Complications and morbidity following breast reconstruction – a review of 16,063 cases from the 2005–2010 NSQIP datasets

Investigating the Impact of Operative Time on Breast Augmentation Outcomes

BACKGROUND

Breast augmentation is a widely performed aesthetic surgery, yet the impact of operative time on postoperative outcomes remains unclear. While longer operative times have been linked to increased risks across a wide array of surgical disciplines, this association has not been thoroughly validated in breast augmentation. This multi-institutional study aims to investigate the relationship between operative time and outcomes after breast augmentation with implants.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2008-2022) was queried to identify adult female patients who underwent elective breast augmentation with implants. Preoperative, intraoperative, and postoperative variables, including operative time and 30-day complications, were evaluated. Multivariable logistic regression was used to assess the impact of operative time, analyzing it as both a continuous and a dichotomized variable.

RESULTS

A total of 6531 female patients with a mean age of 34.9 ± 10.1 years and a mean body mass index of 22.9 ± 4.0 kg/m2 were included. One hundred eighteen patients (1.8%) experienced complications, the majority of which were reoperations (n = 69; 1.1%) and surgical complications (n = 30; 0.5%). Multivariable analysis revealed a significant association between operative time and both surgical complications (odds ratio [OR] = 1.01, P = 0.0003) and any complications (OR = 1.01, P = 0.003). For every 10-minute increase in operative time, the risk of surgical and any complications increased by 7.2% and 4.5%, respectively. A critical threshold of 91 minutes was identified, beyond which the odds of complications increased significantly (OR = 1.93, P = 0.001).

CONCLUSIONS

Prolonged operative time is associated with an increased risk of complications following breast implant augmentation. A threshold of 91 minutes was identified, implying that procedures exceeding this duration carry higher postoperative morbidity. These findings underscore the importance of optimizing surgical efficiency to minimize risks and enhance patient outcomes after breast augmentation.

Use of antibiotic-impregnated discs in breast reconstruction among the obese population: A retrospective propensity score-matched analysis

Two-stage breast reconstruction is a well-established post-mastectomy surgical technique. Unfortunately, periprosthetic infections in tissue expanders remain a prevalent concern. Antibiotic-impregnated polymethylmethacrylate (PMMA) plates for infection prophylaxis in TE-based reconstruction have been shown to lower infection rates. With the growing obesity epidemic in the US, this propensity-score matched retrospective study aimed to evaluate the impact of PMMA plates on the obese population. A retrospective chart review was performed for patients with a BMI of 30 and above to record patient demographics, complications, operative details, and post-operative details. One-to-one propensity score matching was used to match the intervention and control group on age, diabetes status, smoking status, neoadjuvant chemotherapy, prior radiation history, and laterality of breast reconstruction, resulting in 48 patients in each group. Chi-squared analysis, and Barnard exact tests assessed significant differences between groups and infection rates. T-tests compared the normally distributed continuous variables. Logistic regression controlled for confounders that have been reported in previously published literature. Chi-square analysis revealed a significant association between PMMA plate usage and infection rate (4.2% compared to 16.7%; p = 0.045). Logistic regression analysis found that the PMMA antibiotic plate group had a statistically significant decrease in infection rate (OR: 0.18 [0.033-0.962]; p = 0.045). Though antibiotic-impregnated PMMA plates have demonstrated effective infection prophylaxis in the general population, this study is the first to explore their use in the obese population. Within our cohort, placing an antibiotic plate resulted in a reduced infection rate.

Effect of Prepectoral Versus Subpectoral Implant-Based Reconstruction on Post-Mastectomy Radiation Dosimetry

BACKGROUND

The placement of breast implants in a prepectoral plane has become increasingly popular in breast reconstruction, although data on how this affects radiation delivery in women with breast cancer are limited. This study aimed to assess the dosimetric differences in radiation plans for immediate breast reconstruction between prepectoral and subpectoral implants.

METHODS

In this study, a retrospective review and dosimetric analysis of patients with breast cancer who underwent immediate implant-based reconstruction and postmastectomy radiation therapy (PMRT) were performed. Patients with pre- or subpectoral implants were matched 1:1 by use of boost and radiation field. Demographics and complications were compared using the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables. Dosimetric data were analyzed to compare doses to the target, heart, lungs, and pectoralis major using a Mann-Whitney U test.

RESULTS

The study identified 42 patients who met the inclusion criteria. Planning target volume (PTV) coverage was better in the prepectoral group (PTV D95%, 45.61 vs. 43.38 Gy; p = 0.04). The heart and lung doses did not differ. The patients with subpectoral implants had a lower absolute volume of pectoralis major receiving 20 to 45 Gy.

CONCLUSION

This assessment of radiation dosimetry for patients undergoing immediate breast reconstruction found that the primary dosimetric difference between prepectoral and subpectoral implants was the dose to the pectoralis major. Otherwise, no significant difference in target coverage was found. These data suggest that implant placement can be selected to optimize reconstructive outcomes, with less concern for compromise to the oncologic quality of PMRT.

Immediate Breast Reconstruction After Mastectomy for Cancer Among US Military Health System Beneficiaries

BACKGROUND

In the Military Health System (MHS), women with breast cancer may undergo surgical treatment in military hospitals (direct care) or in the civilian setting via the insurance benefit (private sector care). We conducted this study to determine immediate breast reconstruction rates among women undergoing mastectomy for cancer in the MHS by setting of care.

METHODS

Using the linked Department of Defense's Central Cancer Registry and MHS Data Repository, the Department of Defense's medical claims database, we identified adult women who underwent mastectomy for breast cancer from 1998 to 2014. Patients were then subgrouped by setting of care (direct vs private sector care). The primary outcome was the rate and type of immediate breast reconstruction. Regression models were constructed to determine factors associated with receipt of immediate breast reconstruction.

RESULTS

The final sample included 3251 women who underwent mastectomy for cancer in the direct (67.0%) or private sector care (32.6%) settings. The overall rate of immediate breast reconstruction was 29.9% with an upward trend noted throughout the study ( P < 0.001). Overall, implant-based reconstruction (81.4%) was more common than tissue-based reconstruction (18.6%). Compared with direct care, the immediate breast reconstruction rate was significantly higher in the private sector care setting (49.3% vs 20.5%, P < 0.001) despite accounting for differences in clinical characteristics (adjusted odds ratio = 4.51, 95% confidence interval [3.72-5.46]).

CONCLUSIONS

Immediate breast reconstruction in the direct care setting lags that in the civilian community during the study time period. Further research is needed to ascertain current immediate reconstruction rates and understand factors contributing to any differences in rates between care settings.

Is Immediate Breast Reconstruction With a Latissimus Dorsi Myocutaneous Flap Safe for Starting Adjuvant Chemotherapy in Patients With Breast Cancer?

INTRODUCTION

Immediate breast reconstruction following mastectomy reduces perceptions of mutilation and femininity issues in oncological patients, but surgical complications should not delay chemotherapy. This study evaluated postsurgical complications in patients who underwent radical breast surgery followed by immediate reconstruction with latissimus dorsi myocutaneous flaps and silicone implants, along with resulting impacts in delaying chemotherapy.

MATERIALS AND METHODS

This retrospective study utilized a prospectively maintained database. Clinical, surgical, and oncological data from 196 women were collected according to the operated side. Patients were grouped according to the time elapsed between surgery and the first cycle of adjuvant chemotherapy: ≤ 60 days (group 1), 61 to 90 days (group 2), or > 90 days (group 3).

