Direct-to-Implant Versus 2-Stage Breast Reconstruction: Which Technique Is Better? An Analysis of 104 Patients at a Single Institution.

BACKGROUND: Two-stage (TS) implant-based reconstruction is the most commonly performed method of reconstruction after mastectomy. A growing number of surgeons are offering patients direct-to-implant (DTI) reconstruction, which has the potential to minimize the number of surgeries needed and time to complete reconstruction, as well as improve health care utilization. However, there are conflicting data regarding the outcomes and complications of DTI, and studies comparing the 2 methods exclusively are lacking. METHODS: Patients undergoing implant-based reconstruction after mastectomy within a large interstate health system between 2015 and 2019 were retrospectively identified and grouped by reconstruction technique (TS and DTI). The primary outcomes were a composite of complications (surgical site occurrences), health care utilization (reoperations, unplanned emergency department visits, and readmissions), and time to reconstruction completion. Risk-adjusted logistic and generalized linear models were used to compare outcomes between TS and DTI. RESULTS: Of 104 patients, 42 underwent DTI (40.4%) and 62 underwent TS (59.6%) reconstruction. Most demographic characteristics, and oncologic and surgical details were comparable between groups ( P > 0.05). However, patients undergoing TS reconstruction were more likely to be publicly insured, have a smoking history, and undergo skin-sparing instead of nipple-sparing mastectomy. The composite outcome of complications, reoperations, and health care utilization was higher for DTI reconstruction within univariate (81.0% vs 59.7%, P = 0.03) and risk-adjusted analyses (odds ratio, 3.78 [95% confidence interval [CI], 1.09-13.9]; P < 0.04). Individual outcome assessment showed increased mastectomy flap necrosis (16.7% vs 1.6%, P < 0.01) and reoperations due to a complication (33.3% vs 16.1%; P = 0.04) in the DTI cohort. Although DTI patients completed their aesthetic revisions sooner than TS patients (median, 256 days vs 479 [ P < 0.01]; predicted mean difference for TS [reference DTI], 298 days [95% CI, 71-525 days]; P < 0.01), the time to complete reconstruction (first to last surgery) did not differ between groups (median days, DTI vs TS, 173 vs 146 [ P = 0.25]; predicted mean difference [reference, DTI], -98 days [95% CI, -222 to 25.14 days]; P = 0.11). CONCLUSIONS: In this cohort of patients, DTI reconstruction was associated with higher complications, reoperations, and health care utilization with no difference in time to complete reconstruction compared with TS reconstruction. Further studies are warranted to investigate patient-reported outcomes and cost analysis between TS and DTI reconstruction.

Immediate Breast Reconstruction for Inflammatory Breast Cancer: Trends in Use and Clinical Outcomes 2004-2016.

INTRODUCTION: National guidelines specify against immediate breast reconstruction (IBR) among inflammatory breast cancer (IBC) patients. However, limited data exist regarding this practice. We report practice patterns and oncologic outcomes among nonmetastatic IBC patients receiving trimodality therapy, with or without IBR. METHODS: Using the National Cancer Database, we identified nonmetastatic IBC patients treated with trimodality therapy from 2004 to 2016. Primary outcome was overall survival (OS), assessed on unadjusted analysis using Kaplan-Meier estimates and on adjusted analysis using multivariable Cox proportional hazards and inverse probability weighting (IPW) models. OS analysis was also conducted with propensity score matched (PSM) cohorts. Secondary outcomes included IBR utilization rates, time to postmastectomy radiotherapy (PMRT), and surgical outcomes. RESULTS: 6589 women were included, including 5954 (90.4%) non-reconstructed and 635 (9.6%) IBR. Among IBR recipients, 250 (39.4%) underwent autologous reconstruction, 171 (26.9%) underwent implant-based reconstruction, and 214 (33.7%) unspecified. IBR utilization increased from 6.3% to 10.1% from 2004 to 2016 at a 4% average annual growth rate (P < 0.001). Median follow-up was 43 and 45 months for IBR and non-reconstructed patients, respectively (P = 0.29). On Cox multivariable analysis, IBR was associated with improved OS (HR 0.63, 95% CI 0.44-0.90, P = 0.01), but this association was not significant on IPW analysis (P = 0.06). In PSM cohorts, this association remained significant (HR 0.60, 95% CI 0.40-0.92, P = 0.02). Margin status, time to PMRT, 30-day readmission, and 30-/90-day mortality did not differ between groups (all P > 0.05). CONCLUSION: Although not endorsed by national guidelines, IBR is increasing among IBC patients; however, more granular data are needed to determine oncologic safety.

