Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction.

BACKGROUND: Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase. METHODS: The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point. RESULTS: A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively. CONCLUSIONS: Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy.

INTRODUCTION: Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. METHODS: We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. RESULTS: One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. CONCLUSIONS: Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.

Surgical Correction of Breast Animation Deformity with Implant Pocket Conversion to a Prepectoral Plane.

BACKGROUND: Animation deformity is an undesirable outcome of subpectoral breast reconstruction that results in abnormal breast contraction with activity, breast pain, and increased implant visibility. Surgical correction requires implant removal and conversion of the reconstruction to a prepectoral plane. The authors present their institutional experience with their preferred surgical technique to treat this challenging problem and outline solutions for increased success in these patients. METHODS: A retrospective review was performed of all patients undergoing conversion of their subpectoral breast reconstruction to a prepectoral plane at the authors' institution. Patient demographics and surgical details were analyzed, and postoperative outcomes and morbidity were assessed. The effects of changing operative strategies on enhanced success are also reported. RESULTS: A total of 80 breast conversions were performed over a 2.5-year period. All patients demonstrated resolution of animation deformity at a mean follow-up of 15.2 months. Two reconstructions (2.5 percent) required an unplanned return to the operating room, and 11 reconstructions (13.8 percent) were treated for infection. Preconversion fat grafting and the use of acellular dermal matrix were both associated with a reduced incidence of postoperative asymmetry and capsular contracture (p < 0.05). There were no reconstructive failures associated with conversion to a prepectoral pocket. CONCLUSIONS: Treatment of animation deformity in the reconstructed patient can be safely performed by surgical conversion to a prepectoral plane. The use of acellular dermal matrix, and preconversion fat grafting, in appropriate patients can improve results. The authors promote this operative algorithm for all reconstructive patients experiencing symptomatic animation deformity with subpectoral breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The impact of conflict of interest in abdominal wall reconstruction with acellular dermal matrix.

INTRODUCTION: Conflict of interest (COI) and disclosure of financial relationships have received increased attention recently owing in part to the passage of the Physician Payments Sunshine Act, which requires manufacturers of drugs, medical devices, and biological to record payments to physicians and health care systems. The impact of financial relationships with industry sponsorship and COI reporting on surgical outcomes of abdominal wall reconstruction with acellular dermal matrices (ADMs) has not been previously explored. METHODS: A systematic review of the literature for studies that evaluated surgical outcomes in abdominal wall reconstruction using ADM was conducted. The level of evidence of these studies was evaluated; and data concerning the type of industry, government, or national society sponsorship, primary outcome, complications, and statistical results were collected. The overall favorability of the study with respect to ADM use was systematically assessed. Comparisons between type of sponsorship and significant results were analyzed using the Pearson χ2 test. RESULTS: A total of 204 studies were identified, of which 124 fulfilled our inclusion criteria. Sixty-four (52%) studies had a disclosure statement present. Conflict of interest was reported in 39 (61%) of these studies. Taken collectively, studies that report no COI are more likely to be unfunded (P<0.001). Studies with a reported COI are more likely to report a favorable outcome with respect to infection (P<0.01), wound complications (P<0.01), and overall morbidity (P<0.07) and mortality (P<0.05). CONCLUSIONS: Industry sponsorship and COI are common in abdominal wall reconstruction studies with ADM. Studies authored by groups disclosing an industry conflict that report clinical outcomes are significantly associated with reporting lower postoperative complications, and consequently describing positive research findings.

Burn management in sub-Saharan Africa: opportunities for implementation of dedicated training and development of specialty centers.

BACKGROUND: In low- and middle-income countries burn injuries remain responsible for a large burden of death and disability. Given an annual worldwide incidence of almost 11 million new individuals affected per year, major burn injuries have a higher annual incidence than HIV and tuberculosis combined. METHODS: A survey instrument was adapted for use as an international assessment tool and then used to measure the availability of personnel, materials, equipment, medicines, and facility resources in nine Rwandan hospitals, including three referral centers. RESULTS: Forty-four percent of surveyed hospitals had a dedicated acute-care burn ward, while two-thirds had intensive care options. Relevant wound-care supplies were widely available, but gaps in the availability of critical pieces of equipment such as monitors, ventilators, infusion pumps, electrocautery, and dermatomes were discovered in many of the surveyed institutions, including referral hospitals. Early excision and grafting were not performed in any of the hospitals and there were no physicians with specialty training in burn care. CONCLUSIONS: Whereas all surveyed hospitals were theoretically equipped to handle the initial resuscitation of burn patients, none of the hospitals were capable of delivering comprehensive care due to gaps in equipment, personnel, protocols, and training. Accordingly, steps to improve capacity to care for those with thermal injury should include training of physicians specialized in critical care and trauma surgery, as well as plastic and reconstructive surgery. Consideration should be given to creation of national referral centers specializing in burn care.