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Wang CS, Al-Nowaylati AR, Matusko N, Momoh AO, Kung TA. Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes. Ann Surg Oncol 2024:10.1245/s10434-024-15266-0. [PMID: 38619709 DOI: 10.1245/s10434-024-15266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. METHODS A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. RESULTS Overall, 137 subjects were identified and 64 met the inclusion criteria (n = 28 study, n = 36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p < 0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5 min, p < 0.01). CONCLUSIONS A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.
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Affiliation(s)
- Christine S Wang
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Niki Matusko
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
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Guo CR, Rivera Perla KM, Leary OP, Sastry RA, Borrelli MR, Liu DD, Khunte M, Gokaslan ZL, Liu PY, Kwan D, Fridley JS, Woo AS. Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery. World Neurosurg 2024; 184:103-111. [PMID: 38185457 DOI: 10.1016/j.wneu.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.
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Affiliation(s)
- Cynthia R Guo
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA.
| | - Krissia M Rivera Perla
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Owen P Leary
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mimi R Borrelli
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mihir Khunte
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Paul Y Liu
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel Kwan
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Albert S Woo
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
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Xu J, Zhu XM, Ng KC, Alhefzi MM, Avram R, Coroneos CJ. Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis. J Reconstr Microsurg 2024. [PMID: 38267008 DOI: 10.1055/a-2253-6099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS). METHODS A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes. RESULTS Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different. CONCLUSION CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.
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Affiliation(s)
- Joshua Xu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Xi Ming Zhu
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kimberly C Ng
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Ronen Avram
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Christopher J Coroneos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Escandón JM, Mascaro-Pankova A, DellaCroce FJ, Escandón L, Christiano JG, Langstein HN, Ciudad P, Manrique OJ. The Value of a Co-surgeon in Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5624. [PMID: 38317657 PMCID: PMC10843485 DOI: 10.1097/gox.0000000000005624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/06/2023] [Indexed: 02/07/2024]
Abstract
Using a co-surgeon model has been suggested to improve perioperative outcomes and reduce the risk of complications. Therefore, we evaluated if a co-surgeon model compared with a single microsurgeon model could decrease the surgical time, length of stay, rate of complications, and healthcare-associated costs in adult patients undergoing microvascular breast reconstruction (MBR). A comprehensive search was performed across PubMed MEDLINE, Embase, and Web of Science. Studies evaluating the perioperative outcomes and complications of MBR using a single-surgeon model and co-surgeon model were included. A random-effects model was fitted to the data. Seven retrospective comparative studies were included. Ultimately, 1411 patients (48.23%) underwent MBR using a single-surgeon model, representing 2339 flaps (48.42%). On the other hand, 1514 patients (51.77%) underwent MBR using a co-surgeon model, representing 2492 flaps (51.58%). The surgical time was significantly reduced using a co-surgeon model in all studies compared with a single-surgeon model. The length of stay was reduced using a co-surgeon model compared with a single-surgeon model in all but one study. The log odds ratio (log-OR) of recipient site infection (log-OR = -0.227; P = 0.6509), wound disruption (log-OR = -0.012; P = 0.9735), hematoma (log-OR = 0.061; P = 0.8683), and seroma (log-OR = -0.742; P = 0.1106) did not significantly decrease with the incorporation of a co-surgeon compared with a single-surgeon model. Incorporating a co-surgeon model for MBR has minimal impact on the rates of surgical site complications compared with a single-surgeon model. However, a co-surgeon optimized efficacy and reduced the surgical time and length of stay.