An Analysis of Specialty-Specific Microsurgical Head and Neck Reconstruction: A Look at a Single Institution and National Trends Over a Decade.

INTRODUCTION: Head and neck free flap (HNFF) reconstructions have historically utilized a multidisciplinary approach between otolaryngology head and neck surgery (OHNS) and plastic surgery (PS). However, there seems to be a trend toward both the extirpative and reconstructive portions being performed by OHNS. We aimed to elucidate the volume trend in HNFF reconstruction over the last decade. METHODS: Data were collected by 3 modalities: electronic medical record search of patients who underwent HNFF surgery at our institution (2013-2018), survey data from microsurgery fellowship programs (2007-2017), and National Surgical Quality Improvement Program (NSQIP) query of cases receiving designated HNFF Current Procedural Terminology codes (2011-2016). Data were analyzed with trends in HNFF reconstruction as our primary outcome. RESULTS: At our institution, HNFF reconstructions increased 4-fold (59-227). Percentage of cases by PS decreased from 18.6% to 6.0%, whereas that of OHNS increased 81.4% to 94.0% (P = 0.009). Survey data, completed by microsurgery fellowship program directors (23/81 [27.2%]), revealed the number of OHNS programs in 2007 performing 100 or more HNFF cases compared with PS was 40% (6/15) to 12.5% (1/8) (P = 0.172). By 2016, that number increased significantly for OHNS to 73.3% (11/15), whereas that of PS remained stagnant at 12.5% (1/8) (P = 0.005). According to NSQIP data, the percentage of cases performed by PS in 2011 was 52%, which was greater than OHNS's share of 43%. The other 5% was allotted to either orthopedic, oral and maxillofacial surgery, or general surgery. In 2013, those numbers reached a peak for PS at 55% and a nadir for OHNS at 36%. However, by 2016, the percentage of HNFF cases reversed. where 58% of cases were performed by OHNS and only 38% by PS. When comparing the 2011 data to the 2016 data, OHNS had a 134% increase, whereas PS had a 27% decrease (P = 0.003). CONCLUSIONS: Head and neck free flap reconstruction has grown dramatically over the last 10 years. Plastic surgeons are performing fewer cases, whereas otolaryngology head and neck surgeons perform more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data.

Autologous breast reconstruction in the postbariatric patient population.

BACKGROUND: Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution. METHODS: Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts. RESULTS: Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00). CONCLUSIONS: As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction.

BACKGROUND: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure. METHODS: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014. RESULTS: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459). CONCLUSIONS: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction.

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

Increased Lower Extremity Venous Stasis May Contribute to Deep Venous Thrombosis Formation after Microsurgical Breast Reconstruction-An Ultrasonographic Study.

Background Despite guideline-compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant-based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. Methods An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Results Eighteen patients with a mean age and body mass index of 52.7 years (range, 29-76 years) and 31.3 kg/m2 (range, 21.9-43.4 kg/m2) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (p < 0.0001). Similarly, a 24.3 and 69.9% increase in CFV circumference (p = 0.0007) and area (p < 0.0001) were noted, respectively. These correlated with a 28.4% decrease in maximum flow velocity in the CFV (p = 0.0001). Of note, none of these parameters displayed significant changes for the IJV, thus indicating that observed changes in the CFV were not the result of changes in perioperative fluid status. Conclusion Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.

The Timing of Breast Irradiation in Two-Stage Expander/Implant Breast Reconstruction.

