but its multifaceted etiology, including genetic, behavioral, and environmental variables, is critical to understanding its epidemiology and pathophysiology. Obesity is a critical predisposing factor for illnesses including type II diabetes, cardiovascular disease, and cancer, with higher morbidity and death. Obesity rates are rising, and so will the need for perioperative anesthesia for subjects with obesity. Obesity epidemiology, biochemistry, and pathophysiology are significant concepts in perioperative anesthesia management for subjects with obesity. To provide optimal intraoperative care for subjects with obesity, preoperative cardiovascular assessment for coronary artery disease and drug monitoring is required. Individuals suffering from obesity have significantly higher oxygen consumption rates and a higher risk of desaturation and surgical complications. Individuals suffering from obesity require specialized perioperative treatment related to higher prevalence of perioperative complications.