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Affiliation(s)
- Joseph M. Escandón
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | | | - Frank J. DellaCroce
- Center for Restorative Breast Surgery and the Tulane School of Public Health and Tropical Medicine, New Orleans, La
| | - Lauren Escandón
- Universidad El Bosque, School of Medicine, Bogotá D.C., Colombia
| | - Jose G. Christiano
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | - Howard N. Langstein
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J. Manrique
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
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Schmidt G, Mayo T, Paepke S, Kiechle M, Müller D. Microsurgical training curriculum in a gynecological breast cancer center: a benefit for patients and surgeons? Arch Gynecol Obstet 2024; 309:281-286. [PMID: 37644236 PMCID: PMC10770192 DOI: 10.1007/s00404-023-07198-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Autologous breast reconstruction improves patient satisfaction and quality of life after mastectomy. In Germany, free flap surgery and implant-based reconstruction is usually separate between reconstructive surgery and gynecology. Cooperation between the specialist disciplines and implementation of microsurgery into breast surgeon training could enhance surgical treatment for breast cancer patients. This evaluation is intended to demonstrate the learning progress within a microsurgical training program and the complication rate in relation to microsurgical experience. METHODS At the breast cancer center at Klinikum rechts der Isar, TU Munich, a three-stage training program for autologous breast reconstruction and microsurgery for gynecological breast surgeons was developed. Between 2019 and 2022, 74 women received autologous free flap breast reconstruction by a consistent team consisting of a gynecological surgeon in training and an expert microsurgeon. Peri- and postoperative data were collected to analyze the feasibility and safety of a microsurgical training in gynecology. RESULTS Within the training, operative steps of free autologous breast reconstruction were increasingly taken over by the gynecological surgeon in training. The analysis showed a decrease in operating times with consistently low complication rates during the training. CONCLUSION This study demonstrated that a training in free autologous breast reconstruction for gynecological surgeons is safely feasible through close cooperation between gynecological and reconstructive surgery.
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Affiliation(s)
- Georg Schmidt
- Department of Gynecology and Obstetrics, Klinikum Rechts Der Isar and Comprehensive Cancer Center (CCCTUM), Technical University Munich, Munich, Germany.
| | - Theresa Mayo
- Department of Gynecology and Obstetrics, Klinikum Rechts Der Isar and Comprehensive Cancer Center (CCCTUM), Technical University Munich, Munich, Germany
| | - Stefan Paepke
- Department of Gynecology and Obstetrics, Klinikum Rechts Der Isar and Comprehensive Cancer Center (CCCTUM), Technical University Munich, Munich, Germany
| | - Marion Kiechle
- Department of Gynecology and Obstetrics, Klinikum Rechts Der Isar and Comprehensive Cancer Center (CCCTUM), Technical University Munich, Munich, Germany
| | - Daniel Müller
- Department of Gynecology and Obstetrics, Klinikum Rechts Der Isar and Comprehensive Cancer Center (CCCTUM), Technical University Munich, Munich, Germany
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Tartanus J, Meroni M, Scaglioni MF. The use of double free flaps with intra-flap anastomosis for complex defects reconstruction. Microsurgery 2024; 44:e31083. [PMID: 37401118 DOI: 10.1002/micr.31083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/02/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Over the years, the improvements in microsurgical field allowed the reconstruction of increasingly larger and more complex defects. In this context, we conceived linking more flaps with a single vascular supply. The double free flaps with intra-flap anastomosis offer a better match with recipient site requirements, still having a minimal donor and recipient site morbidity. In the present paper, we describe our experience with this procedure, focusing on its features and providing a collection of cases in different areas and clinical settings. PATIENTS AND METHODS Consecutive single-center case series with 16 patients who received defect reconstruction using double free flaps with intra-flap anastomosis between February 2019 and August 2021. The median age was 58 years old (range 39-77). Nine patients were men and seven were women. The defects were located throughout the body, including breast, head and neck, lower and upper limbs. In 12 cases, the cause of the defect was surgical removal of a tumor, while in four cases the cause was trauma. The main indication for this procedure was related to the need of covering a large defect, either in terms of volume or surface, resorting to only one vascular axis. RESULTS A total of 32 flaps were harvested, including 10 different techniques. The flaps size ranged from 6 × 3 cm to 24 × 8 cm. Eleven patients completely healed without any complications. No flaps were lost. Three patients developed a minor wound dehiscence and one a wound infection treated conservatively with antibiotic therapy. One patient experienced both of these complications. The median follow up was 12 months and ranged between 6 and 24 months. At the final clinical evaluation, the reconstructive result was stable in all cases and all the patients had a complete resumption of their daily activities. CONCLUSIONS Double free flaps reconstruction with intra-flap anastomosis represents a valid and reliable option for the coverage of complex defects in case of depleted recipient sites. This procedure allows us to transfer high amounts of tissue resorting to a single vascular axis. However, it represents a technical challenge and a highly experienced microsurgical team is required.
