The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction

BACKGROUND

Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction.

METHODS

A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered.

RESULTS

Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps.

CONCLUSIONS

Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours

INTRODUCTION

The DIEP flap is considered the gold standard in autologous breast reconstruction. Despite the benefit of a lifelong natural reconstruction, some argue that the potential drawbacks, specifically operative time and recovery, are significant. We recently focused specifically on process analysis in our DIEP flap practice and present a comprehensive analysis in efficient DIEP flap breast reconstructions.

METHODS

Fifty consecutive bilateral DIEP flaps were prospectively tracked (100 flaps). The procedure was divided into segments (recipient site preparation, DIEP flap dissection/harvest, microsurgery, breast shaping, and abdominal closure). All individual step times were recorded for each team member. Relevant patient characteristics, intraoperative details and postoperative outcomes were recorded.

RESULTS

Average surgical time was 3 hours and 58 minutes (the fastest time recorded was 2 h and 14 min). There were no immediate postoperative complications. The anastomotic revision rate was 6%. Four surgeons contributed 34.7% of the time, three surgeons 32.2% of the time, two surgeons 23.6% of the time, and one surgeon 4.8% of total time. In procedures under 4 hours, four surgeons contributed simultaneously 36.7% of the time compared to 21.8% in the longer procedures (P = 0.004). Four surgeons contributed 45.4% of the time (P = 0.01) in the sub-three-hour bilateral DIEP flap procedures.

CONCLUSIONS

Efficient DIEP flap breast reconstruction can be accomplished with a well-trained and coordinated team approach involving like-minded surgeons with extensive experience working together. The synergistic map shows constant movement with utilization of hidden time, without sacrificing education, outcomes, or innovation.

A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis

BACKGROUND

This study aims to use the National Surgical Quality Improvement Program database to identify factors associated with extended postoperative length of stay after breast reconstruction with free tissue transfer.

METHODS

Consecutive cases of breast reconstruction with free tissue transfer were retrieved from the National Surgical Quality Improvement Program (2005 to 2017) database using CPT code 19364. Extended length of stay (dependent variable) was defined as greater than 5 days.

RESULTS

Nine thousand six hundred eighty-six cases were analyzed; extended length of stay was noted in 34 percent. On regression, patient factors independently associated with extended length of stay were body mass index (OR, 1.5; 95 percent CI, 1.2 to 1.9; p < 0.001), diabetes (OR, 1.3; 95 percent CI, 1.1 to 1.6; p = 0.003), and malignancy history (OR, 1.9; 95 percent CI, 1.22 to 3.02; p = 0.005). Operation time greater than 500 minutes (OR, 3; 95 percent CI, 2.73 to 3.28; p < 0.001) and immediate postmastectomy reconstruction (OR, 1.7; 95 percent CI, 1.16 to 2.48; p < 0.001) conferred risk for extended length of stay. Bilateral free tissue transfer was not significant. Operations performed in 2017 were at lower risk (OR, 0.2; 95 percent CI, 0.06 to 0.81; p = 0.02) for extended length of stay. Reoperation is more likely following operative transfusion and bilateral free tissue transfers, but less likely following concurrent alloplasty. Given a known operation time (minutes), postoperative length of stay (days) can be calculated using the following equation: length of stay = 2.559 + 0.003 × operation time.

CONCLUSIONS

This study characterizes the risks for extended length of stay after free tissue transfer breast reconstruction using a prospective multicenter national database. The result of this study can be used to risk-stratify patients during surgical planning to optimize perioperative decision-making.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

BACKGROUND

Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement.

METHODS

A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes.

RESULTS

A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange.

CONCLUSIONS

Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.