Certain patients who initiate expander/implant (E/I) reconstruction following mastectomy may require radiation therapy (XRT). XRT may be delivered during the tissue expander (TE) expansion process or after exchange for a permanent implant (PI). We studied a series of women treated with E/I reconstruction and XRT to determine whether there is a difference in complication rates between those who had XRT to the TE versus PI. All two-stage E/I reconstructions at our institution from April 2005 to January 2013 were reviewed to identify patients who underwent XRT after TE placement. Our database was queried for reconstructive details, oncologic treatment, and complications. Statistical analyses were performed to establish significance of complication rate differences. Fifty-two patients underwent XRT after TE placement, 42 of which had XRT to the TE and 11 of which had XRT to the PI. The major complication rates (complications requiring emergent reoperation/readmission) were 27% versus 0% (p = 0.05) for XRT to the TE versus XRT to the PI, but there were no significant differences in minor complication rates (outpatient complications). Specifically, the rates of Grade 3/4 capsular contracture were similar between the two groups, 27% for the XRT to the TE group and 36% for the XRT to the PI group. Radiation of the PI versus radiation of the TE did not result in significant differences in overall surgical complication rates but had fewer major complications and no implant failures. Other factors must also be considered, such as patient preference, risk of cancer reoccurrence, and cosmesis. It is essential for a patient to have a team of a plastic surgeon and radiation, surgical, and medical oncologists working together to achieve each patient's goals.

Assessing Surgical and Medical Complications in Bilateral Abdomen-Based Free Flap Breast Reconstructions Compared With Unilateral Free Flap Breast Reconstructions.

BACKGROUND: Prophylactic mastectomy is more common, with many patients seeking reconstruction. Bilateral free flap reconstructions subject patients to 2 flaps and longer operations, potentially increasing their risk for complications. We hypothesized that bilateral abdomen-based free flap reconstruction patients are a unique patient population with a higher rate of perioperative complications. METHODS: A retrospective chart review compared all 444 bilateral abdomen-based free flap breast reconstructions (in 222 patients) and 367 unilateral free flap breast reconstructions, performed at a single institution between March 2005 and July 2011. Patient and surgical characteristics and complications were studied. RESULTS: Bilateral reconstruction patients were slightly younger and heavier (mean, 49.2 years and 77.7 kg) and more likely to be white. Bilateral reconstructions were more often immediate reconstructions and less likely to have postoperative radiation therapy. These patients had longer surgical times and higher rates of intraoperative arterial thrombosis, but there were no significant differences in postoperative thrombosis or flap loss rates between the groups. The bilateral reconstruction patients, however, did have higher rates of minor surgical and medical complications, including a higher rate of lower extremity deep venous thrombosis (1.8% vs 0.3%, P = 0.045). CONCLUSIONS: We find that bilateral abdomen-based free flap breast reconstruction patients do not have higher rates of major postsurgical complications such as flap loss or postoperative thrombosis. However, higher rates of minor surgical and postoperative medical complications, including significantly more cases of lower extremity deep venous thrombosis, are seen. These findings are important for patient counseling and perioperative management.

Bilateral Free Flap Breast Reconstruction After Unilateral Radiation: Comparing Intraoperative Vascular Complications and Postoperative Outcomes in Radiated Versus Nonradiated Breasts.

BACKGROUND: Radiation induces vessel damage and impairs tissue healing. To date, only 1 study has examined radiation's impact in autologous breast reconstruction on intraoperative vascular complications and postoperative outcomes. In this follow-up paper, we examine a larger cohort with an improved study design to better control for patient characteristics. METHODS: A database of 1780 patients who underwent autologous breast free flap reconstruction at the University of Pennsylvania's Health System between 2003 and 2014 was searched for patients who underwent bilateral breast reconstruction after unilateral radiation, returning 199 patients for review. These were then analyzed for intraoperative vascular complications as well as postoperative complications. McNemar tests were performed on all variables, comparing between radiated and nonradiated fields. RESULTS: Fields with prior radiation were significantly more likely to have any type of intraoperative vascular complication and need for arterial anastomotic revision compared to fields without prior radiation (14% versus 7%, P = 0.03 and 8% versus 3%, P = 0.04, respectively). Although there was a trend for more frequent arterial thrombosis in radiated compared to nonradiated fields, this was nonsignificant (7% versus 3%, P = 0.08). There was no significant difference in venous thrombosis or need for venous anastomotic revision. Radiated fields were significantly more likely to have postoperative wound infections compared to nonradiated fields (4% versus 0.5%, P = 0.04). There was no difference in other postoperative complications, including postoperative thrombosis, flap loss, mastectomy flap necrosis, fat necrosis, hematoma, seroma, or delayed wound healing. CONCLUSIONS: Intraoperative vascular complications and postoperative wound infections are significantly more likely to occur in autologous breast free flap reconstruction with previous radiation therapy. It is important to plan for and counsel patients that fields with previous radiation are at higher risk for these complications.

