Breast Reconstruction with Free Tissue Transfer from the Abdomen in the Morbidly Obese:

[Impact of the number of pregnancies on the venous outflow of DIEP flap in breast reconstruction: A clinical and CT-scan study]

INTRODUCTION

The DIEP (deep inferior epigastric perforator) flap is the "gold standard" for breast reconstruction after cancer, giving better benefits on the quality of life. The most common complication is the venous congestion, because of the dominance of superficial venous outflow while the flap is drained by the deep epigastric vein. Pregnancy, by its physiological and vascular modifications, can reduce the risk of the venous congestion. Few studies explored the impact of pregnancy on the DIEP vascularization.

MATERIAL AND METHODS

We studied the preoperative CT-scans of 104 patients who benefited reconstruction surgery by DIEP from January 2011 until March 2022. The patients were separated into 5 groups according to number of pregnancies. For each CT-scan, a concomitant vein of deep epigastric artery diameter/SIEV diameter ratio was performed on each side, to assess the relation between pregnancy and the reduction of venous complications.

RESULTS

The results showed an increase of this ratio with the number of pregnancies. Patients with no pregnancy (G0) have the highest complication rate, with 41.7% of venous congestion case. On the other hand, in the group of four pregnancies or more (G4), the complication rate was significantly lower, at 10%, and none venous congestion was observed. These results suggest the beneficial effects of pregnancy on vascularization and especially on venous drainage in the DIEP flap.

CONCLUSION

This study highlights the benefit effect of the number of pregnancies on the DIEP vascularization, especially for the reduction of the venous congestion risk. The ratio DIEV/SIEV may be a useful help to predict the risk of venous complications in nullparous patients. These results open to new studies to deepen the understanding of the physiological effects of the pregnancy on the breast reconstruction surgery.

Not All Deep Inferior Epigastric Artery Perforator Flaps Are Created Equal: A Review of Donor-site Morbidity in Abdominally Based Autologous Breast Reconstruction

Background

Breast reconstruction after mastectomy is one of the most common procedures performed in plastic surgery. Autologous reconstruction is associated with better long-term patient satisfaction than implant-based reconstruction but with the requisite donor site and potential for associated morbidity.

Methods

The authors review the literature regarding the technical evolution of abdominally based autologous breast reconstruction and the effect of these changes as well as patient morbidities on bulge, hernia, and all-cause donor-site morbidity.

Results

The impact of patient risk factors on surgical outcomes is evaluated in the context of constantly improving technical surgical innovation. Patients' premorbid abdominal condition and prior abdominal procedures along with traditional complicating factors such as age, obesity, and smoking are associated with increased rates of donor-site complications. Conversely, shorter fascial incisions with or without robotic and laparoscopic assistance are associated with lower rates of abdominal weakness and healing complications than traditional abdominal free flap harvest. Perforator selection and abdominal closure techniques also play a key role.

Conclusions

There are contributions of both patient factors and technical aspects that when optimized can help minimize the risk of donor-site morbidity in deep inferior epigastric artery perforator flap breast reconstruction.

Effect of Enhanced Recovery after Surgery in Morbidly Obese Patients Undergoing Free Flap Breast Reconstruction

BACKGROUND

 Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

METHODS

 A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.

RESULTS

 Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.

CONCLUSION

 ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

Risks of Autologous Abdominal Free Flap Breast Reconstruction in Patients With Elevated Body Mass Index

Background

Obesity is widely recognized as a significant risk factor for postoperative complications of breast reconstruction. Despite extensive research, there remains a lack of consensus regarding the specific complications and outcomes experienced by patients with obesity who undergo deep inferior epigastric perforator (DIEP) flap reconstruction. To provide a clearer understanding of the challenges faced by patients with obesity, we present a single-center outcome analysis of individuals who underwent DIEP flap reconstruction.

Methods

A cohort of 194 patients who underwent at least 1 DIEP flap was retrospectively analyzed at the University of Nebraska Medical Center utilizing electronic medical records. Patients who underwent DIEP flap breast reconstruction were organized into 5 categories using World Health Organization weight status by body mass index (BMI) obtained from the day of surgery. Surgical complications within 120 days and postsurgical complication-related procedural interventions were also evaluated and compared. Comparisons of variables of interest between weight groups were assessed using Mantel-Haenszel chi-square tests or Spearman correlations.

Results

Increases in patient weight category were associated with increased length of operation (P = 0.003), increased rates of breast fat necrosis (P = 0.04), breast wound dehiscence (P = 0.01), abdominal wound dehiscence (P = 0.02), numbers of abdominal complications (P = 0.001), and rates of requiring an intervention (P = 0.03).

Conclusions

The findings imply that higher BMI values may lead to a higher likelihood of postoperative complications and the need for intervention. It is crucial for patients with obesity to be aware of the elevated risk associated with rising BMI values.

Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity

BACKGROUND

 Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction.

METHODS

 A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m2) and Obese (BMI ≥ 30 kg/m2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups.

RESULTS

 Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time.

CONCLUSION

 The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.

The Effects of Body Mass Index on Postoperative Complications in Patients Undergoing Autologous Free Flap Breast Reconstruction

BACKGROUND

 The prevalence of obesity in the United States exceeds 40%, yet perioperative effects of higher body mass index (BMI) in autologous breast reconstruction remain poorly studied. The purpose of this study was to investigate BMI's impact on postop complications in abdominal and gluteal-based autologous breast reconstruction.

