Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction.

BACKGROUND: Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. METHODS: A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013-2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. RESULTS: Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). CONCLUSION: Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

A Paradigm Shift: Outcomes of Early Autologous Breast Reconstruction after Radiation Therapy.

BACKGROUND: Radiation creates significant challenges for breast reconstruction. There is no consensus regarding optimal timing for autologous reconstruction following radiation. This study explores clearly defined, shorter time intervals between completion of radiation and reconstruction than previously reported. METHODS: A retrospective review was performed on patients who underwent autologous reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Cohorts were selected by time elapsed between radiation and autologous reconstruction including <3 months, 3 to 6 months, 6 to 9 months, 9 to 12 months, 12 to 24 months, and >24 months. Analysis compared baseline characteristics, operative details, complications, revision rates, and BREAST-Q scores. Analysis of variance was used for continuous variables and chi-square for discrete variables. RESULTS: In total, 462 radiated patients underwent 717 flaps. There were 69 patients at <3 months (14.9%), 97 at 3 to 6 months (21%), 64 at 6 to 9 months (13.9%), 36 at 9 to 12 months (7.8%), 73 at 12 to 24 months (15.8%), and 123 at >24 months (26.6%). Age, time from mastectomy, and failure of primary reconstruction were higher at >24 months (p < 0.001). There was no difference between cohorts in intraoperative complications in radiated or nonradiated breasts. There was no difference in acute and late postoperative complications between cohorts. Wound-healing complications in radiated sides were lowest at <3 months and 3 to 6 months (5/69 [7.3%] and 11/97 [11.3%], respectively) compared with other groups (18.8-22.2%) but did not reach significance (p = 0.11). More fat graft revisions occurred at <3 months (p = 0.003). CONCLUSION: Reconstruction can be safely performed within 3 months after radiation without increases in intraoperative, acute, or late reconstructive complications.

Characterizing Outcomes of Medial and Lateral Perforators in Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity. METHODS: A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses. RESULTS: Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators. CONCLUSION: There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

Closed-Incision Negative Pressure Therapy Prevents Major Abdominal Donor-Site Complications in Autologous Breast Reconstruction.

BACKGROUND: Outcomes in autologous breast reconstruction continue to improve with refinements in microsurgical techniques; however, donor-site morbidity remains a concern. Closed-incision negative pressure therapy (ciNPT) has been shown to reduce wound complications. Limited evaluation in abdominal donor sites has shown promising results. We hypothesize that ciNPT will reduce abdominal donor-site complications. METHODS: A retrospective chart review was performed of patients who underwent abdominally based autologous free tissue transfer for breast reconstruction by 4 microsurgeons at an academic institution from 2015 to 2020. The application of a commercial ciNPT for donor-site management was at the discretion of the operating surgeon. Demographics, operative details, and management of donor-site complications were analyzed. RESULTS: Four hundred thirty-three patients underwent autologous breast reconstruction; 212 abdominal donor sites were managed with ciNPT and 219 with standard dressings. Demographics were statistically similar between groups. Abdominal wound healing complications were noted in 30.2% of ciNPT patients (64/212) and 22.8% of control patients (50/219, P = 0.08); however, overall wound complications were attributed to obesity on multivariable analysis. Closed-incision negative pressure therapy significantly decreased complications requiring reoperation (ciNPT 6.2%, 4/64; control 26.5%, 13/51; P = 0.004). There were no significant differences in surgical site infection rates (P = 0.73) and rates of abdominal scar revisions (ciNPT 11.8%, 25/212; control 9.1%, 20/219; P = 0.37). CONCLUSIONS: Use of ciNPT in abdominal donor-site management significantly decreases the incidence of delayed wound healing requiring surgical intervention, with one major wound healing complication prevented for every 6 donor sites managed with ciNPT.

A Comparative Analysis of Outcomes of Free Nipple Areolar Grafting in Autologous Breast Reconstruction.

