Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction.

BACKGROUND: The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. METHODS: Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. RESULTS: Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). CONCLUSION: Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

Aesthetic Implications of Bilateral Profunda Artery Perforator Flaps on Thigh and Buttock Proportions.

BACKGROUND: The profunda artery perforator (PAP) flap has emerged as an excellent secondary option for autologous breast reconstruction. Despite the increased acceptance, potential secondary benefits concerning aesthetic proportions of proximal thigh and buttock at the donor site have never been systematically investigated. METHODS: A retrospective review of 151 patients who underwent breast reconstruction with horizontally designed PAP flaps (292 flaps) from 2012 to 2020 was performed. Patient characteristics, complications, and numbers of revision surgeries were collected. In bilateral reconstructions, pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in proximal thigh and buttock contour. The patients' own perception of postoperative aesthetic changes was determined by an electronic survey. RESULTS: The patients had a mean age of 51 and a mean body mass index of 26.3 kg/m2. The most common complications were minor and major wound complications affecting 35.1% of patients, followed by cellulitis (12.6%), seroma (7.9%), and hematoma (4.0%). A total of 38 patients (25.2%) underwent revision of the donor site. After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05 ± 0.04 vs. 0.13 ± 0.05, p < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85 ± 0.05 vs. 0.76 ± 0.05, p < 0.0001). Among the 85 patients who responded to the survey (56.3% response rate), 70.6% felt that PAP surgery had aesthetically either improved their thigh contour (54.12%) or not changed it (16.47%), whereas only 29.4% reported that the surgery negatively impacted their thigh contour. CONCLUSION: PAP flap breast reconstruction leads to improved aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh, a poorly defined infragluteal fold, and inadequate anterior-posterior buttock projection.

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.

Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition and Buttock Projection.

BACKGROUND: The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when abdominal donor sites are not available. OBJECTIVES: The aim of this study was to determine how the LAP donor site affects waistline and gluteal proportions, and whether LAP flaps may produce potential secondary benefits concerning donor site aesthetics. METHODS: A retrospective review of 50 patients who underwent bilateral breast reconstruction with LAP flaps (100 flaps) between 2018 and 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized frontal and lateral patient photographs were analyzed to identify postoperative changes in waist-to-hip ratio (WHR) to assess waistline definition and buttock projection. The patients' individual perception of postoperative aesthetic changes to their waistline and buttocks was determined by an electronic survey. RESULTS: The patients had a mean age of 51 years (range, 24-63 years) and a mean BMI of 26.9 kg/m2 (range, 19.3-37.4 kg/m2). Postoperative donor site complications included seroma (n = 10), wound dehiscence (n = 5), hematoma (n = 4), and wound infection (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have a more defined waistline, indicated by a significantly decreased WHR on frontal images (mean [standard error of the mean], 0.85 [0.05] vs 0.80 [0.05], P < .005) and a more projected buttocks indicated by a significant reduction in WHR on lateral images (0.92 [0.07] vs 0.87 [0.07], P < .0001). Among the patients who responded to the survey, 73% indicated that their waistline had aesthetically improved, 6.7% felt it had not changed, and 20% felt that it had worsened. An aesthetic improvement of the buttocks was reported by 53%, 40% felt their buttocks had not changed, and 6.7% felt their buttocks appearance had worsened. CONCLUSIONS: Bilateral LAP flap breast reconstruction leads to improved waistline definition and buttock projection, bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients who are not candidates for abdominal free flaps, but who demonstrate excess flank tissue and seek a more defined waistline and projected buttocks.

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.

Long-term Implications of Cosmetic Breast Surgeries on Subsequent Breast Reconstruction.

BACKGROUND: Cosmetic breast surgeries, such as augmentation, mastopexy, and reduction, are common aesthetic medical procedures for enhancing physical appearance. Despite their popularity, the influence of these surgeries on subsequent breast reconstruction for cancer patients remains underexplored. OBJECTIVES: This study seeks to investigate the effects of previous cosmetic breast surgeries on the outcomes of breast reconstruction. METHODS: A retrospective chart review was conducted from January 2011 to May 2023. This analysis compared patients with histories of implant augmentation, breast reduction, mastopexy, and augmentation-mastopexy against those receiving reconstruction without any cosmetic surgery history. Demographics, comorbidities, complications, revisions, and BREAST-Q surveys were collected. Statistical analysis was performed using SPSS, with significance set at p<0.05. RESULTS: The study included 124 patients (50 autologous, 74 implant) with a history of cosmetic breast surgery (102 implant augmentations, 17 breast reductions, five mastopexies, and nine augmentation mastopexies). They were analyzed against 1307 patients (683 autologous, 624 implant) without prior cosmetic breast surgery. Patients with prior cosmetic surgeries showed a higher incidence of hematoma with tissue expander placement. A preference for implant-based reconstruction was more common among patients with augmentation history (p<0.001), whereas autologous reconstruction was more common in those with history of breast reduction (p=0.047). Patients with history of breast augmentation had on average significantly more breast revisions (p <0.05). CONCLUSIONS: This study demonstrates a significantly higher hematoma rate and number of revisions compared to patients without a history of cosmetic surgery. Furthermore, it suggests that types of cosmetic breast surgery influence the decision-making process regarding implant versus autologous reconstruction.