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Affiliation(s)
- Justyna Tartanus
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Dang S, Green K, Bottegal M, Khan NI, Solari MG, Sridharan SS, Kubik MW. Co-surgery in head and neck microvascular reconstruction. Am J Otolaryngol 2024; 45:104062. [PMID: 37769506 DOI: 10.1016/j.amjoto.2023.104062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE Co-surgery with two attending reconstructive surgeons is becoming increasingly common in breast microvascular reconstruction due to case complexity and the potential for improved outcomes and operative efficiency. The impact of co-surgery on outcomes in head and neck microvascular reconstruction has not been studied. METHODS Our multidisciplinary head and neck reconstruction team (Otolaryngology, Plastic Surgery) at the University of Pittsburgh transitioned to a practice of co-surgery on head and neck free flaps. In this study, we compare outcomes of two surgeon head and neck reconstruction to single surgeon reconstruction in a prospectively maintained database. RESULTS 384 patients met our inclusion criteria from 2020 to 2022. Cases were performed by a single surgeon in 77.8 % of cases (299/384) and two surgeons in 22.1 % (85/384). The mean age was 62.5 years. There was no difference between the single surgeon cohort and the co-surgery cohort in terms of flap survival, procedure time, ischemia time, hospital length of stay, recipient site complications, or rates of return to the operating room. Donor site complications were less common in the co-surgery cohort (0 % vs 4.7 %, p = 0.021). For our reconstructive team, the transition to co-surgery has increased total surgeon fee collection per free flap by 28 % and increased surgeon flap related RVU production by 35 %. CONCLUSION Co-surgery is feasible and safe in head and neck microvascular reconstruction. Benefits may include reduced complications, increased reimbursement, and improved interdisciplinary collaboration.
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Affiliation(s)
- Sophia Dang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Katerina Green
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew Bottegal
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Nayel I Khan
- Department of Otolayrngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Mario G Solari
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shaum S Sridharan
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mark W Kubik
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
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Yalamanchi P, Peddireddy NS, McMichael B, Keilin C, Casper KA, Malloy KM, Moyer JS, Prince MEP, Rosko AJ, Stucken CL, Spector ME, Chinn SB. Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2023; 149:1021-1026. [PMID: 37796525 PMCID: PMC10557027 DOI: 10.1001/jamaoto.2023.3028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/13/2023] [Indexed: 10/06/2023]
Abstract
Importance Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care. Objective To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction. Design, Setting, and Participants This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included. Main Outcomes and Measures Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision. Results Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach. Conclusions and Relevance Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nithin S. Peddireddy
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Brennan McMichael
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Charles Keilin
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Keith A. Casper
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Kelly M. Malloy
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Jeffrey S. Moyer
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Mark E. P. Prince
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Andrew J. Rosko
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Chaz L. Stucken
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Matthew E. Spector
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Steven B. Chinn
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
- Rogel Cancer Center, University of Michigan, Ann Arbor
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Cho MJ, Slater CA, Skoracki RJ, Chao AH. Building Complex Autologous Breast Reconstruction Program: A Preliminary Experience. J Clin Med 2023; 12:6810. [PMID: 37959275 PMCID: PMC10648036 DOI: 10.3390/jcm12216810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/12/2023] [Accepted: 10/21/2023] [Indexed: 11/15/2023] Open
Abstract
Autologous breast reconstruction is an increasingly popular method of reconstruction for breast cancer survivors. While deep inferior epigastric perforator (DIEP) flaps are the gold standard, not all patients are ideal candidates for DIEP flaps due to low BMI, body habitus, or previous abdominal surgery. In these patients, complex autologous breast reconstruction can be performed, but there is a limited number of programs around the world due to high technical demand. Given the increased demand and need for complex autologous flaps, it is critical to build programs to increase patient access and teach future microsurgeons. In this paper, we discuss the steps, pearls, and preliminary experience of building a complex autologous breast reconstruction program in a tertiary academic center. We performed a retrospective chart review of patients who underwent starting the year prior to the creation of our program. Since the start of our program, a total of 74 breast mounds have been reconstructed in 46 patients using 87 flaps. Over 23 months, there was a decrease in median surgical time for bilateral reconstruction by 124 min (p = 0.03), an increase in the number of co-surgeon cases by 66% (p < 0.01), and an increase in the number of complex autologous breast reconstruction by 42% (p < 0.01). Our study shows that a complex autologous breast reconstruction program can be successfully established using a multi-phase approach, including the development of a robust co-surgeon model. In addition, we found that a dedicated program leads to increased patient access, decreased operative time, and enhancement of trainee education.