METHODS

 We conducted a retrospective study using TriNetX, a health care database containing de-identified data from more than 250 million patients. Patients undergoing autologous breast reconstruction were identified by Current Procedural Terminology codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and 35 to 39.99 kg/m2. Outcomes of interest were defined by International Classification of Diseases, Tenth Revision (ICD-10) codes. A two-sample t-test was performed to compare incidence of postoperative complications between cohorts within 3 months of surgery. Patients with a BMI < 24.99 kg/m2 served as the control. Cohorts were balanced on age, race, and ethnicity.

RESULTS

 We identified 8,791 patients who underwent autologous breast reconstruction. Of those, 1,143 had a BMI < 24.99 kg/m2, 1,867 had a BMI of 25 to 29.99 kg/m2, 1,396 had a BMI of 30 to 34.99 kg/m2, and 559 had a BMI of 35 to 39.99 kg/m2. Patients with a BMI of 25 to 29.99 kg/m2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to 34.99 and 35 to 39.99 kg/m2 had a significantly increased risk of cellulitis, surgical site infection, need for debridement, wound dehiscence, and flap failure.

CONCLUSION

 Our study illustrates that there is an increased risk of postoperative complications associated with higher BMI classes. Understanding these data are imperative for providers to adequately stratify patients and guide the procedural decision-making.

Evaluation of Morphometric Measurements on Preoperative CT Angiograms to Determine Risk of Abdominal Donor Site Complications-A Retrospective Review of 174 Patients

Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection (P = .005), epidermolysis (P = .031), and seroma (P = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity (P = .024), history of smoking (P = .049), and the number of perforators harvested (P = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks.

Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study

BACKGROUND

The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood.

METHODS

We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics.

RESULTS

A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population.

CONCLUSIONS

Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

The Effect of Body Mass Index on Free Flap Breast Reconstruction

BACKGROUND

 Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class.

METHODS

 Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time.

RESULTS

 Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001).

CONCLUSION

 This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

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

BACKGROUND

 The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients.

METHODS

 This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications.

RESULTS

 Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87.

CONCLUSION

 This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

Rates of major complications and flap loss for abdominally based breast reconstruction in obese patients are independent of WHO class of obesity

INTRODUCTION

Obesity is a risk factor for complications following autologous breast reconstruction. Little is known regarding outcomes based on the degree of obesity. This study compares breast reconstruction outcomes and complication rates for the three classes defined by the body mass index (BMI)-based WHO classification.

METHODS

The authors conducted a retrospective chart review identifying obese patients who underwent abdominally based breast reconstruction between January 2011 and January 2021. Patients were stratified by BMI class [class 1 (C1) = 30-34.99 kg/m2, class 2 (C2) = 35-39.99 kg/m2, and class 3 (C3) = 40 kg/m2 + ]. Outcomes were compared.

RESULTS

A total of 232 patients (395 flaps) were included with 138 patients were classified as C1, 68 patients as C2, and 26 patients as C3. Rates of any complication (80%) and at least one major complication (31%) did not vary significantly (P = 0.057, 0.185). Individual rates of 30-day readmission (18%) or reoperation (26%) did not vary significantly (P = 0.588 and 0.059). Rates of seroma (C1 = 15%, C2 = 16%, and C3 = 35%), hernia (C1 = 0%, C2 = 4%, and C3 = 8%), and incisional dehiscence (C1 = 30%, C2 = 44%, and C3 = 62%) were associated with significantly increased risk with higher classes of obesity (P < 0.05). The rate of flap failure did not vary significantly (P = 0.573).

CONCLUSION

The risk of major complications and total flap loss associated with abdominally based breast reconstruction does not differ between the classes of obesity. Although complication rates are high overall in the obese population, detrimental complications do not vary between the classes. Patients should be counseled regarding their individual risk without the need for arbitrary BMI cutoffs.

Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management

BACKGROUND

Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning.

METHODS

This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications.

RESULTS

In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time.

CONCLUSIONS

Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

Autologous breast reconstruction with latissimus dorsi flap in obese patients: Time-to-event analysis

BACKGROUND

Obesity is a multisystem disease process that confers increased surgical risk. In patients who are not surgical candidates for breast reconstruction with implants/tissue expanders or abdomen-based flaps, the latissimus dorsi flap (LDF) remains a versatile alternative due to its safety profile. We conducted an analysis of patients who underwent reconstruction with LDFs and compared outcomes between two groups: obese and nonobese patients.

METHODS

We reviewed records from patients undergoing total mastectomy and breast reconstruction with LDFs between January 2011 and December 2021. We compared the surgical outcomes between obese and nonobese patients. Associations between risk factors and the presence of wound-related complications were analyzed using multivariable Cox proportional-hazards models.

RESULTS

One-hundred ten reconstructions were performed in obese patients (67.5%) and fifty-three in nonobese patients (32.5%). The median body mass index was 34.96 kg/m2 [32.6-39.2] in the obese patients' group and 26.8 kg/m2 [25.7-28.9] in the nonobese group (P < 0.001). The mean age was comparable between groups (54 years; P = 0.632). The rate of donor-site and recipient-site complications was similar between groups. The rate of revision procedures for secondary fat grafting and donor- or recipient-site revisions was comparable between obese and nonobese patients. Preoperative radiotherapy (hazard ratio [HR], 2.44), nipple-sparing mastectomy (HR, 3.26), and vertical pattern mastectomy (HR, 2.86) were associated with an increased risk of wound disruption.