A Propensity Score-Matched Comparison of Perioperative Outcomes in Prepectoral Smooth Versus Textured Tissue Expander Breast Reconstruction.

INTRODUCTION: Textured tissue expanders (TEs) had previously gained popularity due to minimizing expander migration, rotation, and capsule migration. Recent studies, though, have revealed increased risk of anaplastic large-cell lymphoma associated with certain macrotextured implants, prompting surgeons at our institution to switch to smooth TEs; evaluation is thus required for specific viability and similarity of outcomes of smooth TEs. Our study aims to evaluate perioperative complications in prepectoral placement of smooth versus textured TEs. METHODS: Our retrospective study evaluated perioperative outcomes of patients who underwent bilateral prepectoral TE placement, with either smooth or textured TE, at an academic institution between 2017 and 2021 performed by 2 reconstructive surgeons. The perioperative period was defined as the interval between expander placement until conversion to flap/implant or removal of TE due to complications. Our primary outcomes included hematoma, seroma, wounds, infection, unspecified redness, total number of complications, and returns to operating room secondary to complications. Secondary outcomes included time to drain removal, total number of expansions, hospital length of stay, length of time until the next breast reconstruction procedure, next breast reconstruction procedure, and number of expansions. RESULTS: Two hundred twenty-two patients were evaluated in our study (141 textured, 81 smooth). After propensity matching (71 textured, 71 smooth), our univariate logistic regression showed no significant difference in perioperative complications between smooth and textured expanders (17.1% vs 21.1%; P = 0.396) or complications that required a return to the operating room (10.0% vs 9.2%; P = 0.809). No significant differences were noted for hematoma, seroma, infections, unspecified redness, or wounds between both groups. A significant difference was noted in days to drain out (18.57 ± 8.17 vs 20.13 ± 0.07, P = 0.001) and type of the next breast reconstruction procedure (P < 0.001). Our multivariate regression showed that breast surgeon, hypertension, smoking status, and mastectomy weight were significant for increased risk for complications. CONCLUSION: Our study demonstrates similar rates and effectiveness of smooth versus textured TE when used for prepectoral placement, making smooth TEs a safe and valuable alternative for breast reconstruction because of their decreased risk of anaplastic large-cell lymphoma compared with textured TEs.

Aesthetic Evaluation and Validation: Umbilicus Reconstruction after DIEP Flap.

BACKGROUND: The most common method for autologous breast reconstruction is the deep inferior epigastric perforator (DIEP) flap. The umbilicus can be managed in various ways, including re-inset, neoumbilicus, and umbilectomy without reconstruction. This study evaluated the aesthetic differences in umbilicus reconstruction choice and variation in patients' postoperative satisfaction with their abdomen. METHODS: A retrospective review of 1,019 patients treated with DIEP flap breast reconstruction between August 2009 and January 2022 was conducted. Patients were stratified by management of the umbilicus: preservation and re-inset of the native umbilicus, umbilectomy with delayed reconstruction, and umbilectomy with no reconstruction. A crowdsourced survey was created to assess the aesthetic preference of each photograph using a Likert scale. RESULTS: There were 1,063 responses to the umbilicus preference crowd source survey. Patients who had delayed umbilicus reconstruction after umbilectomy were rated to be significantly more attractive (4.397 ± 1.697) than both preservation of the native umbilicus (4.176 ± 1.669) and lack of the umbilicus (3.994 ± 1.733; p < 0.001 and <0.001, respectively). In an analysis of the BREAST-Q scores, delayed reconstruction patients had a similar change across measures when compared to the re-inset group. The delayed group had a significantly higher change in overall satisfaction and well-being with abdomen when compared with the no reconstruction group (p = 0.006 and 0.027, respectively). CONCLUSION: This study demonstrates that umbilectomy with delayed reconstruction yields a significantly higher aesthetic rating and comparable patient satisfaction when compared to re-inset of the umbilicus.

Influence of Triple-Negative versus Luminal A Breast Cancer Subtype on Choice of Autologous versus Implant-Based Delayed-Immediate Breast Reconstruction.