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Affiliation(s)
- Min-Jeong Cho
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (C.A.S.); (R.J.S.); (A.H.C.)
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10
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Todd AR, Genereux O, Schrag C, Hatchell A, Matthews J. Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5231. [PMID: 38152707 PMCID: PMC10752470 DOI: 10.1097/gox.0000000000005231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/07/2023] [Indexed: 12/29/2023]
Abstract
Background Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency. Methods A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician. Results Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019. Conclusions Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.
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Affiliation(s)
- Anna R. Todd
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Olivia Genereux
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Christiaan Schrag
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Hatchell
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Matthews
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
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11
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Egan KG, Elver AA, Godbe KN, Nazir N, Holding J, Butterworth J, Lai E. Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction. J Reconstr Microsurg 2023; 39:43-47. [PMID: 35636433 DOI: 10.1055/s-0042-1748978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. METHODS A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013-2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. RESULTS Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). CONCLUSION Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.
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Affiliation(s)
- Katie G Egan
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Ashlie A Elver
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Kerilyn N Godbe
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Niaman Nazir
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
| | - Julie Holding
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - James Butterworth
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Eric Lai
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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12
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Nazarian D, Dikarev A, Mokhirev M, Zakharov G, Fedosov A, Potapov M, Chernenkiy M, Vasilev Y, Kyalov G, Chausheva S, Khachatryan A, Tevosyan A, Arakelyan G. Maxillo-mandibular Defect Reconstruction with Bilateral Free Fibula Flaps with Dental Implant Placement and Immediate Loading: A Case Report of the Three-team Approach. Arch Plast Surg 2022; 49:652-655. [PMID: 36159367 PMCID: PMC9507612 DOI: 10.1055/s-0042-1756350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/17/2022] [Indexed: 11/08/2022] Open
Abstract
Patients with advanced malignant tumors, including both jaws, is a challenging task for a head and neck surgeon. Current treatment landscape demonstrates good functional, anatomical, and aesthetic results in patients who could previously receive only palliative care. The extensive tissue defects resulting from oncological resections in the head and neck region require immediate reconstruction due to the exposure of vital structures and their contact with the external environment. A patient was operated using a three-team multidisciplinary approach involving simultaneous work of three specialized teams of maxillofacial and reconstructive microsurgeons, as well as an implantologist and a prosthodontist. This approach allowed simultaneous tumor resection with subsequent reconstruction of the intraoperative defect involving bilateral harvesting of two revascularized free fibular osteomusculocutaneous flaps with dental implantation and simultaneous rehabilitation of dentition with crowns.