RESULTS

A total of 198 immediate reconstructions were performed on 196 patients between August 1, 2010 and March 31, 2020; after surgery, 47.4% had minor complications and 7.1% had major complications. Ninety-six patients (48.5%) received adjuvant chemotherapy. The mean time elapsed between surgery and the first chemotherapy cycle was 65.4 days (median: 59), with 52.7% of the patients assigned to group 1, 37.4% to group 2, and 9.9% to group 3. The occurrence of major postoperative complications significantly affected the start of chemotherapy (64.0 vs. 94.5 days; P = .044). Additionally, patients with 2 or more comorbidities were more likely to experience major complications (OR: 3.35; 95% CI: 1.03-10.95; P = .045) than those with 1 or 0.

CONCLUSION

Major postoperative complications significantly delayed initiation of adjuvant chemotherapy in oncological patients who underwent radical breast surgery followed by immediate reconstruction with a latissimus dorsi myocutaneous flap and silicone implants.

Latissimus Dorsi Flap and Thoracodorsal Artery Perforator Flap with Immediate Fat Transfer (LIFT and TIFT): A Retrospective Study about Total Breast Reconstruction in High-Risk Patients

INTRODUCTION

Microsurgical breast reconstruction has become popular over the past twenty years and allows a tailor-tuck approach to each patient. However, smoking or coagulation disorders may switch surgeon's choice towards alternative options. When facing these risk factors, we performed pedicled latissimus dorsi (LD) flap and thoracodorsal artery perforator (TDAP) flap reconstruction with immediate fat transfer (LIFT and TIFT), achieving satisfactory surgical outcomes. Hence, we aim to present our seven-years case-series and discuss our decisional algorithm.

MATERIALS AND METHODS

Thirty smoker women and seven women affected by coagulation disorder (n = 37) respectively had LIFT and TIFT surgery and were retrospectively evaluated. Patients' demographics and outcomes were recorded and compared.

RESULTS

LIFT patients received higher volumes of immediate fat grafting compared to TIFT patients (p < 0.05), which required additional lipofilling to provide adequate volume amount, since the TDAP flap was not immediately grafted. However, the additional lipofilling procedures and fat volume were similar (p > 0.05). Flap survival reached 100%, and flap necrosis or loss did not occur. Few minor complications were evidenced in the LIFT group only (p > 0.05).

CONCLUSION

Based on our experience, we support the reliability of pedicled LD and TDAP flaps with immediate fat transfer in breast reconstruction as valuable alternative to microsurgery in smokers (LIFT) and patients with coagulation disorders (TIFT). However, the results of our study are not conclusive since still must be clarified the role of the smoking and coagulation disorders in microsurgery and the real benefit of a non-microsurgical procedure.

LEVEL OF EVIDENCE IV

Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

One versus two vein anastomoses in breast reconstruction with a profunda artery perforator flap-does it make a difference

BACKGROUND

The profunda artery perforator (PAP) flap has gained popularity as a reliable alternative in breast reconstruction. Extensive research has focused on its vascular supply, dissection techniques, and broader applications beyond breast reconstruction. This study aims to investigate the correlation between the number of veins anastomosed for the PAP flap and postoperative complications.

METHODS

A retrospective study was conducted to evaluate the outcomes of breast reconstructions with PAP flaps at our institution between 2018 and 2022. A total of 103 PAP flaps in 88 patients were included. Statistical analysis was performed to compare outcomes between flaps with one vein anastomosis and those with two vein anastomoses. Patient characteristics, intra and postoperative parameters were analysed.

RESULTS

One vein anastomosis was used in 36 flaps (35.0%), whereas two vein anastomoses were used in 67 flaps (65.0%). No significant differences were found in patient characteristics between the one vein and two vein groups. The comparison of ischemia times between flaps with one versus two veins revealed no statistically significant difference, with mean ischemia times of 56.2 ± 36.8 min and 58.7 ± 33.0 min, respectively. Regarding outcomes, there were no statistically significant differences in secondary lipofilling, revision of vein anastomosis, or total flap loss between the two groups. Fat necrosis was observed in 5 (13.9%) one vein flaps and 5 (7.5%) two vein flaps, indicating no statistically significant difference between the two groups (p = .313). In the one vein group, the most frequently employed coupler ring had a diameter of 2.5 mm. In the two vein group, the most prevalent combination consisted of a 2.0 mm diameter with a 2.5 mm diameter.

CONCLUSION

Based on our study results, both one vein anastomosis and two vein anastomoses are viable options for breast reconstruction with PAP flap. The utilization of either one or two veins did not significantly affect ischemia time or flap loss. Fat necrosis exhibited a higher incidence in the single-vein group; however, this difference was also not statistically significant. These findings underscore the effectiveness of both approaches, providing surgeons with flexibility in tailoring their surgical techniques based on patient-specific considerations and anatomical factors.

Simultaneous Free Flap Breast Reconstruction Combined With Contralateral Mastopexy or Breast Reduction: A Propensity-Matched National Surgical Quality Improvement Program Study on Postoperative Outcomes

BACKGROUND

Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can increase patient satisfaction and minimize the need for a second procedure. Surgeon concerns of increases in operative time, postoperative complications, and final breast symmetry may decrease the likelihood of these procedures being done concurrently. This study analyzed postoperative outcomes of simultaneous contralateral mastopexy or breast reduction with free flap breast reconstruction.

METHODS

By using the American College of Surgeons National Surgical Quality Improvement Program database (2010-2020), we analyzed 2 patient cohorts undergoing (A) free flap breast reconstruction only and (B) free flap breast reconstruction combined with contralateral mastopexy or breast reduction. The preoperative variables assessed included demographic data, comorbidities, and perioperative data. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 602 free flap breast reconstruction patients and 621 with concurrent contralateral operation patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.

RESULTS

We identified 11,308 cases who underwent microsurgical free flap breast reconstruction from the American College of Surgeons National Surgical Quality Improvement Program database from the beginning of 2010 to the end of 2020. A total of 621 patients underwent a free flap breast reconstruction combined with contralateral mastopexy or breast reduction. After propensity score matching, there were no significant differences in patient characteristics, perioperative variables or postoperative medical complications between the 2 cohorts.

CONCLUSIONS

Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can be performed safely and effectively without an increase in postoperative complication rates. This can improve surgeon competence in offering this combination of procedures as an option to breast cancer survivors, leading to better patient outcomes in terms of symmetrical and aesthetically pleasing results, reduced costs, and elimination of the need for a second operation.

Neoadjuvant chemotherapy impact on outcomes in immediate breast reconstruction with latissimus dorsi flap and silicone implant

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy (NCH) has demonstrated efficacy in downsizing tumors and facilitating less extensive surgery. However, immediate breast reconstruction (IBR) after NCH has raised concerns regarding higher complication rates. This study evaluates the impact of NCH on outcomes following IBR with a latissimus dorsi flap and implant (LDI) after mastectomy.

METHODS

Cases from a prospective maintained database were reviewed, and patients classified according to whether or not they received NCH. Risk factors and major and minor complications in both groups were then analyzed.