BACKGROUND: Triple-negative (TN) and luminal A breast cancer molecular subtypes have divergent clinical and prognostic characteristics for breast cancer patients. Our study aims to compare the reconstructive choice of these two groups from the time they receive a tissue expander (TE) to the time they complete autologous or implant-based breast reconstruction. METHODS: A total of 255 patients who underwent delayed-immediate breast reconstruction with TE placement from 2013 to 2017 diagnosed with either TN (n = 73) or luminal A (n = 182) invasive breast cancer subtype seen by two surgeons at a single institution were identified. Preference of autologous and implant-based reconstruction was analyzed, along with TE complications, race, age, body mass index (BMI), smoking, adjuvant therapy, and comorbidities. RESULTS: There was a significant difference in the choice of implant- or autologous-based reconstruction among these two groups (p < 0.05). A greater proportion of luminal A patients underwent implant-based reconstruction (63.47%) and a greater proportion of TN patients underwent autologous-based reconstruction (53.13%). With regard to TE outcomes, there was no significant difference between the two groups with regard to duration of TE placement by reconstructive type or TE surgical complications. Significantly, more TN patients underwent radiation therapy (p < 0.01) and neoadjuvant chemotherapy (p < 0.0001) than luminal A patients. BMI, comorbidities, radiation therapy, and overall TE complications were identified as predictive factors of patients electing for autologous reconstruction over implants. CONCLUSION: TN breast cancer patients mostly chose autologous-based reconstruction, while luminal A patients chose implant-based reconstruction. Both patient groups carried their TEs for similar duration with similar complication profile. Radiation therapy is likely a major factor in the decision for the type of delayed-immediate reconstruction among this population.

Upper-Extremity Phlegmasia Cerulea Dolens With Compartment Syndrome in Coronavirus Disease 2019 Sepsis.

A 54-year-old woman with leukemia presented with coronavirus disease 2019 and a right upper-extremity indwelling peripherally inserted central catheter line for chemotherapy administration. On hospital admission day 9, she developed acute right upper-extremity edema and pain. Ultrasound demonstrated complete superficial and deep venous thrombosis up to the proximal subclavian vein. Her examination result was consistent with acute phlegmasia cerulea dolens and compartment syndrome, but respiratory instability prevented transfer and vascular surgery intervention. Instead, we performed bedside fasciotomies and administered therapeutic heparin, and the limb was salvaged. This case underscores the potential for successful limb salvage in patients with phlegmasia in the setting of coronavirus disease 2019 via compartment release and therapeutic anticoagulation.

Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution. METHODS: This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant. RESULTS: A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group. CONCLUSION: Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.

Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. METHODS: This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. RESULTS: Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. CONCLUSION: The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition. METHODS: A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant. RESULTS: A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005). CONCLUSION: With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.

Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction?

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. METHODS: Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. RESULTS: A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. CONCLUSION: Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes.

BACKGROUND: Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. METHODS: Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. RESULTS: Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). CONCLUSION: With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

Composite Tissue Preservation.

Composite tissue (CT) preservation is important to outcomes after replant or transplant. Since the first limb replant, the mainstay of preservation has been static cold storage with the amputated part being placed in moistened gauze over ice. Historically, the gold-standard in solid organ preservation has been static cold storage with specialized solution, but this has recently evolved in the last few decades to develop technologies such as machine perfusion and even persufflation. This review explores the impact of cooling and oxygenation on CT, summarizes the work done in the area of CT preservation, discusses lessons learned from our experience in solid organ preservation, and proposes future directions.

Clinical Decision Making Using CTA in Conjoined, Bipedicled DIEP and SIEA for Unilateral Breast Reconstruction.

BACKGROUND: Using a hemi-abdominal flap for unilateral breast reconstruction in patients may not be ideal due to paucity of abdominal tissue, presence of a lower abdominal midline scar, or a larger and/or ptotic contralateral native breast. Several algorithms exist to make these flaps successful, but all of them require an anastomosis sequence ultimately. In this study, we present our experience with the use of imaging to predict flap dominance and anastomosis sequence to make them consistently successful. METHODS: Seventy-five consecutive conjoined, bipedicled abdominal composite free flaps for unilateral breast reconstruction were performed. Preoperative computed tomographic angiography (CTA) was obtained to depict the pattern of perforators, flap dominance, and feasibility for intraflap anastomosis. Patient demographics, type/weights of flaps, number of anastomoses, location of perforators, length/type of pedicles, and flap-related complications were reviewed. RESULTS: Seventy-five patients underwent composite deep inferior epigastric perforator (DIEP) and/or superficial inferior epigastric artery (SIEA) flaps. There were 62 DIEP-DIEP flaps, 11 DIEP-SIEA flaps, and two SIEA-SIEA flaps. The mean age was 57 years with an average body mass index of 27 kg/m2 and flap weight of 1,054 g. Thirty-one patients underwent intraflap (41%) and 44 patients underwent crania/caudal anastomoses (59%). In comparison to bilateral DIEPs, the total number of perforators was significantly lower (2.9 vs. 3.8), and fat necrosis rate was lower (2.7 vs. 14.4%) as well. CONCLUSION: Guided by preoperative CTA imaging, we recommend the consistent use of these conjoined, bipedicled hemi-abdominal flaps for unilateral breast reconstruction, primarily those with delayed reconstruction and radiation deficits. Preoperative CTA imaging is crucial in directing perforator dissection to maximize overlapping perfusion zones and guide in performing anastomoses.