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Affiliation(s)
- David Nazarian
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Aleksei Dikarev
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Mikhail Mokhirev
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Georgy Zakharov
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Alexander Fedosov
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Maksim Potapov
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Mikhail Chernenkiy
- Maxillofacial and Reconstructive Surgery Department, NK Clinic, Moscow, Russia
| | - Yuriy Vasilev
- Radiology Department, Research and Practical Clinical Center of Diagnostics and Telemedicine Technologies, Moscow, Russia
| | - Grigoriy Kyalov
- Maxillofacial and Reconstructive Surgery Department, NK Clinic, Moscow, Russia
| | | | - Arbak Khachatryan
- Maxillofacial and Reconstructive Surgery Department, FSBI NMRCO FMBA, Moscow, Russia
| | - Artur Tevosyan
- Department of clinical medicine, International School "Medicine of the Future", Sechenov University
| | - Gevorg Arakelyan
- Department of clinical medicine, International School "Medicine of the Future", Sechenov University
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13
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Ganor O, Jolly D, Wu CA, Boskey ER. Can gender-affirming surgeries be safely combined? An NSQIP analysis of 30-day outcomes and case planning factors. J Plast Reconstr Aesthet Surg 2022; 75:2664-2670. [PMID: 35597710 DOI: 10.1016/j.bjps.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/07/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022]
Abstract
As gender-affirming surgeries are being performed, new techniques have been developed to meet patient desires, including recent reports of several gender-affirming procedures being combined into a single operative encounter. Such a development may provide several advantages to both patients and providers. However, it is less clear whether combining these procedures affects patient safety and surgical case planning factors. To address this, we compared the complication rates and the length of hospital stay and operative time for standalone and combined gender-affirming procedures (e.g., hysterectomy and bilateral mastectomy, breast augmentation, and vaginoplasty) performed between 2005 and 2019 in the National Surgical Quality Improvement Program database. There were 1857 standalone mastectomies, 826 standalone hysterectomies, and 30 cases where they were combined. There were 379 vaginoplasties, 648 breast augmentations, and 31 cases where they were combined. There was no evidence of differences in overall health status between those undergoing combined and standalone procedures. Two-sample proportion testing did not find significant differences in any of the complications experienced between standalone and combined procedures. Similarly, two-sample t-tests did not find significant differences in the length of the hospital stays nor in the length of the operative encounter between standalone and combined masculinizing surgeries. Combining breast augmentation and vaginoplasty, however, saved an average of 97.86 min (p = .000) of operating time. These results suggest that combining gender-affirming procedures may be a safe and viable option for individuals who desire multiple gender-affirming procedures and may even be an advantageous option for patients and practitioners alike.
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Affiliation(s)
- Oren Ganor
- Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Surgery, Harvard Medical School, Boston, MA, United States
| | - Divya Jolly
- Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States.
| | - Catherine A Wu
- Student, Harvard Medical School, Boston, MA, United States
| | - Elizabeth R Boskey
- Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Surgery, Harvard Medical School, Boston, MA, United States; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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14
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Hudson L, Reese E, Hecksher A, Schepel C, Trufan SJ, Cruz A, Verbyla A, White RL, Hadzikadic-Gusic L. Single surgeon versus co-surgeon bilateral mastectomy: Comparing outcomes and costs based on health economic modeling from the perspective of the hospital system. J Surg Oncol 2022; 126:239-246. [PMID: 35411951 DOI: 10.1002/jso.26891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/14/2022] [Accepted: 04/02/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Co-surgeon approach for bilateral mastectomy may lead to shorter operative times and improved outcomes compared with single-surgeon approach, but cost differences remain unclear. Economic models were applied to determine whether either approach offered a lower cost opportunity. METHODS A retrospective review of 409 patients undergoing single-surgeon or co-surgeon bilateral mastectomy between January 1, 2010 through April 30, 2016 was conducted. Outcomes included narcotic and antinausea doses, length of stay (LOS), and operative time. Analyses stratified by reconstruction and no reconstruction included Wilcoxon tests, Poisson regression, generalized linear models, and a cost calculator. RESULTS Of 409 patients, 310 had reconstruction and 99 had no reconstruction. Compared with single-surgeon approach, co-surgeon approach was associated with less operative time and shorter LOS (233 vs. 250 min and 1.0 vs. 1.8 days no reconstruction; and 429 vs. 493 min and 2.2 vs. 2.8 days reconstruction). Economic analysis demonstrated less operative time, shorter LOS, and lower average cost for co-surgeon approach ($32,400 vs. $34,400 no reconstruction; and $76,700 vs. $79,400 reconstruction). CONCLUSION Compared with the single-surgeon, the co-surgeon approach with reconstruction was associated with a statistically significant decrease in operative time and LOS. Economic analysis estimated the co-surgeon approach could lead to lower costs.