RESULTS

Among the 196 patients who underwent 198 IBR procedures, 38.4% received NCH and 66.1% did not. The overall complication rate was 46.7% in the non-NCH group and 53.3% in the NCH group (p =  0.650). The presence of comorbidities increased the likelihood of any complication (odds ratio [OR]: 3.46; 95% confidence interval [CI]: 1.38-8.66; p = 0.008) as well as major complications (OR: 3.35; 95% CI: 1.03-10.95; p = 0.045). Although patients in the NCH group experienced more major complications (10.5% vs. 4.9%; p = 0.134) and early loss of breast reconstruction (3.9% vs. 0.8%; p = 0.128), these findings were not statistically significant.

CONCLUSION

This study found no statistically significant association between NCH and higher risk of complications or loss of IBR with LDI after mastectomy.

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study

BACKGROUND

Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy.

STUDY DESIGN

The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge.

RESULTS

The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased.

CONCLUSION

The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Textured versus Smooth Tissue Expanders: A Comparison of Complications in 3526 Breast Reconstructions

BACKGROUND

Increased understanding of breast implant-associated anaplastic large-cell lymphoma has led to a shift away from textured breast devices. A few small studies have compared the complication rates of textured and smooth tissue expanders (TEs). The aim of this study was to compare complication profiles in patients undergoing two-stage postmastectomy breast reconstruction with either textured or smooth TEs.

METHODS

The authors performed a retrospective review of female patients who underwent immediate breast reconstruction with textured or smooth TEs from 2018 to 2020 at their institution. Rates of seroma, infection/cellulitis, malposition/rotation, exposure, and TE loss were analyzed in the overall cohort and subgroups undergoing prepectoral and subpectoral TE placement. A propensity score-matched analysis was used to decrease the effects of confounders comparing textured and smooth TEs.

RESULTS

The authors analyzed 3526 TEs (1456 textured and 2070 smooth). More frequent use of acellular dermal matrix, SPY angiography, and prepectoral TE placement was noted in the smooth TE cohort ( P < 0.001). Univariate analysis suggested higher rates of infection/cellulitis, malposition/rotation, and exposure in smooth TEs (all P < 0.01). Rates of TE loss did not differ. After propensity matching, no differences were noted in infection or TE loss. Prepectoral smooth expanders had increased rates of malposition/rotation.

CONCLUSIONS

TE surface type did not affect rates of TE loss, although increased rates of expander malposition were noted in the smooth prepectoral cohort. Further research is needed to examine breast implant-associated anaplastic large-cell lymphoma risk with temporary textured TE exposure to improve decision-making.

CLINICAL QUESTION/LEVEL OF EVIDENCW

Therapeutic, III.

Endoscopy-assisted latissimus dorsi muscle flap harvesting technique for immediate breast reconstruction

BACKGROUND

The purpose of this study is to investigate the usefulness of endoscopy-assisted latissimus dorsi muscle flap (LDMF) harvesting in immediate breast reconstruction following partial mastectomy.

MATERIALS AND METHODS

From November 2016 to December 2019, sixteen female breast cancer patients who underwent immediate breast reconstruction following partial mastectomy underwent LDMF harvesting with endoscopic assistance. This surgical technique was carried out with only one subaxillary skin incision without leaving a scar on the back. Patients' demographic characteristics, histopathologic factors, operative data, postoperative complications, and oncologic safety were collected through electronic chart review.

RESULTS

In sixteen patients, LDMFs were harvested successfully using an endoscopy-assisted technique without conversion to an open technique. The mean age of the patients was 48.0±8.0 years, and the mean body mass index was 24.4±3.9kg/m2. The most common histologic subtype was invasive ductal carcinoma, with a mean tumor size of 3.2±2.3cm. In terms of LDMF harvesting time, it took 168.4±44.0minutes. The most common postoperative complication, donor site seroma (75%), was managed non-surgically during the outpatient visit. In terms of cosmetic aspects, we've seen a high level of patient satisfaction, especially with scarring.

CONCLUSIONS

Endoscopy-assisted LDMF harvesting technique is safe and useful for breast reconstruction after partial mastectomy. Compared to the conventional open technique, this method does not leave a long scar on the donor site. As a result, it leads to better cosmetic outcomes and improves patient satisfaction.

A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels

Recipient vessel selection is vital for successful autologous free-flap breast reconstruction. Internal mammary artery perforators have gained interest as a recipient vessel option. However, previous studies on their microsurgical safety and efficacy are limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to assess the safety and effectiveness of using internal mammary artery perforators as recipient vessels in breast reconstruction.

Methods

The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies).

Results

Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%).

Conclusions

This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.

Breast Reconstruction with DIEP Flap: The Learning Curve at a Breast Reconstruction Center and a Single-Surgeon Study

Although microsurgical breast reconstruction represents a very interesting and rewarding field of plastic surgery, appropriate microsurgical training is not possible in every plastic surgery department. In this retrospective study, we present the learning curve of our plastic surgery department as a whole and of a single microsurgeon assessing breast reconstruction procedures with a deep inferior epigastric artery perforator (DIEP) flap between July 2018 and June 2021. The present study included 115 patients and 161 flaps. Cases were stratified into single DIEP/double DIEP groups and into early and late groups based on the flap order. Surgery times and postoperative complications were analyzed. Regarding the institution, the length of hospital stay was lower in the late group than in the early group (single 7.1 ± 1.8 vs. 6.3 ± 1.5 days, p = 0.019; double 8.5 ± 3.8 vs. 6.6 ± 1.4 days, p = 0.043). Apart from that, no statistically significant differences were found between the start and end of our study. In terms of the single surgeon, there was a significant improvement in the total surgery time (single 296.0 ± 78.7 vs. 227.5 ± 54.7 min, p = 0.018; double 448.0 ± 85.6 vs. 341.2 ± 43.1 min, p = 0.008), flap ischemia time (53.6 ± 15.1 vs. 40.9 ± 9.5 min, p = 0.007) and length of stay among the compared groups. There was no significant difference in flap loss rate or other complications between the early and late groups. Further performance of surgeries seemed to improve the surgeon's skills as well as the overall experience of the medical institution.

Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center

INTRODUCTION

Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race.

METHODS

Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race.

RESULTS

African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women.

CONCLUSIONS

We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.

Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction: A Randomized Clinical Trial

Importance

Multiple-dose antibiotic prophylaxis is widely used to prevent infection after implant-based breast reconstruction despite the lack of high-level evidence regarding its clinical benefit.

Objective

To determine whether multiple-dose antibiotic prophylaxis is superior to single-dose antibiotic prophylaxis in preventing surgical site infection (SSI) after implant-based breast reconstruction.

Design, Setting, and Participants

This prospective, multicenter, randomized clinical superiority trial was conducted at 7 hospitals (8 departments) in Sweden from April 25, 2013, to October 31, 2018. Eligible participants were women aged 18 years or older who were planned to undergo immediate or delayed implant-based breast reconstruction. Follow-up time was 12 months. Data analysis was performed from May to October 2021.

Interventions

Multiple-dose intravenous antibiotic prophylaxis extending over 24 hours following surgery, compared with single-dose intravenous antibiotic. The first-choice drug was cloxacillin (2 g per dose). Clindamycin was used (600 mg per dose) for patients with penicillin allergy.

Main Outcomes and Measures

The primary outcome was SSI leading to surgical removal of the implant within 6 months after surgery. Secondary outcomes were the rate of SSIs necessitating readmission and administration of intravenous antibiotics, and clinically suspected SSIs not necessitating readmission but oral antibiotics.

