Outcomes of Breast Reconstruction After Mastectomy Using Deep Inferior Epigastric Perforator Flap After Massive Weight Loss.

BACKGROUND: Because of the correlation between breast cancer and obesity, plastic surgeons may encounter patients requiring reconstructive breast surgery after massive weight loss (MWL). Use of redundant abdominal skin for deep inferior epigastric artery perforator (DIEP) flap in these patients is a novel concept whose value has not been adequately studied. OBJECTIVE: Assess the outcomes of the DIEP technique for breast reconstruction in the massive weight loss population. PATIENTS: From 103 breast reconstruction patients having 150 DIEP flap procedures, 9 DIEP flaps were performed in MWL patients. Propensity score matching was used in a 1:2 ratio. Eighteen nonweight loss (NWL) patients were selected for comparison with 9 DIEP flaps performed in 6 MWL patients. MEASUREMENTS: Patients in 2 groups were matched for age and body mass index (BMI). Massive weight loss patients were compared with NWL patients on the basis of immediate versus delayed reconstruction and history of radiation; DIEP flap characteristics, including coupler size, additional venous anastomosis, need for re-exploration, and flap loss; length of hospital stay; abdominal wound healing complication; and hernia or bulging. RESULTS: There was no difference in the incidence of flap failures, bulging, or hernias requiring surgery in the MWL group. Additionally, there was no statistical difference in flap survival, abdominal complications, hospitalization days, operative time, or operative characteristics between the 2 groups. There was a significant positive correlation between immediate wound healing complications and comorbidities (P = 0.041). However, there was no correlation between wound healing complications and weight loss history. LIMITATIONS: Only 6 MWL patients of a single surgeon were studied. CONCLUSIONS: For breast reconstruction after mastectomy, DIEP flaps can be used in MWL and NWL populations with equal flap success and abdominal donor site results. Therefore, cosmetic surgeons performing contouring procedures should consider sparing redundant abdominal tissues in patients requiring breast reconstruction.

Estimating the cost of no-shows and evaluating the effects of mitigation strategies.

OBJECTIVE: To measure the cost of nonattendance ("no-shows") and benefit of overbooking and interventions to reduce no-shows for an outpatient endoscopy suite. METHODS: We used a discrete-event simulation model to determine improved overbooking scheduling policies and examine the effect of no-shows on procedure utilization and expected net gain, defined as the difference in expected revenue based on Centers for Medicare & Medicaid Services reimbursement rates and variable costs based on the sum of patient waiting time and provider and staff overtime. No-show rates were estimated from historical attendance (18% on average, with a sensitivity range of 12%-24%). We then evaluated the effectiveness of scheduling additional patients and the effect of no-show reduction interventions on the expected net gain. RESULTS: The base schedule booked 24 patients per day. The daily expected net gain with perfect attendance is $4433.32. The daily loss attributed to the base case no-show rate of 18% is $725.42 (16.4% of net gain), ranging from $472.14 to $1019.29 (10.7%-23.0% of net gain). Implementing no-show interventions reduced net loss by $166.61 to $463.09 (3.8%-10.5% of net gain). The overbooking policy of 9 additional patients per day resulted in no loss in expected net gain when compared with the reference scenario. CONCLUSIONS: No-shows can significantly decrease the expected net gain of outpatient procedure centers. Overbooking can help mitigate the impact of no-shows on a suite's expected net gain and has a lower expected cost of implementation to the provider than intervention strategies.