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Affiliation(s)
- Laura Hudson
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Emily Reese
- EMD Serono Research and Development Institute, Inc, Boston, Massachusetts, USA
| | - Anna Hecksher
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Courtney Schepel
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sally J Trufan
- Department of Cancer Biostatistics, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Adilen Cruz
- Department of Cancer Biostatistics, Health Economics and Outcomes Research, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Allison Verbyla
- Department of Cancer Biostatistics, Health Economics and Outcomes Research, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Richard L White
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Lejla Hadzikadic-Gusic
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
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15
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Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value. Plast Reconstr Surg 2022; 149:338-348. [PMID: 35077407 DOI: 10.1097/prs.0000000000008715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs. METHODS The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs. RESULTS The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p < 0.001) and cost (change in total cost, -$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates. CONCLUSION The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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16
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Case Volume-Dependent Changes in Operative Morbidity following Free Flap Breast Reconstruction: A 15-Year Single-Center Analysis. Plast Reconstr Surg 2021; 148:365e-374e. [PMID: 34432682 DOI: 10.1097/prs.0000000000008209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Operative morbidity is a common yet modifiable feature of complex surgical procedures. With increasing case volume, improvement in morbidity has been reported through designated procedural processes and greater repetition. Defined as a volume-outcome association, improvement in breast reconstruction morbidity with increasing free flap volume requires further characterization. METHODS A retrospective analysis was conducted among consecutive free flap patients using a two-microsurgeon model between January of 2002 and December of 2017. Patient demographics and operative characteristics were obtained from medical records. Complications including unplanned surgical intervention (take-back) and flap loss were obtained from prospectively kept databases. Individual surgeon operative volume was estimated by considering overall practice volume and correcting for the number of surgeons at any given time. RESULTS During the study period, 3949 patients met inclusion criteria. A total of 6607 breasts underwent reconstruction with 6675 free flaps. Mean patient age was 50 ± 9.4 years and mean body mass index was 28.8 ± 5.0 kg/m2. Bilateral reconstruction was performed on 2633 patients (66.5 percent), with 4626 breasts (70.5 percent) reconstructed in the immediate setting. Overall, breast and donor-site complications were reported in 507 breasts (7.7 percent) and 607 cases (15.4 percent), respectively. Take-back was required in 375 cases (9.5 percent), with complete flap loss occurring in 57 cases (0.9 percent). Based on annual flaps per surgeon, the incidence of complications decreased with increasing volume (slope = -0.12; p = 0.056). CONCLUSION Through procedural efficiency and execution of defined clinical processes using a two-microsurgeon model, increases in microsurgical breast reconstruction case volume result in decreased morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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17
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Moellhoff N, Broer PN, Heidekrueger PI, Ninkovic M, Ehrl D. Impact of Intraoperative Hypothermia on Microsurgical Free Flap Reconstructions. J Reconstr Microsurg 2020; 37:174-180. [PMID: 32862415 DOI: 10.1055/s-0040-1715880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients requiring microsurgical defect reconstruction are highly susceptible to intraoperative hypothermia, given oftentimes long operative times and exposure of large skin surface areas. While the impact of hypothermia has been extensively studied across various surgical fields, its role in the setting of microsurgical free flap reconstruction remains elusive. This study evaluates the effects of hypothermia on outcomes of free flap reconstructions. METHODS Within 7 years, 602 patients underwent 668 microvascular free flap reconstructions. The cases were divided into two groups regarding the minimal core body temperature during free flap surgery: hypothermia (HT; < 36.0°C) versus normothermia (NT; ≥36.0°C). The data were retrospectively screened for patients' demographics, perioperative details, flap survival, surgical complications, and outcomes. RESULTS Our data revealed no significant difference with regard to the rate of major and minor surgical complications, or the rate of revision surgery between both groups (p > 0.05). However, patients in the HT group showed significantly higher rates of total flap loss (6.6% [HT] vs. 3.0% [NT], p < 0.05) and arterial thrombosis (4.6% [HT] vs. 1.9% [NT], p < 0.05). This translated into a significantly longer hospitalization of patients with reduced core body temperature (HT: mean 16.8 days vs. NT: mean 15.1 days; p < 0.05). CONCLUSION Hypothermia increases the risk for arterial thrombosis and total flap loss. While free flap transfer is feasible also in hypothermic patients, surgeons' awareness of core body temperature should increase. Taken together, we suggest that the mean intraoperative minimum temperature should range between 36 and 36.5°C during free flap surgery as a pragmatic guideline.