Results

A total of 711 women were assessed for eligibility, and 698 were randomized (345 to single-dose and 353 to multiple-dose antibiotics). The median (range) age was 47 (19-78) years for those in the multiple-dose group and 46 (25-76) years for those in the single-dose group. The median (range) body mass index was 23 (18-38) for the single-dose group and 23 (17-37) for the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of SSI. Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%), and 190 women (27.7%) received oral antibiotics because of clinically suspected SSI. There was no significant difference between the randomization groups for the primary outcome implant removal (odds ratio [OR], 1.26; 95% CI, 0.69-2.65; P = .53), or for the secondary outcomes readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65-2.15; P = .58) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51-1.02; P = .07). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05-2.55; P = .03).

Conclusions and Relevance

The findings of this randomized clinical trial suggest that multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing SSI and implant removal after implant-based breast reconstruction but comes with a higher risk of adverse events associated with antibiotic treatment.

Trial Registration

EudraCT 2012-004878-26.

Comparison of short-term outcomes between pedicled- and free-flap autologous breast reconstruction: a nationwide inpatient database study in Japan

BACKGROUND

Despite the increasing popularity of autologous breast reconstruction, limited evidence is available. The aim of the present study was to compare the short-term outcomes of pedicled- and free-flap breast reconstructions.

METHODS

Using a nationwide Japanese inpatient database, we identified 13,838 patients who underwent breast reconstruction for breast cancer (July 2010-March 2020) using a pedicled or free-flap (pedicled- and free-flap groups, n = 8279 and 5559, respectively). One-to-one propensity score matching was performed to compare the occurrence of postoperative complications, duration of anesthesia, length of stay, and total costs between the two groups. We also performed subgroup analyses stratified by hospital volume.

RESULTS

The propensity score-matched analysis involving 3524 pairs showed that the pedicled-flap group had significantly lower proportions of takeback (2.1% vs. 3.2%, p < 0.001), thrombosis (0.6% vs. 1.7%, p < 0.001), and postoperative bleeding (2.1% vs. 5.7%, p < 0.001) than the free-flap group. No significant differences were found in wound dehiscence or tissue necrosis. Compared to the free-flap group, the pedicled-flap group had a short duration of anesthesia (412 vs. 647 min, p < 0.001) and low total hospitalization costs (12 662 vs. 17 247 US dollars, p < 0.001) but a prolonged postoperative length of stay (13 vs. 12 days, p < 0.001). The subgroup analyses showed results compatible with those of the main analysis.

CONCLUSIONS

In this large nationwide cohort of patients who underwent breast reconstruction, pedicled-flap reconstruction was associated with fewer postoperative complications (excluding necrosis and wound dehiscence) and lower hospitalization costs but a longer postoperative length of stay than free-flap reconstruction.

Chest Feminization in Male-to-Female Transgender Patients: A Review of Options

Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.

Implant infections after breast reconstruction surgery following mastectomy: Experience from a Greek breast unit

BACKGROUND

Despite the dominance of implant-based breast reconstruction after mastectomy, during recent years, it has been correlated to some complications. The aim of this study is to present the Greek experience about management of implant infections after breast reconstructions and to investigate the relationship between possible risk factors and breast pocket fluid cultures.

METHODS

In total, 260 patients underwent implant-based breast reconstruction due to breast cancer in our center from 2016 until 2020. 46 patients, that underwent implant or expander replacement after breast reconstruction due to mastectomy were included in the present study.

RESULTS

260 patients underwent breast reconstruction in our center and in 46 (18%) of them an implant replacement was required. 21 patients (8%) presented clinically with an implant infection, but 12 of them (5%) had positive cultures from the breast pocket fluid. On the contrary, 25 patients (10%) presented no clinical signs of implant infection, but 5 of them (2%) had a positive culture. In addition, we demonstrated a correlation between implant infection and positive cultures (p = 0.009), along with an association between chemotherapy before implant placements and negative cultures (p = 0.035). Finally, the most common pathogen was Staphylococcus epidermidis (29%), followed by Escherichia coli (24%) and Staphylococcus aureus (18%).

CONCLUSION

Implant infection still remains a very serious complication after breast reconstruction surgery. The establishment of a therapeutic protocol, with specific antimicrobial and surgical targets seems as an effective strategy against implant infections.

Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program

INTRODUCTION

Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay.

RESULTS

The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21).

CONCLUSIONS

Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.

Smoking as a Risk Factor for Surgical Site Complications in Implant-Based Breast Surgery

Background Smoking is a cause of many postoperative complications, including delayed wound healing, tissue necrosis, and reconstructive flap loss. However, there is a paucity of evidence-based guidelines for smoking cessation in patients undergoing implant-based breast surgery. Objective The objective of this study was to determine if smoking is associated with wound dehiscence or superficial/deep surgical site infection (SSI) in women undergoing implant-based breast surgery. Methods Using theAmerican College of Surgeons National Surgical Quality Improvement Program, data was obtained of U.S. adult females (n=10,077) between the ages of 18 and 70 who underwent insertion of a breast prosthesis from 2014 to 2016. The patient's preoperative smoking status, demographics, and comorbidities were analyzed to determine association with wound dehiscence, superficial SSI, and deep SSI. Unadjusted and adjusted logistic regression analyses were used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). Results Patients who smoked had a statistically significant higher proportion of wound complications (2.4%) compared to non-smokers (1.3%; p<0.01). Adjusted analysis demonstrated a significantly higher odds of wound complications in smoking patients compared to those who did not smoke (OR 2.0; 95% CI 1.3-3.2). Conclusions Our study suggests that smoking is an independent risk factor for postoperative complications in patients undergoing implant-based breast surgery. These results have significant clinical implications, as increased precautions can be taken in smokers undergoing breast surgery to minimize postoperative wound complications. Future studies may determine the optimal amount of time that patients should abstain from smoking prior to implant-based breast surgery.

Broad-Spectrum Antibiotics for Breast Expander/Implant Infection: Treatment-Related Adverse Events and Outcomes

BACKGROUND

Despite best practices, infection remains the most common complication after breast reconstruction with expanders and implants, ranging from 2% to 29%. Empiric broad-spectrum antibiotics are frequently used in nonsurgical treatment of implant-associated infections in an effort to salvage the reconstruction. Pitfalls of antibiotherapy include adverse events, vascular access site complications, and drug resistance. Our goals were to describe management of implant infections with broad-spectrum antibiotics, review treatment related adverse events, and report on outcomes of therapy.

PATIENTS AND METHODS

A retrospective review was carried out to identify patients who were treated with intravenous (IV) antibiotics for periprosthetic infection. Patient characteristics, surgical details, and antibiotic therapy-related adverse events were collected. Eventual outcome related to expander/implant salvage was noted.

RESULTS

A total of 101 patients (111 treatment episodes) were identified. Mean duration of antibiotic treatment was 18 days (range, 1-40 days). The most commonly used parenteral treatment was a combination of daptomycin with piperacillin-tazobactam (65%) or an alternative agent (16%). Fifty-nine percent of treatment episodes resulted in salvage of the expander or implant. Thirty-five percent treatment episodes were associated with 1 or more adverse events: diarrhea (12.6%), rash (10%), vaginal candidiasis (3.6%), agranulocytosis/neutropenic fever (3.6%), nausea (3.6%), urinary complaint (0.9%), myositis (0.9%), headache (0.9%), vascular line occlusion (1.8%), deep vein thrombosis (1.8%), and finger numbness (0.9%). No patients developed Clostridium difficile colitis. Five episodes (4%) needed discontinuation of antibiotics because of severe adverse events. The prosthesis was explanted in 3 of the cases of discontinued treatment.