CONCLUSION

The LDF is a reliable and safe alternative for autologous breast reconstruction in obese patients. The rates of surgical site complications were comparable between obese and nonobese patients.

Sarcopenia Best Predicts Complications in Free Flap Breast Reconstruction

Breast reconstruction remains a major component of the plastic surgeon's repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes.

Methods

All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed.

Results

In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model.

Conclusions

Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

The nuances of abdominal free flap harvest: Technical and patient factors affecting abdominal donor site morbidity in autologous breast reconstruction

INTRODUCTION

Abdominal donor site morbidity after autologous breast reconstruction is common and often underreported. This work aims to compare prospectively collected technical details of the procedure and patient factors and their impact on the development of symptomatic and asymptomatic abdominal bulges (ASB and SB).

METHODS

A review of patients undergoing abdominal-based autologous breast reconstruction from May 2012 to October 2017 by two surgeons at a single institution was performed. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were ASB or SB and wound healing complications.

RESULTS

Overall, 196 free flaps from 117 patients were included. The average follow-up was 1.9 ± 1.7 years. Thirteen (11.1%) patients developed ASB, and 13 (11.1%) patients developed SB. Patients with BMI ≥ 30, bilateral ms-TRAM reconstruction, and an onlay type of abdominal closure were 2×, 2.3×, and 8.1× more likely to develop a bulge, respectively (p = 0.017, p = 0.010, p = 0.049). Every one-point increase in BMI above 30 increased the odds of developing a bulge by 10.8%. Prior abdominal surgery increased the risk of SB by 7-fold (p = 0.017). The size of the harvested muscle, use of mesh, or nerve preservation did not affect the rate of bulge development.

CONCLUSION

High BMI, bilateral ms-TRAM, onlay type of abdominal closure, and prior abdominal surgery increase the risk of ASB and SB development to varying degrees, while several other operative variables did not seem to make a difference. Breast reconstruction patients can use this information for preoperative counseling and intraoperative decision-making.

Abdominally based free flap breast reconstruction in the severely obese population: Is it safe?

INTRODUCTION

Class 3 (severe) obesity is defined as a body mass index (BMI) greater than 40 kg/m² . Obesity is common and an independent risk factor for breast cancer. The plastic surgeon will be tasked with providing reconstruction for obese patients after mastectomy. This presents a surgical dilemma because patients with elevated BMI are known to have greater rates of morbidity when undergoing free flap reconstruction, however free flap reconstruction is associated with greater functional and aesthetic outcomes. This study quantifies complication rates in a cohort of patients with class 3 obesity that underwent abdominally based free flap breast reconstruction. This study may be able answer whether this surgery is feasible or safe.

METHODS

Patients with a class 3 obesity who underwent abdominally-based free flap breast reconstruction between January 1, 2011 and February 28, 2020 at the authors' institution were identified. A retrospective chart review was performed to record patient demographics and peri-operative data.

RESULTS

Twenty-six patients met inclusion criteria. Eighty percent of patients had at least one minor complication including infection (42%), fat necrosis (31%), seroma (15%), abdominal bulge (8%), and hernia (8%). Thirty-eight percent of patients had at least one major complication (requiring readmission (23%) and/or a return to the operating room (38%)). No flaps failed.

CONCLUSION

Abdominally based free flap breast reconstruction in patients with class 3 obesity is associated with great morbidity, however, no patients experienced flap loss or failure which may imply that this population can safely undergo surgery so long as the surgeon is prepared for complications and takes steps to mitigate risk.

Risk Stratification of Surgical Site Outcomes by BMI & Flap Type in Autologous Breast Reconstruction

INTRODUCTION

Afflicting 2 million lives annually worldwide, breast cancer remains devastating. This study utilized a continuously updated network of electronic medical records (TriNetX Inc, Cambridge, MA) for analysis of 90-day postoperative outcomes of autologous breast reconstruction by increasing body mass index (BMI).

METHODS

The deidentified electronic medical records (EMRs) of 29,453,000 females, age 18-99 years, were retrospectively screened from 45 healthcare organizations. A combined cohort of 7136 patients undergoing autologous breast reconstruction via transverse rectus abdominus muscle (TRAM), deep inferior epigastric perforator (DIEP), or latissimus flap was categorized by BMI into 5 subgroups: normal (n = 3568), overweight (n = 1239), class I (n = 1166), class II (n = 807), and class III (n = 356) obesity. The normal BMI cohort was then compared with each elevated BMI cohort. BMI strata were analyzed for risk of surgical-site occurrences within 90 days of surgery using CPT codes. Stringent propensity score matching was performed.

RESULTS

For the combined group (N = 7136), significant linear increases in risk were observed with increasing BMI for infection (risk ratio [RR] 1.39-2.91,p < 0.05) and dehiscence (RR 2.65-5.17, p < 0.05). Similar linear increases were observed for the abdominally based group (N = 5454) for infection (RR 1.45-2.47, p < 0.05) and dehiscence (RR 2.54-4.77, p < 0.05). For DIEP (N = 4874), near-linear increases were observed for infection (RR 1.60-2.79, p < 0.05) and dehiscence (RR 1.57-5.59, p < 0.05). For TRAM (N = 714), significant increases were observed for seroma, infection, dehiscence, deep vein thrombosis (DVT), sepsis, and PE while increased risks of seroma, DVT, PE, and hernia were observed for latissimus (N = 1380).