Vascular variations of the transverse upper gracilis flap in consideration for breast reconstruction.

PURPOSE: The transverse upper gracilis (TUG) myocutaneous flap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. METHODS: A retrospective review of records was performed on patients undergoing a TUG flap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). RESULTS: A total of 36 TUG flaps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of flap harvest. CONCLUSIONS: Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for flap dissection when the microsurgeon encounters such aberrancies.

The Patient's Perspective on the Effect of Autologous Breast Reconstruction on Lymphedema.

BACKGROUND: Lymphedema is a well-documented complication of the treatment for breast cancer. Although the onset of lymphedema is rare after delayed autologous breast reconstruction, no studies have surveyed a patient's perspective on the effects of reconstruction on lymphedema. METHODS: The design of this study was a retrospective review of delayed unilateral breast reconstruction performed by the senior authors between 2005 and 2009 combined with the use of a well-validated survey instrument that can be used to diagnose lymphedema. Patients were mailed a series of questions to determine if they had lymphedema. In addition, they were asked separate questions about reconstruction's effect on arm symptoms. RESULTS: During this period, 90 patients underwent delayed unilateral breast reconstruction with an autologous free flap. After 2 mailings, 68.8% (n = 62) of patients returned the survey and were included in data analysis. Of the 62 respondents, 11.3% (n = 7) had been diagnosed and documented as having lymphedema in the medical record. This is in stark contrast to the survey that reported 48.3% (n = 30) with lymphedema (P < 0.01), which is more consistent with previous reports of lymphedema after mastectomy. Overall, 29.0% (n = 18) reported mild lymphedema and 20.0% (n = 12) reported moderate/severe lymphedema. Of those diagnosed by survey, 51.7% thought there was no change, 27.6% were worse, and 20.7% were better after reconstruction. Although not necessarily indicative of a diagnosis of lymphedema, when asked questions about arm symptoms, 38.4% thought their symptoms were worse, 30.8% reported no change, and 30.8% stated they were better. Of those patients with lymphedema by survey, only 18.5% reported discussing this with their plastic surgeon. CONCLUSIONS: Overall, the prevalence of lymphedema was similar to published reports in the cancer literature, but much more common than reported in our plastic surgery clinic or recent plastic surgery literature. On the whole, delayed reconstruction seems to have no effect on lymphedema. Although more prospective study is necessary to answer this question conclusively, as part of a multidisciplinary team, plastic surgeons should be aware that lymphedema is common; patients may not volunteer their symptoms and may in fact benefit from specific questioning to aid in diagnosis and treatment.

Outcomes and Cost Analysis in High-Risk Patients Undergoing Simultaneous Free Flap Breast Reconstruction and Gynecologic Procedures.

BACKGROUND: For patients with BRCA mutations, a simultaneous procedure that combines risk-reducing operation of the ovaries with mastectomy and breast reconstruction is an attractive option. The purpose of this study was to assess the outcomes and associated cost of performing simultaneous mastectomy, free flap breast reconstruction (FFR), and gynecologic procedure. METHODS: A retrospective chart review was performed on patients who underwent bilateral FFR from 2005 to 2012. Four hundred twenty-two patients were identified who underwent bilateral breast reconstruction without a simultaneous gynecologic procedure. Forty-two patients were identified who underwent simultaneous FFR and gynecologic procedure. Clinical outcomes, medical and surgical complications, and hospital costs were analyzed and compared between the 2 groups. RESULTS: A total of 928 free flaps were performed on 464 patients. Forty-two patients had a simultaneous gynecologic procedure at the time of breast reconstruction. Twenty-three (54.8%) patients within the study group underwent simultaneous bilateral salpingo oophorectomy (BSO), whereas the other 19 (45.2%) underwent both total abdominal hysterectomy and BSO. Eighty-four free flaps were performed in this cohort (n = 48 muscle-sparing transverse rectus abdominis myocutaneous, n = 28 deep inferior epigastric perforator, n = 4 superficial inferior epigastric perforator, n = 4 transverse upper gracilis). Mean operative time was 573 minutes. Mean hospitalization was 5.3 days. Postoperatively, 4 patients experienced an anastomotic thrombosis; 2 patients had an arterial thrombosis and 2 patients had a venous thrombosis. There were 2 flap failures, 2 patients with mastectomy skin flap necrosis, 11 patients who developed breast wound healing complications, and 6 patients who developed abdominal wound healing complications. Surgical and medical complication rates did not differ significantly between those who had simultaneous procedures, and those who did not. There was a statistically significant difference in the average total cost when comparing the group of patients receiving prophylactic mastectomy/FFR/total abdominal hysterectomy and/or BSO versus the patients who did not have combined gynecologic procedures at the time of reconstruction ($22,994.52 vs $21,029.23, P = 0.0004). CONCLUSIONS: For the high-risk breast cancer patient, a combined mastectomy, free flap reconstruction, and gynecologic procedure represents an attractive and safe option.