CONCLUSIONS

Our findings show favorable outcomes and well-tolerated adverse effects with broad-spectrum parenteral antibiotherapy for periprosthetic infection. However, every effort should be made to deescalate therapy by narrowing the spectrum or limiting the duration, to minimize adverse events and development of bacterial resistance. Treating surgeons need to carefully weigh benefits of therapy and be aware of potential complications that might necessitate discontinuation of treatment.

Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery

BACKGROUND

Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS.

MATERIALS AND METHODS

Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss.

RESULTS

956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567).

CONCLUSION

In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Optimal reconstructive strategies in the setting of post-mastectomy radiotherapy - A systematic review and network meta-analysis

BACKGROUND

A third of breast cancer patients require mastectomy. In some high-risk cases postmastectomy radiotherapy (PMRT) is indicated, threatening reconstructive complications. Several PMRT and reconstruction combinations are used. Autologous flap (AF) reconstruction may be immediate (AF→PMRT), delayed-immediate with tissue expander (TE [TE→PMRT→AF]) or delayed (PMRT→AF). Implant-based breast reconstruction (IBBR) includes immediate TE followed by PMRT and conversion to permanent implant (PI [TE→PMRT→PI]), delayed TE insertion (PMRT→TE→PI), and prosthetic implant conversion prior to PMRT (TE→PI→PMRT).

AIM

Perform a network metanalysis (NMA) assessing optimal sequencing of PMRT and reconstructive type.

METHODS

A systematic review and NMA was performed according to PRISMA-NMA guidelines. NMA was conducted using R packages netmeta and Shiny.

RESULTS

16 studies from 4182 identified, involving 2322 reconstructions over three decades, met predefined inclusion criteria. Studies demonstrated moderate heterogeneity. Multiple comparisons combining direct and indirect evidence established AF-PMRT as the optimal approach to avoid reconstructive failure, compared with IBBR strategies (versus PMRT→TE→PI; OR [odds ratio] 0.10, CrI [95% credible interval] 0.02 to 0.55; versus TE→PMRT→PI; OR 0.13, CrI 0.02 to 0.75; versus TE→PI→PMRT OR 0.24, CrI 0.05 to 1.05). PMRT→AF best avoided infection, demonstrating significant improvement versus PMRT→TE→PI alone (OR 0.12, CrI 0.02 to 0.88). Subgroup analysis of IBBR found TE→PI→PMRT reduced failure rates (OR 0.35, CrI 0.15-0.81) compared to other IBBR strategies but increased capsular contracture.

CONCLUSION

Immediate AF reconstruction is associated with reduced failure in the setting of PMRT. However, optimal reconstructive strategy depends on patient, surgeon and institutional factors. If IBBR is chosen, complication rates decrease if performed prior to PMRT.

PROSPERO REGISTRATION

CRD 42020157077.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A comparison of perioperative safety for breast augmentation in cis- vs. trans patients

Background

Gender-affirming surgery provides a psychosocial benefit to transgender women. However, increased medical complexity within the transgender population has limited access for some transgender women. This study compared patient population comorbidities and 30-day peri-operative safety following primary augmentation mammoplasty between cis- and transgender women.

Methods

Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database between 2007 and 2016. Transgender patients were identified using ICD-9 &10 codes for gender dysphoria. Categorical variables were compared using chi-squared and Fisher's exact tests while independent t-tests were used for continuous variables. Statistical significance was set at P<0.05.

Results

There were 4,234 breast augmentations identified in cisgender women and 137 in transgender women. Transgender women had a higher frequency of ASA-II and ASA-III patients (P<0.001), diabetes (P<0.001), hypertension (P=0.006), and active smoking status (P<0.001). Despite the higher comorbidity burden and routine use of hormonal therapy, there were no significant differences between populations in major or minor peri-operative complication rates.

Conclusions

Top surgery improves quality of life in transgender women. Despite the more complex pre-operative risk profile in the transgender population, there is no difference in peri-operative safety profiles. Plastic surgeons treating this patient population should consider more liberal surgical indications for reconstructive top surgery compared with cosmetic breast augmentation.

Study of Inflammatory and Infection Markers in Periprosthetic Fluid: Correlation with Blood Analysis in Retrospective and Prospective Studies

BACKGROUND

Surgical site infection represents the most severe complication in prosthetic breast reconstruction. Risk profiling represents a useful tool for both clinicians and patients.

MATERIALS AND METHODS

In our hospital, 534 breast reconstructions with tissue expander implants, in 500 patients, were performed. Several clinical variables were collected. In our study, we evaluated the different inflammatory markers present in the periprosthetic fluid and we compared them with the ones present in plasma.

RESULTS

The surgical site infection rate resulted to be 10.5%, and reconstruction failed in 4.5% of the cases. The hazard ratio for complications was 2.3 in women over 60 (CI: 1.3-4.07; p = 0.004), 2.57 in patients with expander volume ≥ 500 cc (CI: 1.51-4.38; p < 0.001), 2.14 in patients submitted to previous radiotherapy (CI: 1.05-4.36; p < 0.037), and 1.05 in prolonged drain use (CI: 1.03-1.07; p < 0.001). 25-OH, PCT, and total protein were less concentrated, and ferritin and LDH were more concentrated in the periprosthetic fluid than in plasma (p < 0.001). CRP (p = 0.190) and β-2 microglobulin (p = 0.344) did not change in the two fluids analyzed. PCT initial value is higher in patients who underwent radiotherapy, and it could be related to the higher rate of their postoperative complications. Patients with a tissue expander with a volume ≥ 500 cc show an increasing trend for CRP in time (p = 0.009).

CONCLUSIONS

Several risk factors (prolonged time of drains, age older than 60 years, and radiotherapy) have been confirmed by our study. The study of markers in the periprosthetic fluid with respect to their study in plasma could point toward earlier infection detection and support early management.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Early postoperative outcomes in implant, pedicled, and free flap reconstruction for breast cancer: an analysis of 23,834 patients from the ACS-NSQIP datasets

INTRODUCTION

Many patients seek breast reconstruction following mastectomy. Debate exists regarding the best reconstructive option. The authors evaluate outcomes comparing implant, free flap, and pedicled flap reconstruction.

METHODS

Patients undergoing implant, pedicled flap, and free flap reconstruction were identified in the 2011-2016 NSQIP database. Demographics were analyzed and covariates were balanced using overlap propensity score. Logistic regression was used for binary outcomes and Gamma GLM for length of stay (LOS).

RESULTS

Of 23,834 patients, 87.7% underwent implant, 8.1% free flap, and 4.2% pedicled flap reconstruction. The implant group had the lowest mean operative time (206 min, SD 85.6). Implant patients had less pneumonia (OR 0.09, CI 0.02-0.36, p < 0.01), return to operating room (OR 0.62, CI 0.50-0.75, p < 0.01), venous thromboembolism (VTE) (OR 0.33, CI 0.14-0.79, p = 0.01), postoperative bleeding (OR 0.10, CI 0.06-0.15, p < 0.01), and urinary tract infections (UTI) (OR 0.21, CI 0.07-0.58, p < 0.01) than free flap patients. Pedicled flap patients had less postoperative bleeding (OR 0.69, CI 0.49-0.96, p = 0.03) than free flap patients. Pedicled flap patients had more superficial surgical site infections (p = 0.03), pneumonia (p = 0.02), postoperative bleeding (p < 0.01), VTE (p = 0.04), sepsis (p = 0.05), and unplanned reintubation (p = 0.01) than implant patients. Implant patients had the lowest LOS (1.6 days, p < 0.01).