Classification and Management of Donor-Site Wound Complications in the Profunda Artery Perforator Flap for Breast Reconstruction.

BACKGROUND: Profunda artery perforator (PAP) flap breast reconstruction has emerged as a popular choice for patients who are not optimal candidates for autologous breast reconstruction using abdominal-based techniques such as the deep inferior epigastric perforator flap. Despite increased utilization of PAP flaps, there are no previous studies on the donor-site morbidity. In this study, we present risk factors, classification of thigh wounds, and our management of donor-site wounds. METHODS: Retrospective review of 69 patients who underwent PAP flap from 2013 to 2016 was performed. Demographic, patient characteristic, and flap data were collected. Postoperative photographs of donor sites were reviewed, and the wounds were classified into three types: type I-normal wound, type II-minor scab, and type III-dehiscence. RESULTS: Of the 69 patients (130 flaps), there were 13 patients (17 flaps) with wound dehiscence (13%), 8 patients with cellulitis (8.5%), 2 patients with seroma (3%), and 1 patient with hematoma (1.5%). The patients with wound dehiscence had statistically higher body mass index (BMI) (29.2 vs. 26.5) with p-value < 0.05 than the patients without wound complications. These patients had higher flap weight (514 vs. 439.7 g), were older (50.8 vs. 48.6 years old), and had a higher chance of being a diabetic (6 vs. 2%), but statistical significance was not achieved. The patients with dehiscence were managed with local wound care (63%), wound vacuum (26%), and operative intervention (11%). CONCLUSION: Our study shows that BMI plays a significant role in the development of postoperative thigh wounds, and all wounds occurred at the medial thigh. However, the majority of the study population did not require any intervention, and revision of scar using the posterior thigh advancement flaps can be used to improve the gluteal aesthetics. We believe findings from our study can help plastic surgeons to counsel and assist patients who will undergo breast reconstruction with a PAP flap.

Co-surgeons in breast reconstructive microsurgery: What do they bring to the table?

INTRODUCTION: Current research within other surgical specialties suggests that a co-surgeon approach may reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved patient and surgical outcomes. We sought to evaluate the role of the co-surgery team and its development in free flap breast reconstruction. METHODS: A retrospective review of free-flap breast reconstruction by two surgeons from 2011 to 2016 was conducted. We analyzed 128 patients who underwent bilateral-DIEP breast. Surgical groups were: single-surgeon reconstruction (SSR; 35 patients), co-surgery where both surgeons are present for entire reconstruction (CSR-I; 69 patients), and co-surgery reconstruction where co-surgeons appropriately assist in two concurrent or staggered cases (CSR-II; 24 patients). Efficiency data collected was OR time and patient length-of-stay (LOS). The rate of flap-failure, return to OR, infection, wound breakdown, seroma, hematoma, and PE/DVT were compared. RESULTS: Single-surgeon reconstruction had significantly longer OR time (678 vs. 485 min, P < .0001), LOS (5 vs. 3.9 days, P < .001), higher wound occurrences of the umbilical site that required surgical correction [11.4 percent (n = 4) vs. 1.5% (n = 1); P < .043] compared to CSR-I. Similarly, SSR had significantly longer average OR time (678 vs. 527 min P < .0001), average LOS (5 vs. 4 days, P = .0005) when compared with CSR-II. There were no total increased patient related complications associated with co-surgery (CSR-I or II). CONCLUSION: The addition of a co-surgeon, even with concurrent surgery, reduces operative time, average patient LOS, and postoperative complications. This work lends a strong credence that co-surgery model is associated with increased operative efficiency.

The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction.

Although the medial femoral condyle has been used for reconstruction in various areas of the body, to the authors' knowledge it has not been used for frontal sinus reconstruction. The authors describe a novel approach to a complex patient using the medial femoral condyle cortiocoperiosteal free flap to reconstruct an anterior frontal sinus defect in conjunction with a recalcitrant mucocele.