Do Prior Abdominal Surgeries Increase Complications in Abdominally Based Breast Reconstructions?

BACKGROUND: A large proportion of patients presenting for autologous breast reconstruction have a history of prior abdominal surgeries such as obstetric, gynecologic, or general surgical procedures. The impact of prior abdominal wall violation on the ability to perform free tissue transfer from the abdomen needs to be explored and characterized. The purpose of this study was to assess the impact of prior abdominal surgery on perfusion-related complications and donor-site morbidity in free tissue abdominal transfer. METHODS: All patients who underwent abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at the Hospital of the University of Pennsylvania were included. In addition to collecting data on standard patient past medical histories, comorbidities, and case characteristics, we also noted specific types of prior abdominal surgeries, number of prior surgeries, and if the rectus sheath was violated. Outcomes assessed included thrombotic complications, flap loss, major surgical complications, minor surgical complications, delayed wound healing, and subsequent hernia formation. RESULTS: Eight hundred twelve patients underwent 1257 free flap breast reconstructions during the study period. Four hundred seventeen (51.4%) women had undergone prior abdominal surgery. The most common prior abdominal surgeries included total abdominal hysterectomy and/or bilateral salpingo-oophorectomy (35.7%), cesarean delivery (33.8%), and appendectomy (12.7%). No significant differences were noted in the number of major intraoperative complications (P = 0.68), total thrombotic events (P = 0.339), or flap losses (P = 0.53). Patients who had undergone prior rectus sheath violation were found to experience a greater amount of delayed healing of the donor site (22.7% vs 16.5%, P = 0.03). Additionally, a higher rate of postoperative hernia formation was noted in patients who had undergone prior hernia repairs (13.6% vs 3.3%, P = 0.04). CONCLUSIONS: A significant portion of patients presenting for breast reconstruction have had prior abdominal surgeries. This study demonstrates that these prior procedures represent an acceptable level of risk; although this issue should still be addressed during preoperative patient counseling. In patients with prior hernia repairs, however, additional care should be given to the fascial closure as these patients may be at higher risk for subsequent hernia formation after abdominally based breast reconstruction.

Loupes-Only Microsurgery is a Safe Alternative to the Operating Microscope: An Analysis of 1,649 Consecutive Free Flap Breast Reconstructions.

BACKGROUND: Loupes-only microsurgery challenges the paradigm that free flap surgery requires an operating microscope. We describe our loupes-only microsurgery experience with an emphasis on rates of intraoperative anastomotic revision and total flap loss. METHODS: We identified all patients having breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric perforator (DIEP) flaps over 7 years. We examined rates of intraoperative anastomotic revision and total flap loss as markers of technical quality. For one high-volume surgeon who started loupes-only microsurgery while at our institution, we examined rates of intraoperative anastomotic revision and total flap loss rates over time to evaluate for a learning curve. RESULTS: We performed 1,649 ms-TRAM or DIEP flaps in 1,063 patients. For 1,649 flaps, the rate of artery anastomotic revision was 2.2% (36 arteries) and venous anastomotic revision was 2.2% (37 veins). Any microvascular revision was performed in 3.5% (58 flaps). Total flap loss rate was 1.2% (20 flaps).For the "learning curve" analysis, there were no clinically relevant differences in rates of any intraoperative anastomotic revision or total flap loss during the first 60 months after loupes-only microsurgery was adopted. Total flap loss during this surgeon's first 60 months of loupes-only microsurgery was 1.6% (10 of 638 flaps). CONCLUSIONS: Loupes-only microsurgery is a safe alternative to the operating microscope for free flap breast reconstruction using the deep inferior epigastric system. Our total flap loss rate of 1.2% in 1,649 flaps is at the low end of published flap loss rates.