CONCLUSION

Implant reconstruction has less short-term postoperative complications than free flaps and pedicled flap reconstructions. The overall complication rate among all reconstructive modalities remains acceptably low and patients should be informed of all surgical options.

Long-term outcomes of latissimus dorsi flap breast reconstructions: A single-centre observational cohort study with up to 12 years of follow up

INTRODUCTION

The Latissimus Dorsi Myocutaneous Flap (LDMF) is used in post-mastectomy reconstruction. This study has evaluated long-term (up to 12 years) surgical- and patient-reported outcomes from LDMF procedures.

METHOD

A retrospective analysis of consecutive LDMF procedures in two UK hospitals, performed between 2006 and 2016. Case notes were reviewed for indications and outcomes. Patients were sent the BREAST-Q^Ⓡ survey by post. Outcomes, including surgical adverse events, revision, and implant loss rates, were correlated with patient risk factors.

RESULTS

A BREAST-Q was posted to 199/248 LDMF patients in 2018, (excluding 49 patients due to death, reduced cognitive function and incorrect coding) of whom 77 patients responded (38.7%). In 188 cases (representing 208 LDMFs), surgical outcomes were assessable. Median time since LDMF surgery was 7 years (range 2-12). Rates of acute implant loss were 9/139 (6.4%), flap necrosis 7/208 (3.4%), shoulder stiffness 4/208 (1.9%), chronic pain 24/208 (11.5%) and unplanned revision surgery 13/208 (7%). Median satisfaction levels were high with 78% of patients satisfied with treatment outcomes, 65% of patients satisfied with their breasts, 71% of patients satisfied psychosocially and 75% of patients satisfied with their chest. Receipt of radiotherapy was not associated with a higher risk of flap necrosis or capsule formation.

CONCLUSION

Long-term follow-up of a large cohort of LDMF reconstruction patients show relatively low levels of adverse events and unplanned revision surgery and high patient satisfaction, which demonstrates how temporally robust the technique is. With the rise in popularity of acellular dermal matrix reconstructions, the LDMF has relatively fallen out of favour but its potential in primary and delayed reconstruction is demonstrated.

Early Expander-to-Implant Exchange after Postmastectomy Reconstruction Reduces Rates of Subsequent Major Infectious Complications

Major infectious complications after implant-based postmastectomy reconstruction commonly occur late (>30 days postoperative). We set out to determine if early expander-to-implant exchange (3-6 weeks after tissue expander placement) reduced rates of subsequent major infectious complications.

METHODS

We retrospectively examined patients after mastectomy and tissue expander reconstruction followed by early expander-to-implant exchange versus exchange at least 6 months after initial tissue expander placement (the control group). Multivariate logistic regression analysis was performed to determine whether the timing of implant exchange independently predicted major infectious complications occurring more than 30 days after initial tissue expander placement after adjusting for differences in patient variables between groups.

RESULTS

In total, 252 consecutive patients (430 breasts) between August 2014 and October 2019 were included. While the rates of major early infectious complications after mastectomy and tissue expander placement were similar between the groups, the control group had more subsequent major infectious complications during the reconstructive process [9.8% (n = 22) versus 1.9% (n = 4), P < 0.001].

CONCLUSIONS

Early implant exchange results in a reduced subsequent rate of major infectious complications. This protocol reduces the window of time for late infectious complications to develop by proceeding with exchange within 6 weeks of tissue expander placement instead of the standard 6 months, which is common practice. We hypothesize that early exchange allows for washout of the mastectomy cavity, eliminating indolent bacterial contamination that could have subsequently manifested as a late infection. This protocol also obviates the need to operate on patients that undergo post-mastectomy radiotherapy, which also reduces reconstructive failure rates.

Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction

BACKGROUND

Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps.

METHODS

This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed.

RESULTS

Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants.

CONCLUSIONS

Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.

Negative-pressure wound therapy - does it lower the risk of complications with closed wounds following breast surgery?

Introduction: Breast surgery complications are important not only due to their morbidity and psychological impact, but also the delays that can occur for adjuvant treatment or the loss of implants in severe cases. There is growing evidence that negative pressure dressing on closed wounds can reduce the complications following surgery. Methods: This study aimed to assess whether negative-pressure dressings reduced complications in patients undergoing bilateral reduction mammoplasty with randomization of a side to negative pressure and standard care, fixation strips, on the contralateral side. This allowed patients to act as their own controls. Results: This study found a significant reduction in the rate of wound complications but used a wide definition for what constituted a wound complication. Discussion: This finding is mirrored in existing work with studies showing that negative-pressure therapy is a cost-effective intervention. Further work is required to validate this finding and targeting those at highest risk may be preferential.

Impact of overweight/obesity on the development of hematoma following tissue expander-based breast reconstruction

BACKGROUND

Overweight and obesity are well-known risk factors for postoperative complications; however, their impacts on hematoma formation have not been clarified. Several studies have suggested that overweight/obesity could have procoagulative effects, potentially reducing a risk for developing postoperative bleeding complications. This study aimed to investigate the effects of overweight/obesity on hematoma formation following tissue expander-based breast reconstruction.

METHOD

Patients who underwent immediate tissue expander-based unilateral breast reconstruction between January 2010 and November 2018 were reviewed. They were categorized into four groups according to body mass index (BMI): underweight (<18.5 kg/m2), normal weight (18.5-25.0 kg/m2), overweight (25.0-30.0 kg/m2), and obesity (>30.0 kg/m2). The outcome was major postoperative hematoma, defined as one requiring emergent surgical intervention. Independent impacts of variables on hematoma development were evaluated via uni- and multivariable analyses.

RESULTS

A total of 1,431 patients were analyzed, including 133 cases (9.3%) with underweight, 952 (66.5%) with normal weight, 302 (21.1%) with overweight, and 44 (3.1%) with obesity. Postoperative major hematoma developed in 29 cases (2.0%). The rate of hematoma formation was 2.3%, 2.6%, 0.3%, and 0% in the underweight, normal weight, overweight, and obesity groups, respectively, showing a significantly decreasing trend (p = 0.009), while those of other complications including seroma and mastectomy flap necrosis revealed the opposite trends, being significantly elevated as patient BMI increased. Multivariate analyses found overweight to be an independent protector against major hematoma compared with normal weight (p = 0.014; odds ratio=0.071).

CONCLUSION

Overweight/obesity might have a protective effect on development of major bleeding complications following tissue expander-based breast reconstruction.

Single-port laparoscopically harvested omental flap for immediate breast reconstruction

PURPOSE

Immediate breast reconstruction using laparoscopically harvested omental flap is a safe and feasible technique, providing natural contour and softness to reconstructed breasts with reduced donor-site morbidity and deformity. We report our experience using single-port laparoscopically harvested omental flap (SLOF) for immediate breast reconstruction.

METHODS

Between February 2015 and December 2018, 129 patients with malignant neoplasm of the breast underwent nipple-sparing mastectomy (NSM) or breast-conserving surgery (BCS) followed by immediate SLOF reconstruction at Seoul National University Bundang Hospital. We assessed their clinicopathological data, complications, and cosmetic and oncologic outcomes. Cosmetic outcomes were evaluated by three-panel assessment and the BCCT.core software program.