CONCLUSIONS

Regardless of flap type, our analysis suggests that a BMI> 39.9 is the inflection point beyond which it may be beneficial not to perform autologous breast reconstruction. Limitations include this study's retrospective nature; thus, future prospective studies would be beneficial.

The Association Between Metabolic Derangement and Wound Complications in Elective Plastic Surgery

INTRODUCTION

The incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk.

METHODS

Patients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI] > 30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI > 30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status.

RESULTS

Of 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P < 0.001) and adverse events (12.4% versus 9.6%; P < 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P < 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P < 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P < 0.001).

CONCLUSIONS

Diabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

Deep inferior epigastric perforator (DIEP) flap safety profile in slim versus non-slim BMI patients: A systematic review and meta-analysis

BACKGROUND/PURPOSE

The complications of breast reconstruction using deep inferior epigastric perforator (DIEP) flaps in non-slim patients are well recognized. However, the effects of this surgery performed on slim patients are yet to be consolidated. This study aims to compare the outcomes of performing DIEP flap breast reconstruction in slim and non-slim body mass index (BMI) patients.

METHODS

Meta-analysis was performed with a multi-database search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Sciences) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on 1 February 2021. Data from articles meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.

RESULTS

Seven studies were included, comprising 574 slim patients and 901 non-slim BMI patients who underwent autologous DIEP flap breast reconstruction. When comparing between the slim and non-slim groups, no statistically significant difference was found in terms of complete flap loss (OR=0.53, 95% CI: 0.11-2.68, p=0.44), partial flap loss (OR=0.92, 95% CI: 0.3-2.82, p=0.88), and fat necrosis (OR=0.91, 95% CI: 0.61-1.37, p=0.66). Similarly, in terms of general surgical complications, there was no statistically significant difference between groups in terms of all complications (OR=0.83, 95% CI: 0.45-1.51, p=0.54), abdominal wound healing complications (OR=1.01, 95% CI: 0.59-1.73, p=0.97), infections (OR=0.74, 95% CI: 0.41-1.37, p=0.34), and seroma (OR=0.89, 95% CI: 0.35-227, p=0.81).

CONCLUSION

There is no increased risk of postoperative complications in either group. DIEP flaps can be safely performed in slim patients, though higher quality research may be required to further confirm this.

Impact of Body Mass Index on Surgical Outcomes in Oncologic Microvascular Head and Neck Reconstruction

BACKGROUND

Despite increasing recognition, obesity continues to represent a major health issue for millions of people in the USA and worldwide. There is a paucity in the literature regarding the effect of body mass index (BMI) on microsurgical head and neck reconstruction. The present study hypothesized that high BMI is predictive of postoperative recipient- and donor-site complications with longer operative times.

PATIENTS AND METHODS

Retrospective review of patients who underwent free flap surgery for head and neck reconstruction was performed between January 2005 and December 2018. Patients were categorized into four groups based on BMI: < 20 kg/m², 20-30 kg/m², 30-40 kg/m², and ≥ 40 kg/m². Patient characteristics and surgical outcomes were compared between the four groups.

RESULTS

Overall, 4000 free flap surgeries were included in the present study, performed on 3753 patients, of whom 9.9% had a BMI < 20 kg/m², 64.9% had a BMI between 20 and 30 kg/m², 21.6% had a BMI between 30 and 40 kg/m², and 3.6% had a BMI ≥ 40 kg/m². After adjusting for potential confounders, multivariate analysis showed no association between BMI and any complication, major recipient complications, or total flap loss. However, multivariate linear regression model showed BMI 30-40 kg/m² and BMI ≥ 40 kg/m² to be independently associated with longer operative times compared with BMI < 20 kg/m².

CONCLUSION

Obesity and high BMI increase operative times; however, with meticulous surgical technique and diligent postoperative care, microvascular head and neck reconstructions can be performed safely and reliably in the majority of patients regardless of BMI with similar overall, recipient-site, and donor-site complications.

Pedicle flap reconstruction for treatment of infected median sternotomy wounds after cardiac surgery in overweight and obese patients: proposal of a management algorithm based on a case series analysis

BACKGROUND

A relationship between obesity and adverse outcomes in patients with post-sternotomy wounds undergoing pedicle flap reconstruction is not well-documented. In this study, we present a single-centre retrospective case series analysis of early postoperative outcomes of patients with infected post-sternotomy wounds undergoing pedicle flap reconstruction. We also propose a management algorithm for such patients, based on BMI and wound width.

METHODS

We retrospectively analyzed all patients, who underwent pedicle flap reconstruction for major sternal wound infections after sternotomy for cardiac surgery in a tertiary hospital in Germany during a 5-year period. Exclusion criteria included patients younger than 18 years of age and patients with BMI < 18.5 kg/m2. Patients were divided into 2 groups according to BMI: normal-weight (NW; BMI < 25 kg/m2) and overweight/obese (OB/OW; BMI > 25 kg/m2). Both groups were compared in terms of preoperative parameters and early postoperative outcomes. Preoperative parameters included demographics, wound bacteria and comorbidities. Postoperative outcomes included duration of surgery time (from incision to skin closure), transfusion requirement (during surgery and entire hospital stay), onset of flap and donor-site complications, length of stay and 30-day mortality. We employed the two-tailed t-test to compare continuous variables and the two-sided Fischer's exact test to compare categorical variables. Statistical significance was set at p < 0.05.