Lower extremity free flap outcomes using an anastomotic venous coupler device.

INTRODUCTION: Venous anastomosis is one of the most challenging technical aspects of microsurgery. Recently, it has been expedited by the use of an anastomotic coupler device in multiple reconstructive venues. However, there are few studies in the literature evaluating the use of the coupler in lower extremity reconstruction. We present one of the largest series to date examining the use of the venous coupler in microsurgical reconstruction of the lower extremity. METHODS: A retrospective chart review was completed including all lower extremity soft tissue reconstruction over a 26-month period performed by the senior authors. The Synovis venous coupler was used in all coupled venous anastomoses (Synovis Micro Companies Alliance Inc, Birmingham, Alabama). Patients under 18 years of age were excluded. RESULTS: Forty-nine free flaps were performed in 48 patients. All arterial anastomoses were hand sewn. The anastomotic venous coupler was used in 48 of 49 flaps (97.9%) with 1 hand-sewn case due to attending preference during early experience. There were no intraoperative vascular complications. Successful free flap reconstruction occurred in 47 of 49 flaps (95.9%). Of the flap losses, one was due to delayed venous thrombosis, the other attributed to delayed arterial thrombosis. Venous thrombosis rate was 2.1% when the coupler was used (1 failure in 48 flaps). CONCLUSIONS: The use of the venous coupler device in lower extremity reconstruction can be performed with a high degree of success. The potential of the venous coupler for reduced operative time, more efficient anastomoses with decreased ischemia, and reduced thrombotic rates represents potential benefits of this important tool.

Reexamining free flap breast reconstruction in the community and university setting: is there a difference?

BACKGROUND: This study aimed to compare free flap breast reconstruction outcomes in community and university settings to determine whether the latter is necessary for successful performance of this complex procedure. METHODS: Free tissue transfer procedures for breast reconstruction from 1 university and 1 community hospital performed between 2005 and 2011 were included. Procedures were performed by the same 2 surgeons at both institutions. Demographics and outcome measures were evaluated. RESULTS: Of the 1293 free tissue breast reconstructions performed, 99 (7.7%) were performed in a community hospital and 1194 (92.3%) were performed in a university center. No differences were noted in demographics, comorbidities, or type of free flap reconstruction. However, a number of perioperative characteristics differed. In the community setting, operative time was less (7.3 vs 8.3 hours, P < 0.0001), estimated blood loss was higher (330 vs 248 mL, P < 0.0001), and blood transfusions were more prevalent (24.6% vs 8.3%, P < 0.0001). Furthermore, no significant differences were noted in overall postoperative complications, although a higher rate of abdominal wound infections was noted in the community setting (7.2% vs 2.6%, P = 0.03). The mean number of hospital days was similar between the community and the university (should include value P = 0.44). CONCLUSIONS: Although slight differences were noted in a number of perioperative variables and wound complications, we conclude that the key to a successful free tissue transfer reconstruction is in the expertise of the surgeon and not the setting in which it is performed. Despite its complexity, free flap breast reconstruction can be safely and successfully performed in the community setting.

Transfusions in autologous breast reconstructions: an analysis of risk factors, complications, and cost.

