Optimizing the Fascial Closure: An Analysis of 1261 Abdominally Based Free Flap Reconstructions

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 Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

 Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer.

METHODS

 Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I ² statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models.

RESULTS

 After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I ²= 4) after adjustment for publication bias. No other complications were statistically different between groups.

CONCLUSION

 In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.

Comparison of Phasix, polypropylene, and primary closure of the abdominal donor site after bilateral free flap breast reconstruction: Long-term evaluation of abdominal hernia and bulge formation

BACKGROUND

Abdominal free flap harvest for breast reconstruction may result in significant morbidity in terms of hernias and bulges. Reinforcement of the donor site with mesh has been recommended to minimize the risk of hernias and bulges, but no studies exist evaluating the optimal type of mesh. Polypropylene has traditionally been used but the development of Phasix restorable mesh may be a reasonable alternative. Here, we compared the use of Phasix to polypropylene and primary closure and hypothesize that the former has lower rates of abdominal morbidity in the long term.

PATIENTS AND METHODS

A retrospective review of all patients undergoing bilateral free flap breast reconstruction from the abdomen was performed while patients with pedicle flaps or alternative donor sites were excluded. Patient demographics, medical/surgical history, cancer treatments, and flap type were analyzed. All patients were monitored for a minimum of 2 years for early donor site complications as well as hernia/bulges.

RESULTS

Sixty-six consecutive patients were included (40 patients with Phasix, 20 patients with polypropylene, and 6 patients with primary closure). Use of Phasix mesh resulted in higher initial operative costs ($2,750 vs. $72 vs. $0). Two patients with polypropylene mesh and one patient undergoing primary closure developed an abdominal bulge in an average follow-up of 25.2 months (11.5% vs. 0%, p = .04).

CONCLUSIONS

Mesh placement for abdominal wall reinforcement after bilateral free flap breast reconstruction minimizes the risk of hernias and bulges. Although Phasix results in increased initial costs, abdominal morbidity is significantly decreased after follow-up beyond 2 years.

Function and Strength after Free Abdominally Based Breast Reconstruction: A 10-Year Follow-Up

BACKGROUND

The long-term impact of abdominally based free flap breast reconstruction is incompletely understood. The aim of this study is to provide long-term, subjective and objective health data on abdominally based free flap breast reconstruction patients, with specific attention to the effects of laterality, flap type, and obesity.

METHODS

Patients were enrolled in this prospective study between 2005 and 2010 and completed preoperative, early (<1 year), and long-term (5 to 10 years) evaluations. Objective examination included an assessment of upper and lower abdominal function and a functional independence measure. Patient-reported outcomes included the 36-Item Short-Form Health Survey and the BREAST-Q abdominal well-being module. Scores were compared by laterality (unilateral versus bilateral), flap type (muscle-sparing free transverse rectus abdominis musculocutaneous versus deep inferior epigastric artery perforator), and presence of obesity.

RESULTS

Fifty-one patients were included, with an average 8.1-year follow-up. Overall, 78.8 percent of patients had stable or improved scores across the upper and lower abdominal function and functional independence measures, and minimal objective differences across flap laterality or types were observed. Postoperative scores improved for 36-Item Short-Form Health Survey physical health (p < 0.001) and mental health (p < 0.001), and did not differ based on laterality or flap type. Obesity negatively impacted physical health (p = 0.002) and mental health (p = 0.006).

CONCLUSIONS

Abdominally based autologous breast reconstruction is associated with significant improvements in long-term quality of life across key domains of physical and mental health with little functional impairment and no long-term differences across flap type or laterality. Obese patients, however, may be at risk for subjective physical and mental health impairment, perhaps unrelated to the surgery itself.

Donor-site morbidities in 615 patients after breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap: a single surgeon experience

Transverse rectus abdominis myocutaneous flap is one of the most commonly used reconstruction tools after oncological mastectomy. However, post-operative donor-site morbidities remain an issue to be addressed. In this study, we retrospectively reviewed patients with either immediate or delayed breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap only, performed by a single surgeon, regarding the donor-site morbidity. From January 2012 to July 2017, the study subjects summed up to 615 patients, in a single institution. Preoperative planning and actual surgical techniques were outlined including the evaluation of the location of the perforators using a three-dimensional abdominal computed tomography angiography scan, minimal fascia sacrifice, beveled dissection and minimization of the tension on the central abdomen during closure. During a 1-year follow-up, a total of 33 patients (5.4%) were complicated with any donor-site morbidity. Those in need of secondary revision on their donor-sites accounted for 23 patients (69.7%). No factor was found statistically significant to increase the risk of donor-site morbidity. Many surgical techniques have been devised for closure of the donor-site in transverse rectus abdominis myocutaneous flap patients. And, several factors have been proposed as increasing the risk of donor-site morbidity. Although all the suggested predictive factors failed to prove its significance on increasing the risk, a set of preoperative planning and surgical techniques employed in our study has proven to be both safe and efficient in lowering the postoperative donor-site morbidities.

Internal Mammary Vessels' Impact on Abdominal Skin Perfusion in Free Abdominal Flap Breast Reconstruction

Background

Wound healing problems at the donor site in free abdominal flap breast reconstruction cause significant morbidity to patients. No studies have investigated what impact the use of the internal mammary artery in free abdominal flap breast reconstruction has on abdominal skin perfusion. We hypothesized that harvesting the internal mammary vessels (IMV) has a negative effect on abdominal skin perfusion.

Methods

The abdomen and anterior thoracic wall of 17 patients scheduled for secondary free abdominal flap breast reconstruction using IMV was pre-, intra-, and postoperatively examined with dynamic infrared thermography. Qualitative and quantitative analyses of the rate and pattern of recovery in Huger's vascular zones were made with each patient being its own control. Zone III on the side where IMV were used was numbered zone IV. The contralateral zone III was used as reference.