BACKGROUND: Preserving the nipple areolar complex (NAC) increases satisfaction in breast reconstruction. This study aims to describe outcomes using free NAC grafts in microvascular breast reconstruction. METHODS: A case-control study evaluated prospective outcomes of microvascular breast reconstruction with free NAC grafts compared with matched controls with tattoo or local flap nipple reconstruction. Eligible patients for NAC grafting required correction of ptosis or nipple malposition. Postoperative photographs were rated for complications and aesthetics by the four study authors and two additional unbiased board-certified plastic surgeons. Satisfaction was measured with the BREAST-Q. RESULTS: Twenty patients who underwent 35 autologous breast reconstructions were analyzed. Nipple areolar reconstruction with grafts was completed with 13 NACs in 7 patients. The majority of free NAC grafts (11/13, 85%) were completed in immediate reconstruction, and 15% (2/13) were completed in delayed reconstruction. Partial graft hypopigmentation (mean 18.0%, standard deviation [SD] 7.5) was noted in all grafts. Less than half of grafts had areas of depigmentation (6/13, mean 6.1%, SD 7.5). Minor areas of partial loss occurred in 6/13 grafts (mean 2.9%, SD 4.6). Nipple projection was maintained in 54% of nipples (7/13). Depigmentation, hypopigmentation, graft loss, and projection were not statistically correlated with NAC aesthetic or overall aesthetic rating. However, NAC size (p = 0.003), position (p = 0.022), and symmetry (p = 0.028) were all correlated with aesthetic outcomes. Outcomes and satisfaction were similar to those seen with local flap reconstruction, although partial loss was less common in NAC grafts. CONCLUSION: Nipple reconstruction can successfully be performed in microvascular breast reconstruction using free grafts. Although partial graft hypopigmentation is common, smaller areas of graft loss or depigmentation are anticipated and do not affect aesthetic outcomes. The use of free NAC grafts may allow additional patients to use their own nipples as part of their microvascular reconstruction and avoid secondary NAC reconstruction procedures.

Assessing the Efficacy of Deoxycholic Acid for the Treatment of Submental Fat: A Three-Dimensional Study.

BACKGROUND: Deoxycholic acid is used for the treatment of excess submental fat, offering a potential alternative to more invasive surgical procedures. However, there is currently an absence of high-level evidence in the literature outside of Phase 3 clinical trials. OBJECTIVES: The aim of this study was to evaluate the efficacy of deoxycholic acid for the treatment of submental adiposity by correlating objective 3-dimensional (3D) data with subjective patient assessment scores. METHODS: Thirteen patients were prospectively enrolled into the study. 3D images were obtained prior to initial treatment, at 4-week intervals, and in the acute recovery period. Volumetric changes were calculated using Vectra software. Corresponding subjective surveys using the FACE-Q tool evaluated the perceived treatment results and side effects. RESULTS: Objectively, there was a significant reduction in submental volume following treatment (P = 0.004), with total rounds of treatment averaging 3.4 (SD: 1.19). During the immediate recovery period, there was a statistically significant increase in submental volume, with an average increase of 8.68% (P = 0.0003). Subjectively, patient satisfaction scores improved significantly for both the aesthetics of the area under the chin and jawline (P < 0.005). Self-resolving paresthesia following treatment occurred in all study participants. There were no major complications. Participant scores of early treatment recovery also improved significantly with subsequent treatments (P < 0.005). CONCLUSIONS: This study validates the use of deoxycholic acid for reducing supraplatysmal adiposity in the submental area. Objective volume changes showed positive correlation with subjective improvements in patient satisfaction scores. Recovery and side effect profiles were also described and may aid in future patient education and management.

The incidence of tuberous breast deformity in asymmetric and symmetric mammaplasty patients.

BACKGROUND: Breast asymmetry is commonly accompanied by tuberous deformity. To date, no study has reported the incidence of this breast deformity in the presence of asymmetry. A retrospective analysis of standard preoperative photographs was performed on 375 consecutive female patients presenting for mammaplasty over a 10-year span. METHODS: Women were examined for symmetry, asymmetry, and the presence of tuberous deformity. Patients were graded by the Grolleau Classification System. Patients having congenital anomalies, tumors, infection, radiation, chest wall deformities, previous breast surgery history, and incomplete chart data were excluded. RESULTS: Of the 375 patients studied, 81.1 percent (n = 304) presented with asymmetry. Of these asymmetric women, 88.8 percent (n = 270) were found to have tuberous deformity. Of the 71 patients who were symmetric, 7 percent (n = 5) were tuberous. Concurrent nipple-areola complex involvement in the tuberous asymmetric patient population was present in 50 percent of the women (n = 116). Of the tuberous deformities with nipple-areola complex, 87.9 percent (n = 116) were Grolleau type III. Nipple-areola complex involvement was not found in any of the symmetric patients. Of the 275 women with tuberous deformity, 531 breasts were tuberous and 60.3 percent (n = 320) were Grolleau's type III. In total, 57.1 percent of all reduction mammaplasties (n = 92) and 83.2 percent of all augmentation mammaplasties (n = 178) had asymmetry with tuberous deformity. CONCLUSIONS: This is the first published study to demonstrate that tuberous deformity is strongly associated with asymmetry in women presenting for mammaplasty. This should be evaluated in preoperative planning to ensure optimal outcome. Patients with this deformity should be educated preoperatively so their expectations of postoperative results are realistic.