A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest.

BACKGROUND: The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients. METHODS: This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications. RESULTS: Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87. CONCLUSION: This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

A Comparative Analysis of Sensory Return in Delayed-Immediate Versus Immediate Neurotized Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Breast reconstruction patients who anticipate adjuvant radiation are not suitable candidates for immediate deep inferior epigastric perforator (DIEP) flap reconstruction due to the risk of flap fibrosis, shrinkage, and fat necrosis. Rather, many of these patients undergo delayed-immediate, or "babysitter," reconstruction, where a tissue expander is placed first as a temporizing measure during adjuvant therapy before definitive flap reconstruction. In this study, we aim to compare sensory changes in delayed-immediate to immediate DIEP flap patients. METHODS: Ninety-one patients, including 26 patients (46 breasts) with "babysitter" procedures and 65 patients (120 breasts) with immediate DIEP flaps, were prospectively identified at their preoperative visit. For both cohorts, baseline level (t = 0) is defined as before mastectomy. RESULTS: "Babysitter" patients underwent final-stage neurotized flap reconstruction on average at 12 months after initial tissue expander placement (range, 3-18 months). At 18 month after mastectomy (6 months after DIEP), delayed-immediate patients had comparable sensitivity measurements as immediate DIEP flap patients in all regions of the breast (P > 0.05). For delayed immediate patients, at 18 months postoperatively, sensitivity measurements were comparable with baseline levels only in the outer superior, outer medial, and outer lateral regions of the breast (P > 0.05). At 24 months postoperatively, cutaneous thresholds were comparable with baseline in all regions of the breast except the inner inferior region (P > 0.05), following a similar sensory recovery trajectory as immediate DIEP flap patients. CONCLUSIONS: In patients who undergo "babysitter" procedures, the combination of sensory return from the native mastectomy skin flap along with the neurotized DIEP flap yields sensory recovery comparable with immediate DIEP flap patients after definitive flap reconstruction. When final-stage flap reconstruction occurs by 12 months after mastectomy, sensation can return beginning 24 months postoperatively, or even sooner in some regions of the breast.

A Pilot Study Comparing Sensation in Buried Versus Nonburied Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: Neurotized deep inferior epigastic perforator (DIEP) flaps have been shown to improve sensory recovery after mastectomy and reconstruction. With the recent trend toward nipple-sparing mastectomies, sensation likely originates within the buried DIEP flap and then innervates the breast skin. In contrast, for patients undergoing skin-sparing mastectomies, the DIEP flap skin is preserved, brought up to the surface, and directly innervated. In this study, we aim to evaluate inner breast region sensation between patients whose DIEP flap is buried and whose DIEP flap skin is brought to the surface. METHODS: Seventy patients who underwent mastectomy with immediate reconstruction using the DIEP flap were prospectively identified. Of these, 60 patients underwent nipple-sparing mastectomy with buried DIEP flap reconstruction while 10 patients underwent skin-sparing mastectomy with nonburied DIEP flap reconstruction. Patients in both cohorts received nerve grafting using the 70 × 1-2-mm Avance Nerve Graft in identical fashion. Sensitivity evaluation was performed in five inner breast regions (corresponding to the nonburied DIEP flap area). RESULTS: In the buried DIEP cohort, at 6 months postoperatively, there was a statistically significant difference in inner breast region sensitivity measurements compared with baseline levels ( P < 0.001). In contrast, in the nonburied DIEP cohort, at 6 months postoperatively, sensation in the inner breast region was comparable with preoperative baseline levels ( P = 0.236). At 24 months postoperatively, inner breast region sensitivity measurements in both cohorts were comparable with preoperative baseline measurements ( P > 0.05). CONCLUSIONS: Neurotized DIEP flap skin raised directly to the surface confers earlier sensory recovery than buried DIEP flaps. In patients who undergo skin-sparing mastectomies with nonburied DIEP flap reconstruction, they can expect significantly better sensation in the inner regions of the breast at 6 months postoperatively. In patients who undergo nipple-sparing mastectomies with buried DIEP flap reconstruction, they can expect sensation in the inner breast to return to preoperative baseline levels at a later time point-beginning as early as 24 months postoperatively.

Using Clinical Measurements to Predict Breast Skin Necrosis: A Quantitative Analysis.