RESULTS

The total sample consisted of 48 patients. Overall mean BMI was 28.4 (6.1) kg/m2. Mean age was 67 (12) years. The study group consisted of 28 patients with BMI > 25 kg/m2, who were compared with 20 normal-weight patients. There was a significant difference amongst both groups regarding duration of surgery (120 vs. 174 min, p < 0.05). Donor-site complications requiring intervention were observed in 30% of patients in both groups. Flap-related complications were recorded in 16 (57%) cases in the study group and 7 cases in the control group (35%, p = 0.15).

CONCLUSIONS

We conclude that wound width and BMI can aid the decision-making process for patients with infected sternal wounds after cardiac surgery requiring pedicle flap reconstruction. However, in our case series analysis, OB/OW patients were not found to be at statistically significantly increased risk for worse postoperative outcomes, but were associated with a longer duration of surgery.

Microsurgical Breast Reconstruction in the Obese Patient Using Abdominal Flaps: Complication Profile and Patient Satisfaction

BACKGROUND

The obesity epidemic has led to larger numbers of obese patients seeking breast reconstruction. The aim of this study was to compare complication rates and patient satisfaction between obese and nonobese women undergoing autologous breast reconstruction using abdominal free flaps.

METHODS

The records of all patients who underwent microsurgical breast reconstruction by one surgeon for 15 years were reviewed. Patients were divided into obese (body mass index [BMI] ≥ 30 kg/m and nonobese groups. Demographic data, medical and smoking history, cancer type and treatments, surgical details, and complications were recorded. Breast-Q surveys were mailed to all patients, and satisfaction ratings were compared between obese and nonobese patients.

RESULTS

There were 109 patients and 149 breast reconstructions, with a mean age of 49 years. Follow-up ranged from 6 to 112 months (median = 19 months). There were 59 patients in the obese group and 52 in the nonobese group. The 2 groups did not differ significantly in median age, follow-up, pathology type, presence of chemotherapy or radiation, or smoking history. Obese group had a higher incidence of mastectomy flap necrosis (19.3% vs 7.7%, P < 0.01) and a higher rate of unplanned reoperations (38.6% vs 21.1%, P < 0.01). Obesity was not associated with a higher risk of microsurgical complications or flap loss (7.0% vs 3.8%, P = 0.21). Overall wound complications did not differ between the groups, but the obese group had a higher rate of severe wound complications requiring operative intervention (15.8% vs 3.8%, P < 0.01). The obese group had a higher incidence of hernia or bulge (10.5% vs 0%, P = 0.03). Thirty-three patients returned completed surveys (response rate of 30%). There was no statistically significant difference in any Breast-Q category associated with BMI.

CONCLUSIONS

Obesity was associated with higher rates of wound complications, reoperation, and abdominal bulge after microsurgical breast reconstruction. However, patient satisfaction remained high. Patients should be counseled regarding their relative risks, but high BMI should not be considered an absolute contraindication for microsurgical breast reconstruction.

Latest Advancements in Autologous Breast Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses.

SUMMARY

Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

BACKGROUND

 From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

 A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications.

RESULTS

 When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications.

CONCLUSION

 DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

Influence of BMI, Age, and Gender on the Thickness of Most Common Thinned Flaps

Background:

Since the description of superficial fascia flap harvesting, a new window of opportunity has been open in obese patients, where a higher subcutaneous thickness of tissue is present. To our knowledge, the impact of body mass index on superficial fascial flaps has not been reported.

Methods:

We recruited 122 patients from April 2019 to January 2020. From these patients, the 3 most common thinned flaps were selected: the superficial circumflex iliac perforator flap; the anterolateral thigh flap at the perforator A, B, and C; and the thoracodorsal flap. Two vertical measures were registered: the distance from the skin to the superficial fascia, and from this point to the deep fascia.

Results:

The average flap measurement presented here was within the range, as previous clinical studies. The superficial fatty layer thickness in the superficial circumflex iliac perforator and anterolateral thigh flap was somewhat similar in thickness between overweight and obese patients, showing a minimal increase with higher body mass index. The anterolateral thigh flap was found thicker among women, and no statistical difference was shown between age groups in any of the flaps.

Conclusions:

A better understanding of the fat layers’ thickness will result in better planning, minimizing secondary debulking procedures, decreasing operative time, and reducing general complications among obese patients. Thus, a better understanding of flap structure and physiology in obese patients will lower complications and give more predictable results.

Developing a Wearable Sensor for Continuous Tissue Oxygenation Monitoring: A Proof of Concept Study

Objective Technologies facilitating continuous free tissue flap monitoring such as near infrared spectroscopy (NIRS) have been shown to improve flap salvage rates. However, the size and associated costs of such technology create a barrier to wider implementation. The aim of this study was to develop and validate a wearable sensor for continuous tissue oxygenation monitoring.

Materials and Methods A forearm ischemia model was designed by using a brachial pressure cuff inflation protocol. Twenty healthy subjects were recruited. The forearm tissue oxygenation of each subject was monitored throughout the pressure cuff protocol by using a new optical sensor (Imperial College London), and a gold standard tissue spectrometry system (O2C, Medizintecknik, LEA, Germany). Data were processed to allow quantitative deoxygenation episode comparisons between inflations and sensor modalities.

Results The correlation between O2C and optical sensor oxygenation measurements was moderate (average R = 0.672, p < 0.001). Incremental increases in cuff inflation duration resulted in a linear increase in deoxygenation values with both O2C and optical sensors, with significant differences recorded on consecutive inflations (wall shear rate, p < 0.005). The presence or absence of pulsatile blood flow was correctly determined throughout by both sensor modalities.