RESULTS

One hundred and six (82.2%) underwent NSM and 23 (17.8%) underwent BCS. Mean operation time was 205 (range, 134-316) minutes. Most patients had early-stage disease; 15 (11.6%) received neoadjuvant chemotherapy. Two had malignant phyllodes tumors. Cosmetic outcomes were excellent or good in 96.9% by three-panel assessment and 99.2% by the BCCT.core program with a nearly invisible donor-site scar in the umbilicus. Harvest-associated complications occurred in five (3.9%) patients, including two umbilical wound infections, one intra-abdominal infection, one umbilical hernia, and one pedicle injury. Fat necrosis (13.2%) and epigastric bulging (21.7%) were common mastectomy- or reconstruction-associated complications, but most were mild and some resolved spontaneously. Over a median 38-month follow-up, there were three local, two regional, and three systemic recurrences.

CONCLUSIONS

SLOF reconstruction is a feasible and safe option for immediate breast reconstruction after NSM or extensive BCS with minimal donor-site morbidity and great cosmetic outcomes.

High-Efficiency Same-Day Approach to Breast Reconstruction During the COVID-19 Crisis

PURPOSE

As our hospitals conserve and re-allocate resources during the COVID-19 crisis, there is urgent need to determine how best to continue caring for breast cancer patients. During the time window before the COVID-19 critical peak and particularly thereafter, as hospitals are able to resume cancer operations, we anticipate that there will be great need to maximize efficiency to treat breast cancer. The goal of this study is to present a same-day protocol that minimizes resource utilization to enable hospitals to increase inpatient capacity, while providing care for breast cancer patients undergoing mastectomy and immediate breast reconstruction during the COVID-19 crisis.

METHODS

IRB exempt patient quality improvement initiative was conducted to detail the operationalization of a novel same-day breast reconstruction protocol. Consecutive patients having undergone immediate breast reconstruction were prospectively enrolled between February and March of 2020 at Massachusetts General Hospital during the COVID-19 crisis. Peri-operative results and postoperative complications were summarized.

RESULTS

Time interval from surgical closure to patient discharge was 5.02 ± 1.29 h. All patients were discharged home, with no re-admissions or emergency department visits. No postoperative complications were observed.

CONCLUSION

This report provides an instruction manual to operationalize a same-day breast reconstruction protocol, to meet demands of providing appropriate cancer treatment during times of unprecedented resource limitations. Pre-pectoral implant-based breast reconstruction can be the definitive procedure or be used as a bridge to autologous reconstruction. Importantly, we hope this work will be helpful to our patients and community as we emerge from the COVID-19 pandemic.

The effect of operative time on complication profile and length of hospital stay in autologous and implant-based breast reconstruction patients: An analysis of the 2007-2012 ACS-NSQIP database

BACKGROUND

It is a generally accepted relationship that an increase in operative time results in an increase in postoperative morbidity. However, few studies have investigated the minute by minute effect of increased operation time on outcomes in reconstructive breast surgery. The authors examined the association between operation time and postoperative outcomes for autologous and implant-based breast reconstructions.

METHODS

Data used in these analyses were extracted from all plastic surgery procedures identified in the 2007-2012 ACS-NSQIP datasets. Logistic regression models were used to examine associations between operation time and adverse outcomes. Generalized linear models using a Poisson distribution and a logarithmic link function were used to examine the association between the two continuous variables of operating time and the length of hospital admission.

RESULTS

The results drawn from the database show a statistically significant association between operating length for autologous breast reconstructions and both surgical and medical complications. The OR of 1.0018 and 1.0015 for surgical and medical complications, respectively, reflects a minute by minute increase. For implant-based reconstructions, a similar association was seen with surgical complications with an OR of 1.004. Across both subgroups of breast reconstruction, there was a significant association between an increase in OR time and the length of hospital stay.

CONCLUSION

We have shown a linear relationship that conveys a minute by minute increase in the complication profile and the chance of a longer hospital stay for breast reconstruction patients with regard to operative time.

Elective Revisions after Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium

BACKGROUND

Rates of breast reconstruction following mastectomy continue to increase. The objective of this study was to determine the frequency of elective revision surgery and the number of procedures required to achieve a stable breast reconstruction 2 years after mastectomy.

METHODS

Women undergoing first-time breast reconstruction after mastectomy were enrolled and followed for 2 years, with completion of reconstruction occurring in 1996. Patients were classified based on the absence or presence of complications. Comparisons within cohorts were performed to determine factors associated with revisions and total procedures. Mixed-effects regression modeling identified factors associated with elective revisions and total operations.

RESULTS

Overall, 1534 patients (76.9 percent) had no complications, among whom 40.2 percent underwent elective revisions. The average number of elective revisions differed by modality (p < 0.001), with abdominally based free autologous reconstruction patients undergoing the greatest number of elective revisions (mean, 0.7). The mean total number of procedures also differed (p < 0.001), with tissue expander/implant reconstruction patients undergoing the greatest total number of procedures (mean, 2.4). Complications occurred in 462 patients (23.1 percent), with 67.1 percent of these patients undergoing elective revisions, which was significantly higher than among patients without complications (p < 0.001). The mean number of procedures again differed by modality (p < 0.001) and followed similar trends, but with an increased mean number of revisions and procedures overall. Mixed-effects regression modeling demonstrated that patients experiencing complications had increased odds of undergoing elective revision procedures (OR, 3.2; p < 0.001).

CONCLUSIONS

Breast reconstruction patients without complications undergo over two procedures on average to achieve satisfactory reconstruction, with 40 percent electing revisions. If a complication occurs, the number of procedures increases.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

BACKGROUND

There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors.

METHODS

A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation.

RESULTS

We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood.

CONCLUSIONS

The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

Effect of Pretreatment of S-Ketamine On Postoperative Depression for Breast Cancer Patients

OBJECTIVE

This study aims to investigate the effect of the pretreatment of S-ketamine on postoperative depression (POD) for breast cancer patients with mild/moderate depression.

METHODS

The present randomized, double-blinded controlled trial included 303 breast cancer patients with mild/moderate depression from June 2017 to June 2018. All patients were randomly divided into three groups: (1) control group, patients treated with normal saline; (2) racemic ketamine group, patients treated with racemic ketamine; (3) S-ketamine group, patients treated with S-ketamine. Operation time, blood loss and hospital stay and complications were recorded. The Visual Analog Scale (VAS) score was recorded, and the Hamilton Rating Scale for Depression (HAMD-17) scores, serum brain-derived neurotrophic factor (BDNF) and 5-hydroxytryptamine (5-HT) were measured at three days, one week, one month and three months after surgery.

RESULTS

No significant difference was found in operation time, bleeding volume and complication rate. In both groups, the VAS scores at one day and three days after surgery were significantly lower. The HAMD-17 scores were significantly lower, and the serum levels of both BDNF and 5-HT were remarkably higher at three days, one week and one month after surgery. Meanwhile, the HAMD-17 scores were remarkably lower, while the serum levels of BDNF and 5-HT were remarkably higher in the S-ketamine group. The BDNF and 5-HT levels were negatively correlated with the HAMD-17 score.

CONCLUSION

S-ketamine is more effective for reducing POD for breast cancer patients.

Safety and Efficacy of Smooth Surface Tissue Expander Breast Reconstruction

BACKGROUND

Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation.

OBJECTIVES

The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction.

METHODS

The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated.

RESULTS

A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction.

CONCLUSIONS

STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.