Results

Postoperative abdominal skin perfusion in zone IV was always significantly reduced compared with zone III (1-tailed t test, P < 0.05). The difference between zones II and III was statistically significant for day 1 and 3, but not for day 6 (2-tailed t test, P < 0.05). Skin perfusion in zones II and IV increased during consecutive postoperative days with an increase of hot spots in these areas.

Conclusions

Using the IMV in free abdominal flap breast reconstruction had a significant effect on abdominal skin perfusion and may contribute to abdominal wound healing problems. The reperfusion of the abdominal skin was a dynamic process showing an increase in perfusion in the affected areas during the postoperative days.

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

BACKGROUND

A large proportion of patients presenting for autologous breast reconstruction have a history of prior abdominal surgeries such as obstetric, gynecologic, or general surgical procedures. The impact of prior abdominal wall violation on the ability to perform free tissue transfer from the abdomen needs to be explored and characterized. The purpose of this study was to assess the impact of prior abdominal surgery on perfusion-related complications and donor-site morbidity in free tissue abdominal transfer.

METHODS

All patients who underwent abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at the Hospital of the University of Pennsylvania were included. In addition to collecting data on standard patient past medical histories, comorbidities, and case characteristics, we also noted specific types of prior abdominal surgeries, number of prior surgeries, and if the rectus sheath was violated. Outcomes assessed included thrombotic complications, flap loss, major surgical complications, minor surgical complications, delayed wound healing, and subsequent hernia formation.

RESULTS

Eight hundred twelve patients underwent 1257 free flap breast reconstructions during the study period. Four hundred seventeen (51.4%) women had undergone prior abdominal surgery. The most common prior abdominal surgeries included total abdominal hysterectomy and/or bilateral salpingo-oophorectomy (35.7%), cesarean delivery (33.8%), and appendectomy (12.7%). No significant differences were noted in the number of major intraoperative complications (P = 0.68), total thrombotic events (P = 0.339), or flap losses (P = 0.53). Patients who had undergone prior rectus sheath violation were found to experience a greater amount of delayed healing of the donor site (22.7% vs 16.5%, P = 0.03). Additionally, a higher rate of postoperative hernia formation was noted in patients who had undergone prior hernia repairs (13.6% vs 3.3%, P = 0.04).

CONCLUSIONS

A significant portion of patients presenting for breast reconstruction have had prior abdominal surgeries. This study demonstrates that these prior procedures represent an acceptable level of risk; although this issue should still be addressed during preoperative patient counseling. In patients with prior hernia repairs, however, additional care should be given to the fascial closure as these patients may be at higher risk for subsequent hernia formation after abdominally based breast reconstruction.

Propensity-matched, longitudinal outcomes analysis of complications and cost: comparing abdominal free flaps and implant-based breast reconstruction

BACKGROUND

Choosing a breast reconstructive modality after mastectomy is an important step in the reconstructive process. The authors hypothesized that autologous tissue is associated with a greater success rate and cost efficacy over time, relative to implant reconstruction.

STUDY DESIGN

A retrospective review was performed of patients undergoing free tissue (FF) transfer and expander implant (E/I) reconstruction between 2005 and 2011. Variables evaluated included comorbidities, surgical timing, complications, overall outcomes, unplanned reoperations, and costs. A propensity-matching technique was used to account for the nonrandomized selection of modality.

RESULTS

A total of 310 propensity-matched patients underwent 499 reconstructions. No statistically significant differences in preoperative variables were noted between propensity-matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. The E/I reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs 1.2%, p < 0.001). Expander implant reconstructions were associated with higher rates of seroma (p = 0.009) and lower rates of medical complications (p = 0.02), but overall significantly higher rates of unplanned operations (15.5% vs 5.8%, p = 0.002). The total cost of reconstruction did not differ significantly between groups ($23,120.49 ± $6,969.56 vs $22,739.91 ± $9,727.79, p = 0.060), but E/I reconstruction was associated with higher total cost for secondary procedures ($10,157.89 ± $8,741.77 vs $3,200.71 ± $4,780.64, p < 0.0001) and a higher cost of unplanned revisions over time (p < 0.05).

CONCLUSIONS

Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost. Although autologous reconstruction is not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.

The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction

Background

Perforator flaps minimize abdominal site morbidity during autologous breast reconstruction. The purpose of this study was to assess whether the number of perforators harvested influences the overall deep inferior epigastric perforator (DIEP) flap survival and flap-related complications.

Methods

A retrospective review was performed of all DIEP flaps performed at the Hospital of the University of Pennsylvania from 2006 to 2011. The outcomes assessed included flap loss and major complications. We compared flaps by the number of total perforators (1-4) and then carried out a subgroup analysis comparing flaps with one perforator to flaps with multiple perforators. Lastly, we conducted a post-hoc analysis based on body mass index (BMI) categorization.

Results

Three hundred thirty-three patients underwent 395 DIEP flaps. No significant differences were noted in the flap loss rate or the overall complications across perforator groups. However, the subgroup analysis revealed significantly higher rates of fat necrosis in the case of one-perforator flaps than in the case of multiple-perforator flaps (10.2% vs. 3.1%, P=0.009). The post-hoc analysis revealed a significant increase in the flap loss rate with increasing BMI (<30=2.0%, 30-34.9=3.1%, 35-39.9=3.1%, >40=42.9%, P<0.001) in the DIEP flaps, but no increase in fat necrosis.

Conclusions

This study demonstrates that the number of perforators does not impact the rate of flap survival. However, the rate of fat necrosis may be significantly higher in DIEP flaps based on a single perforator. Multiple perforators should be utilized if possible to decrease the risk of fat necrosis.