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Affiliation(s)
- Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Peter Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Paul I Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
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18
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Zhao R, Shammas RL, Broadwater G, Le E, Hansen-Estruch C, Kaakati R, Cason RW, Lyes M, Orr JP, Hollenbeck ST. Assessing the Influence of Attending Surgeon Continuity on Free Flap Outcomes Following Unplanned Returns to the Operating Room. J Reconstr Microsurg 2020; 36:583-591. [PMID: 32557453 DOI: 10.1055/s-0040-1713173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Unplanned returns to the operating room (OR) may be necessary at times to salvage a compromised free flap. The aim of this study was to assess the influence of attending surgeon continuity on free flap outcomes following a return to the OR. METHODS We retrospectively reviewed patients who underwent free flap reconstruction and experienced an unplanned return to the OR within 30 days from 2002 to 2017. Logistic regression modeling was used to determine factors that predict unplanned returns to the OR. RESULTS Of the 1,177 patients were identified, 267 (22.5%) had an unplanned return to the OR. Of these, 69 (5.9%) patients experienced total flap loss. Overall, 216 take-back procedures were performed by the primary surgeons (80.2%), while 50 were performed by covering surgeons (18.8%). Flap loss occurred more frequently during a weekend procedure (p = 0.013). Additionally, when the take-back procedure was performed within 5 days of the original surgery by the primary as opposed to a covering surgeon, patients experienced lower estimated blood loss (75 vs. 150 cc, p = 0.04). Overall, there was a significantly lower incidence of flap loss when the take-back procedure was performed by the primary, as opposed to the covering, surgeon (20 vs. 47%, p = 0.0001). CONCLUSION Higher rates of flap loss occur when a covering surgeon performs a take-back procedure in comparison to the primary surgeon. It is important to ensure the availability of the primary surgeon in the first few postoperative days following free flap reconstruction. When transfer of care is necessary, photographic or video documentation of the microvascular anastomosis may be helpful in addition to a verbal sign out.
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Affiliation(s)
- Ruya Zhao
- Duke University School of Medicine, Durham, North Carolina
| | - Ronnie L Shammas
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Elliot Le
- Duke University School of Medicine, Durham, North Carolina
| | | | - Rayan Kaakati
- Duke University School of Medicine, Durham, North Carolina
| | - Roger W Cason
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Matthew Lyes
- Duke University School of Medicine, Durham, North Carolina
| | - Jonah P Orr
- Duke University School of Medicine, Durham, North Carolina
| | - Scott T Hollenbeck
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
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19
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Mallory MA, Valero MG, Hu J, Barry WT, Losk K, Nimbkar S, Golshan M. Bilateral mastectomy operations and the role for the cosurgeon technique: A Nationwide analysis of surgical practice patterns. Breast J 2019; 26:220-226. [PMID: 31498509 DOI: 10.1111/tbj.13522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/30/2022]
Abstract
Traditionally, bilateral mastectomy (BM) operations are performed by a single surgeon but a two-attending co-surgeon technique (CST) has been described. A questionnaire was sent to members of the American Society of Breast Surgeons to assess national BM practices and analyze utilization and perceived benefits of the CST. Among surgeons responding, most continue to use the single-surgeon approach for BMs; however, 14.1% utilize the CST and up to 31% are interested in future CST use. Time savings, mentorship, cost savings, and opportunity to learn new techniques were identified as perceived CST advantages.
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Affiliation(s)
- Melissa Anne Mallory
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Monica G Valero
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jiani Hu
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - William T Barry
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katya Losk
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Suniti Nimbkar
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Mehra Golshan
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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