LEVEL OF EVIDENCE: 4

Breast reconstruction patterns and outcomes in academic and community practices within a single institution

Breast reconstruction is a common procedure that is performed in both community and academic settings. At Yale-New Haven Hospital (YNHH), both academic (AP) and community-based (CP) plastic surgeons perform breast reconstructions. We aim to compare practice patterns in breast reconstruction between two practice environments within a single institution. A retrospective chart review of all breast reconstructions at YNHH between 2013 and 2018 was performed. Data collected included demographics, preoperative history, and postoperative outcomes. Results were further subdivided by practice setting. A total of 1045 patients (1683 breasts) underwent breast reconstruction during the study period. About 52.8% were performed by AP while 47.2% were performed by CP. CP had higher rates of autologous reconstruction (P < .001) and nipple-sparing mastectomy (P < .0001). Age and BMI were similar between the cohorts. However, patients cared for by AP had 2.6% increased prevalence of diabetes (P = .064), 5.5% greater prevalence of psychiatric diagnoses (P = .004), and 7.1% higher open abdominal surgery rates (P < .001). Outcomes were similar between the groups except for higher infection rates (P = .027) and explant rates (P = .003) in the CP cohort. When evaluating insurance status, the AP cohort had 30.5% fewer patients with commercial insurance, 16.7% more patients with Medicaid and 6.1% more patients with Medicare (P < .001). Within our institution, academic and community-based plastic surgeons perform breast reconstruction with overall similar complication rates. Patients treated by AP have a higher rate of preoperative medical and psychiatric comorbidities. Patients treated by CP have higher rates of infection and implant explant. AP plastic surgeons care for a significantly higher rate of Medicare and Medicaid patients with proportionally fewer patients with commercial insurance.

Deepithelialized Skin Reduction Preserves Skin and Nipple Perfusion in Immediate Reconstruction of Large and Ptotic Breasts

BACKGROUND

Women with large and/or ptotic breasts are often not considered candidates for nipple-sparing mastectomy (NSM) and/or immediate breast reconstruction given difficulties avoiding ischemic complications and achieving a favorable aesthetic result. We report a novel technique involving deepithelialized skin reduction to simultaneously reduce the skin envelope and preserve perfusion to the skin and nipple in immediate breast reconstruction for women that fit this high-risk anatomic profile.

METHODS

We reviewed cases of NSM and skin-sparing mastectomy (SSM) with immediate implant-based and free autologous reconstruction by a single plastic surgeon from 2013 to 2017. All patients had at least size C cup breasts (>500 g) and/or grade 3 ptosis. Select patients undergoing NSM had devascularization of the nipple-areolar complex (NAC) 1 to 2 months before surgery to promote adaptive circulatory change. After mastectomy, skin reductions were performed via Wise, periareolar, or circumareolar reduction patterns, with infolding of a deepithelialized inferior and periareolar skin flap over a tissue expander or free flap. In NSM, the nipple was advanced superiorly and redirected through a keyhole of deepithelialized skin flap.

RESULTS

Patients had an average age of 43.6 years and body mass index of 27.7. A total of 33 breasts in 19 patients (14 bilateral, 5 unilateral) underwent deepithelialized skin reduction. There were 14 NSM and 19 SSM. Reconstructions consisted of 13 tissue expanders exchanged to implants and 20 abdominally-based free flaps. Four patients underwent devascularization of the NAC before NSM. Six (18%) breasts had partial thickness flap loss that healed by delayed primary (n = 1) or secondary (n = 5) intention. Four nipples, all in patients without prior NAC devascularization, had ischemic complications (2 epidermolysis, 12.5%; 2 partial necrosis, 12.5%), which all healed by secondary intention with the exception of 1 case of NAC removal.

CONCLUSIONS

Skin reduction with deepithelialization and tissue infolding preserves dermal plexus perfusion and promotes nipple and skin flap survival in immediate implant-based and autologous breast reconstruction after SSM and NSM. This technique can be combined with NAC devascularization to further promote nipple perfusion. Overall, this method offers an acceptable complication rate and the potential to expand the reconstructive options available to women with large and/or ptotic breasts.

Are 30-Day Outcomes Enough? Late Infectious Readmissions following Prosthetic-Based Breast Reconstruction

BACKGROUND

Surgical-site infection is a major concern in prosthetic-based breast reconstruction. Thirty-day postoperative readmission rates are a common quality metric, but little is known about readmission rates for later infections.

METHODS

Using the 2013 to 2014 Nationwide Readmissions Database, the authors identified breast cancer patients undergoing breast reconstruction with implants and tissue expanders who had an infectious readmission. The authors used univariate and multivariate logistic regression models to identify predictors of infectious readmission and explantation within the early (0 to 30 days) and late (31 to 90 days) postoperative periods.

RESULTS

In the weighted sample, the authors identified 18,338 patients undergoing prosthetic-based breast reconstruction. The overall infectious readmission rate was 4.1 percent (n = 759): 49.3 percent occurred early and 50.7 percent occurred late. Of the infectious readmissions, 39.5 percent required explantation, 55.1 percent of which occurred during a late infectious readmission. Seventy-five percent of these infectious readmissions and explantations occurred within 49 days of initial surgery. Median annual household income less than $40,000 (p = 0.035), diabetes (p = 0.038), and obesity (p = 0.004) were independent predictors of infectious readmission. Diabetes (p = 0.049) and hypertension (p = 0.011) were independent predictors of early readmission. Median annual household income less than $40,000 (p = 0.049), obesity (p = 0.006), and increasing length of stay during the index procedure (p = 0.028) were independent predictors of late readmission. No statistically significant independent predictors for explantation were identified.

CONCLUSIONS

Traditional 30-day readmission rates are not an adequate quality metric for breast reconstruction given the number of late postoperative readmissions, many of which lead to explantation. Early and late infectious readmissions have different predictors. Interventions targeting these predictors may decrease the number of readmissions, thus reducing cost and improving quality.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Influence of Surgical Specialty on Oncoplastic Breast Reconstruction

BACKGROUND

The integration of oncological surgery with reconstructive techniques has gained popularity in the treatment of breast cancer. oncoplastic reconstruction after partial mastectomy can be performed by the breast surgeon or in cooperation with a consulted plastic surgeon. This study aims to objectively assess the differences in outcomes for partial mastectomy and subsequent oncoplastic reconstruction performed by either general surgery alone or in combination with a plastic and reconstructive surgery team.

METHODS

Unilateral oncoplastic breast reconstruction cases were extracted from the National Surgical Quality Improvement Program databases from 2005 to 2017. Outcomes of cases performed by the general surgery team alone were compared with those in which the partial mastectomy was performed by the general surgeon with subsequent reconstruction performed by plastic surgeons. To account for cohort baseline differences, propensity score-matched analysis was performed.

RESULTS

In total, 4,350 patients were included in this study; 3,759 procedures were performed by general surgery alone versus 591 combined with plastic surgery. The analysis of propensity score-matched cohorts, comprising 490 patients each, showed no statistical difference in the risk for postoperative complications when surgery was performed by either of the 2 specialty services. A longer operative time and length of stay were found in the group reconstructed by plastic surgeons.

CONCLUSIONS

This study found no significant differences in adverse postoperative outcomes for oncoplastic reconstructions after partial mastectomy between the 2 groups. The data may indicate collaboration between both surgical specialties in oncoplastic breast care was not associated with increased morbidity in these patients.