PURPOSE: Free tissue transfer requires lengthy operative times and can be associated with significant blood loss. The goal of our study was to determine independent risk factors for blood transfusions and transfusion-related complications and costs. METHODS: We reviewed our prospectively maintained free flap database and identified all patients undergoing breast reconstruction receiving blood transfusions. These patients were compared with those not receiving a postoperative transfusion. We examined baseline patient comorbidities, preoperative and postoperative hemoglobin (HgB) levels, intraoperative and postoperative complications, and blood transfusions. Factors associated with transfusion were identified using univariate analyses, and multivariate logistic regression was used to determine independently associated factors. RESULTS: A total of 70 (8.2%) patients received postoperative blood transfusions. Multivariate analysis revealed associations between length of surgery (P=0.01), intraoperative arterial thrombosis [odds ratio (OR), 6.75; P=0.01], major surgical complications (OR, 25.9; P<0.001), medical complications (OR, 7.2; P=0.002), and postoperative HgB levels (OR, 0.2; P<0.001). Transfusions were independently associated with higher rates of medical complications (OR, 2.7; P=0.03). A significantly lower rate of medical complications was observed when a restrictive transfusion (HgB level, <7 g/dL) was administered (P=0.04). A cost analysis demonstrated that each blood transfusion was independently associated with an added $1,500 in total cost. CONCLUSIONS: Several key perioperative factors are associated with allogenic transfusion, including intraoperative complications, operative time, HgB level, and postoperative medical and surgical complications. Blood transfusions were independently associated with greater morbidity and added hospital costs. Overall, a restrictive transfusion strategy (HgB level, <7 g/dL or clinically symptomatic) may help minimize medical complications. LEVEL OF EVIDENCE: Prognostic/risk category, level III.

Does breast reconstruction impact the decision of patients to pursue cosmetic surgery?

BACKGROUND: Breast reconstruction is an integral component of breast cancer treatment, often aiding in restoring a patient's sense of femininity. However, many patients choose to have subsequent cosmetic surgery. The purpose of this study is to investigate the reasons that motivate patients to have cosmetic surgery after breast reconstruction. METHODS: The authors performed a retrospective study examining patients who had breast reconstruction and subsequent cosmetic surgery at the University of Pennsylvania Health System between January 2005 and June 2012. This cohort received a questionnaire assessing the influences and impact of their reconstructive and cosmetic procedures. RESULTS: A total of 1,214 patients had breast reconstruction, with 113 patients (9.3%) undergoing cosmetic surgery after reconstruction. Of 42 survey respondents, 35 had autologous breast reconstruction (83.3%). Fifty-two cosmetic procedures were performed in survey respondents, including liposuction (26.9%) and facelift (15.4%). The most common reason for pursuing cosmetic surgery was the desire to improve self-image (n = 26, 61.9%), with 29 (69.0%) patients feeling more self-conscious of appearance after reconstruction. Body image satisfaction was significantly higher after cosmetic surgery (P = 0.0081). Interestingly, a multivariate analysis revealed that patients who experienced an improvement in body image after breast reconstruction were more likely to experience a further improvement after a cosmetic procedure (P = 0.031, OR = 17.83). Patients who were interested in cosmetic surgery prior to reconstruction were also more likely to experience an improvement in body image after cosmetic surgery (P = 0.012, OR = 22.63). CONCLUSION: Cosmetic surgery may improve body image satisfaction of breast reconstruction patients and help to further meet their expectations.

Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction.

BACKGROUND: Free tissue transfer is an accepted method for breast reconstruction. Surgically uncorrectable venous congestion is a rare but real occurrence after these procedures. Here, we report our experience with the management of surgically uncorrectable venous congestion after free flap breast reconstruction using medicinal leech therapy. METHODS: We queried our prospectively maintained institutional database for all patients with venous congestion after free flap breast reconstruction since 2005. Chart review was performed for all patients having post-operative venous congestion. We compared patients with surgically correctable venous congestion and surgically uncorrectable venous congestion requiring medicinal leech therapy. RESULTS: Twenty-three patients had post-operative venous congestion, and four of these patients were surgically uncorrectable requiring medicinal leech therapy. Patients who required leech therapy had lower hemoglobin nadirs, received more blood transfusions, and received a higher number of total units of red blood cells than patients who did not require leech therapy. Among four patients who required leech therapy, one flap was partially salvaged and three flaps were completely lost. Leech therapy was associated with higher total flap loss rates (75.0% vs. 42.1%) and longer length of stay (8.0 ± 3.6 days vs. 6.5 ± 2.1 days) when compared to non-leeched flaps. These differences were not statistically significant (P = 0.32 and P = 0.43, respectively). CONCLUSIONS: In patients with surgically uncorrectable venous congestion after free flap breast reconstruction, total flap loss is common despite leech therapy. When venous congestion cannot be corrected, total flap removal may be a better option than attempted salvage with leech therapy.