Conclusion This study demonstrates the ability of a small optical sensor to detect and quantify tissue oxygenation changes and assess the presence of pulsatile blood flow. Low power, miniaturized electronics make the device capable of deployment in a wearable form which may break down the barriers for implementation in postoperative flap monitoring.

Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study

INTRODUCTION

Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI).

PATIENTS AND METHODS

A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m²), normal weight/ control group (BMI: 18.5-24.9 kg/m²), overweight group (BMI: 25-29.9 kg/m²), moderately obese group (BMI: 30-34.9 kg/m²), and severely obese group (BMI ≥ 35 kg/m²). Surgical complications were accounted for and the five BMI groups were then compared.

RESULTS

Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01).

CONCLUSION

Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.

Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients

BACKGROUND

Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m²] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap.

METHODS

A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated.

RESULTS

Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m², including 12 patients with BMI > 50 kg/m². Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively.

CONCLUSIONS

These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.

The effect of sarcopenia on perioperative complications in abdominally based free-flap breast reconstruction

PURPOSE

The identification of patient-specific risk factors, which predict morbidity following abdominally based microvascular breast reconstruction is difficult. Sarcopenia is a proxy for patient frailty and is an independent predictor of complications in a myriad of surgical disciplines. We predict that sarcopenic patients will be at higher risk for surgical complications following abdominally based microvascular breast reconstruction.

METHODS

A retrospective study of all patients who underwent delayed abdominally based autologous breast reconstruction following postmastectomy radiation therapy from 2007 to 2013 at a single institution was conducted. Univariate and multiple logistic regression models were used to assess the effect of sarcopenia on postoperative outcomes.

RESULTS

Two hundred and eight patients met the inclusion criteria, of which 30 met criteria for sarcopenia (14.1%). There were no significant differences in demographics between groups. There were no significant differences in minor (36.7% vs 44.4%; P = .43) or major (16.7% vs 25.3%; P = .36) complications between groups as well as hospital length of stay. Multivariable logistic regression demonstrated that a staged reconstruction with the use of a tissue expander was the only consistent variable, which predicted major complications (OR, 2.24; 95% CI, 1.18-4.64; P = .015).

CONCLUSIONS

Sarcopenia does not predispose to minor or major surgical complications in patients who undergo abdominally based microsurgical breast reconstruction.

Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer

Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population.

Patient-Reported Satisfaction and Quality of Life in Obese Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients

BACKGROUND

Patients undergoing autologous breast reconstruction have higher rates of patient-reported satisfaction compared to patients undergoing prosthetic reconstruction. Obesity has been shown to increase postoperative complications in both microsurgical and implant reconstructions. The authors evaluated the effects of microsurgical breast reconstruction and prosthetic breast reconstruction on patient-reported outcomes and quality of life in obese patients.

METHODS

A retrospective review of obese patients who underwent breast reconstruction from January of 2009 to December of 2017 was conducted. Patients were divided into two cohorts: microsurgical and two-stage tissue expander/implant-based reconstruction. BREAST-Q survey response, demographic information, complications, and need for revision procedures were analyzed.

RESULTS

One hundred fifty-five patients met the inclusion criteria: 75 (48.4 percent) underwent microsurgical breast reconstruction and 80 (51.6 percent) underwent implant-based reconstruction. Cohorts were similar in body mass index, mean mastectomy specimen weight, laterality, indication for surgery, smoking status, and postoperative complications. Microsurgical reconstruction patients were younger (49.0 years versus 53.0 years; p = 0.02) and more likely to have delayed reconstruction [n = 70 (64.2 percent) versus n = 0 (0.0 percent); p = 0.0001]. BREAST-Q responses showed that microsurgery patients were more satisfied with their breasts (Q-Score of 63.4 ± 6.9 versus 50.8 ± 12.8; p = 0.0001), overall outcome (Q-Score 70.5 ± 13.0 versus 60.3 ± 10.8; p = 0.0001), and chest physical well-being (Q-Score of 69.1 ± 10.9 versus 63.8 ± 8.2; p = 0.01).

CONCLUSIONS

Microsurgical breast reconstruction in obese patients yields higher satisfaction with breasts, overall outcomes, and chest physical well-being than implant-based reconstruction. Despite increased postoperative complications associated with obesity, microsurgical breast reconstruction appears to be a good choice for women who understand its risks and benefits and choose to proceed with it.

Microsurgical Breast Reconstruction in the Obese: A Better Option Than Tissue Expander/Implant Reconstruction?

BACKGROUND

Obesity has reached epidemic proportions, with 72 million people in the United States classified as obese in 2010. This significant increase in obese patients is reflected in the breast cancer population seeking breast reconstruction. Previous studies demonstrated increased complication rates and decreased satisfaction in obese patients undergoing breast reconstruction. This study aims to directly compare prosthetic and autologous reconstruction in the obese population by evaluating surgical outcomes and patient satisfaction.

METHODS

In an institutional review board-approved study, a retrospective chart review was conducted on patients with a body mass index of 30.0 kg/m or greater who underwent breast cancer reconstruction after mastectomy with either free tissue transfer from the abdomen or prosthetic reconstruction over a 3-year period. The authors identified 96 patients with 141 reconstructions. Demographic, intraoperative, and postoperative variables were collected. All patients were sent the BREAST-Q questionnaire by means of mail to study the impact and effectiveness of breast surgery from the patient's perspective. Statistical analysis was completed with Fisher's exact test, Mantel-Haenszel chi-square test, Pearson chi square test, or Mann-Whitney-Wilcoxon test.