BACKGROUND: Breast skin necrosis can lead to poor healing, reoperation, and unaesthetic reconstructive outcomes after mastectomy. Furthermore, the prolonged recovery can delay adjuvant oncologic regimens. This study aims to explore the role of breast surface area as a risk factor for mastectomy skin flap necrosis and to identify predictive clinical measurements. METHODS: The authors retrospectively identified patients who underwent immediate breast reconstruction (N = 926 breasts) by 2 surgeons at a single institution between 2011 and 2021. Preoperative breast measurements such as nipple-notch (NN) distance, nipple-inframammary fold (NF) distance, chest width (CW), breast circumference (BC), and breast height (BH) were used to estimate breast surface area. Univariate analysis and receiver operating characteristic curves were used to determine predictive measurements and optimal cutoff values. RESULTS: When approximated using either a cone without base or a half ellipsoid, larger surface area was a significant risk factor for mastectomy skin flap necrosis (P = 0.027 and P = 0.022, respectively). Larger NN, NF, CW, BC, and BH measurements were significant predictors of necrosis (P < 0.05). Surface area (cone without base) greater than 212 cm2, surface area (half ellipsoid) greater than 308 cm2, NN distance greater than 27 cm, NF greater than 8.5 cm, CW greater than 15 cm, BC greater than 29 cm, and BH greater than 10.5 cm are all values shown to increase the incidence of necrosis. CONCLUSIONS: Larger breast surface area is an independent risk factor for breast skin necrosis. Preoperative breast measurements can be a useful adjunct for predicting necrosis in postmastectomy patients.

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair.

OBJECTIVE: Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. DESIGN: A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. SETTING: New York-Presbyterian Hospital. PATIENTS/PARTICIPANTS: Patients with cleft palate undergoing primary palatoplasty. INTERVENTIONS: Meta-analysis of reported patient outcomes in ERAS and control cohorts. MAIN OUTCOME MEASURE(S): Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. RESULTS: Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. CONCLUSIONS: ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

A Comparative Analysis of Risk Factors for Breast Skin Necrosis following Autologous versus Device-Based Breast Reconstruction.

BACKGROUND: Mastectomy skin flap necrosis often necessitates prolonged wound care, surgical re-excision, and it increases the risk for infection. This study aims to compare rates of skin flap necrosis between autologous and device-based reconstructions and identify risk factors. METHODS: The authors retrospectively identified patients who underwent immediate breast reconstruction using either the deep inferior epigastric perforator (DIEP) flap (n = 373 breasts, 41%) or tissue expanders (n = 529 breasts, 59%) by two surgeons at a single institution between 2011 and 2021. The rate of skin flap necrosis between autologous and device-based reconstructions was compared and multivariate regression analysis was performed to identify risk factors. RESULTS: There was no significant difference in rates of skin flap necrosis between the two cohorts (26.8 vs. 15.5%, p = 0.052). Across all patients, hypertension and body mass index >30 were significant predictors of necrosis (p = 0.024 and p <0.001, respectively). Within our DIEP cohort, mastectomy specimen weight was a significant risk factor for necrosis (p = 0.001). The DIEP flap weight itself did not confer a higher risk for necrosis (p = 0.8). CONCLUSION: Immediate autologous reconstruction does not place patients at higher risk of skin necrosis. Hypertension and obesity (body mass index >30) were independent risk factors for necrosis in all patients. Mastectomy specimen weight was a significant predictor of necrosis in DIEP flap patients while the DIEP flap weight itself did not increase the risk for necrosis.

Using a Machine Learning Approach to Predict the Need for Elective Revision and Unplanned Surgery after Implant-based Breast Reconstruction.

Two-stage implant-based reconstruction after mastectomy may require secondary revision procedures to treat complications, correct defects, and improve aesthetic outcomes. Patients should be counseled on the possibility of additional procedures during the initial visit, but the likelihood of requiring another procedure is dependent on many patient- and surgeon-specific factors. This study aims to identify patient-specific factors and surgical techniques associated with higher rates of secondary procedures and offer a machine learning model to compute individualized assessments for preoperative counseling. A training set of 209 patients (406 breasts) who underwent two-stage alloplastic reconstruction was created, with 45.57% of breasts (185 of 406) requiring revisional or unplanned surgery. On multivariate analysis, hypertension, no tobacco use, and textured expander use corresponded to lower odds of additional surgery. In contrast, higher initial tissue expander volume, vertical radial incision, and larger nipple-inframammary fold distance conferred higher odds of additional surgery. The neural network model trained on clinically significant variables achieved the highest collective performance metrics, with ROC AUC of 0.74, sensitivity of 84.2, specificity of 63.6, and accuracy of 62.1. The proposed machine learning model trained on a single surgeon's data offers a precise and reliable tool to assess an individual patient's risk of secondary procedures. Machine learning models enable physicians to tailor surgical planning and empower patients to make informed decisions aligned with their lifestyle and preferences. The utilization of this technology is especially applicable to plastic surgery, where outcomes are subject to a variety of patient-specific factors and surgeon practices, including threshold to perform secondary procedures.

Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction.

BACKGROUND/OBJECTIVES: Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF). DESIGN: Retrospective cohort study. SETTING: Academic medical center in New York City. PARTICIPANTS: Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF. MEASUREMENTS: We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD). RESULTS: Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005). CONCLUSIONS: Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.