RESULTS

Prosthetic-based breast reconstruction was associated with increased major breast complications (p < 0.001), mastectomy skin flap necrosis (p = 0.009), infection (0.006), and overall reconstructive failure (p < 0.0001) compared with autologous reconstruction. When evaluating the results of the BREAST-Q studies, the autologous reconstruction group had improved satisfaction with breasts (p < 0.0001), satisfaction with outcome (p = 0.01), psychosocial well-being (p = 0.007), and sexual well-being (p = 0.006).

CONCLUSION

In the obese population, reconstruction with free tissue transfer from the abdomen resulted in decreased complications of the breast reconstruction site and improved patient satisfaction with outcomes compared with prosthetic reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Increasing abdominal wall thickness predicts complications in abdominally based breast reconstruction: A review of 106 consecutive patients

BACKGROUND

Body mass index (BMI) has long been the proxy for patient selection in obese patients presenting for abdominally based breast reconstruction. BMI, however, fails to accurately reflect the distribution of abdominal adipose tissue. This study aims to quantify the effect of abdominal wall thickness on the incidence of post-operative complications and contrast abdominal wall thickness and BMI as predictors of post-operative morbidity.

METHODS

We performed a retrospective review of 106 consecutive patients who underwent abdominally based breast reconstruction. Abdominal wall thickness was quantified using preoperative CT angiograms. Primary outcomes included delayed wound healing (abdomen and/or breast), flap fat necrosis, return to OR in 30 days, infection, and flap loss.

RESULTS

Patients experiencing delayed abdominal wound healing (n=38), delayed breast wound healing (n=27), and flap fat necrosis (n=24) had significantly thicker abdominal wall measurements (p<0.0015). Of the 24 patients with palpable fat necrosis, 11 required excision. Increasing abdominal wall thickness significantly increased the odds of delayed abdominal wound healing (p=0.0005), delayed breast wound healing (p=0.0009), flap fat necrosis (p=0.0028), and infection (p=0.0198). Compared to BMI, abdominal wall thickness proved to be a more accurate predictor of delayed breast wound healing, any delayed wound healing, flap fat necrosis, and infection.

CONCLUSIONS

Our data indicate that as abdominal wall thickness increases, so does the risk of postoperative morbidity. Abdominal wall thickness outperformed BMI as a predictor of postoperative morbidity in several areas. This suggests that objective data obtained from preoperative CT scans may allow more accurate, individualized perioperative risk assessment.

The Impact of Obesity on Patient-Reported Outcomes Following Autologous Breast Reconstruction

BACKGROUND

Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant.

OBJECTIVE

Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients.

METHODS

An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction.

RESULTS

Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04).

CONCLUSION

Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.

Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction

INTRODUCTION

The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA).

PATIENTS AND METHODS

We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI.

RESULTS

Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41).

CONCLUSION

We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

BACKGROUND

Microvascular breast reconstruction is a complex procedure that can be associated with high complication rates. Although a number of individual predictors of perioperative complications have been identified, few studies have explored interaction between risk factors. Understanding the synergistic effects of multiple risk factors is central to accurate and personalized preoperative risk prediction.

METHODS

The authors conducted a retrospective cohort study of patients who underwent microvascular breast reconstruction at their institution between 2009 and 2017. All intraoperative and postoperative complications were recorded. A multivariable logistic regression exploratory model identified independent predictors of complications. Interactions between individual variables were then assessed using the relative excess risk index (RERI) and the synergy index (SI).

RESULTS

Nine hundred twelve patients were included in the study and 26.1 percent experienced at least one perioperative complication. Obesity (OR, 1.54; p = 0.009), immediate reconstruction (OR, 1.49; p = 0.028), and comorbidities (OR, 1.43; p = 0.033) were identified as independent predictors of complications. Obesity and comorbidities had significant synergistic interactions with immediate reconstruction (RERI, 0.86; SI, 2.35; p = 0.0002; and RERI, 0.54; SI, 1.78; p = 0.001), bilateral reconstruction (RERI, 0.12; SI, 1.15; p = 0.002; and RERI, 0.59; SI, 3.16; p = 0.005), and previous radiotherapy (RERI, 0.62; SI, 4.43; p = 0.01; and RERI, 0.11; SI, 1.23; p = 0.040). Patients undergoing immediate breast reconstruction who were both obese and smokers had a 12-fold increase in complication rates (OR, 12.68; 95 percent CI, 1.36 to 118.46; p = 0.026) with a very strong synergistic interaction between variables (RERI, 10.55; SI, 10.33).

CONCLUSION

Patient- and treatment-related variables interact in a synergistic manner to increase the risk of complications following microvascular breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap

BACKGROUND

Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs.

OBJECTIVES

The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap.

METHODS

Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed.

RESULTS

The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q.

CONCLUSIONS

Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis.

LEVEL OF EVIDENCE: 4

Prospective Evaluation of Obese Patients Undergoing Autologous Abdominal Free Flap Breast Reconstruction

BACKGROUND

Obesity has been viewed as a relative contraindication against autologous free flap breast reconstruction because of increased risks of complications, including flap loss.

METHODS

The authors conducted a prospective analysis of obese patients undergoing autologous breast reconstruction.

RESULTS

Overall, 72 patients (average age, 48.5 years; average body mass index, 35.7 kg/m) underwent abdominal free flap breast reconstruction. There were 43 bilateral reconstructions and the remainder were unilateral (n = 115 flaps). There were 67 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps (58.3 percent), 44 deep inferior epigastric perforator (DIEP) flaps (38.2 percent), two free bipedicle DIEP flaps, one superficial inferior epigastric perforator flap, and one free TRAM flap. Forty-two patients (58.3 percent) had prior radiation, and 51 (70.8 percent) had prior chemotherapy. Forty-three patients (59.7 percent) underwent delayed reconstruction and 21 (29.2 percent) underwent immediate reconstruction. Eight patients (11.1 percent) had bilateral reconstruction, with one breast reconstructed in an immediate and the other in a delayed fashion. Half of the patients (n = 36) had mesh placed in an underlay fashion to reinforce the donor site. Regarding breast complications, there were 11 wound dehiscences, one hematoma, one infection, and two patients with mastectomy skin flap necrosis. Twelve patients had donor-site wound healing complications, there were four infections, and three patients developed a bulge/hernia. There were no flap losses. Comparison to historic controls demonstrated no significant differences in overall flap loss rates (p = 0.061) or donor-site bulge/hernia (p = 0.86).

CONCLUSION

Autologous abdominal free flaps can be performed safely in obese patients without increased risks for donor-site bulge/hernia or flap loss compared to nonobese patients; however, patients should be counseled carefully regarding the potential risks of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes

BACKGROUND

The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity.

METHODS

A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined.

RESULTS

The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps.

CONCLUSIONS

Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Impact of Body Mass Index on Operative Outcomes in Head and Neck Free Flap Surgery

Objective

Analyze the risk for perioperative complications associated with body mass index (BMI) class in patients undergoing head and neck free flap reconstruction.

Study Design and Setting

Retrospective cohort study.

Subjects and Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried for all cases of head and neck free flaps between 2005 and 2014 (N = 2187). This population was stratified into underweight, normal-weight, overweight, and obese BMI cohorts. Groups were compared for demographics, comorbidities, and procedure-related variables. Rates of postoperative complications were compared between groups using χ2 and binary logistic regression analyses.

Results

Underweight patients (n = 160) had significantly higher rates of numerous comorbidities, including disseminated cancer, preoperative chemotherapy, and anemia, while obese patients (n = 447) had higher rates of diabetes and hypertension. Rates of overall surgical complications, medical complications, and flap loss were insignificantly different between BMI groups. Following regression, obese BMI was protective for perioperative transfusion requirement (odds ratio [OR] = 0.63, P = .001), while underweight status conferred increased risk (OR = 2.43, P < .001). Recent weight loss was found to be an independent predictor of perioperative cardiac arrest (OR = 3.16, P = .006) while underweight BMI was not (OR = 1.21, P = .763). However, both weight loss and underweight status were associated with significantly increased risk for 30-day mortality (OR = 4.48, P = .032; OR = 4.02, P = .010, respectively).

Conclusion

Obesity does not increase the risk for postoperative complications in head and neck free flap surgery and may be protective in some cases. When assessing a patient’s fitness for surgery, underweight status or recent weight loss may suggest a reduced ability to tolerate extensive free flap reconstruction.

Optimizing aesthetic outcomes for breast reconstruction in patients with significant macromastia or ptosis

Background

Achieving excellent aesthetic outcomes in reconstruction of large or ptotic breasts is especially challenging. Incorporating a Wise pattern into the mastectomy design is effective in reducing the excess breast skin, however it increases the risk of mastectomy skin necrosis. The aim of this study is to describe surgical maneuvers which optimize aesthetic outcomes, anticipate flap volume requirements, and limit mastectomy skin necrosis in autologous reconstruction in patients with macromastia and grade III ptosis.

Methods

This is a retrospective review of operative and clinical records of patients who underwent unilateral or bilateral breast reconstruction with autologous tissue between August 2015 and May 2017. Patients were divided into macromastia and ptosis groups. Key surgical maneuvers for safely achieving aesthetically optimal results were identified.

Results

A total of 29 breasts were successfully reconstructed in 19 patients with a Wise pattern mastectomy skin reduction. Free flap weights were similar in both groups, mastectomy weights were greater in the macromastia group, p < 0.05. Complications were limited to three cases of wound breakdown and one case of mastectomy skin necrosis. Total number of revision stages was reduced in unilateral reconstructions when a contralateral breast reduction or mastopexy was performed during the first stage.

Conclusions

A Wise pattern can safely and effectively be incorporated into a mastectomy incision design in patients who are not candidates for a nipple sparing mastectomy. Optimal aesthetics are achieved with similar volume flaps for both macromastia and ptosis patients. In cases of unilateral breast reconstruction a contralateral breast reduction or mastopexy should be performed at the time of the immediate breast reconstruction.

Super obesity is not necessarily a contraindication to deep inferior epigastric perforator flap breast reconstruction

The deep inferior epigastric perforator (DIEP) flap is widely recognised as a safe and reliable flap for use as a first-choice option in autologous tissue breast reconstruction. Patients with obesity represent a challenging group for autologous breast reconstruction, as they are at increased risk of developing major and minor complications in comparison with patients with normal weight. We report a 59-year-old woman with super obesity, who presented to our department with right breast skin necrosis after implant reconstruction following mastectomy for right breast cancer. After implant removal and local treatment with both surgical debridement and negative pressure wound therapy, the patient successfully underwent a DIEP flap breast reconstruction. We conclude that super obesity should not be a contraindication to DIEP flap breast reconstruction.