COVID-associated complications after reconstructive breast surgery: a retrospective cohort study

PURPOSE

The COVID pandemic significantly influenced reconstructive breast surgery regimens. Many surgeries were cancelled or postponed. COVID entails not only respiratory, but also coagulative symptoms. It, therefore, potentially increases the risk of postoperative complications. The incidence of perioperative COVID infection and its influence on postoperative recovery after reconstructive breast surgery is still unknown.

METHODS

This dual center retrospective cohort study included patients that underwent reconstructive breast surgery between March 2020 and July 2021. Post-mastectomy autologous or implant-based breast reconstruction (ABR; IBR), as well as post-lumpectomy oncoplastic partial breast reconstruction (PBR) were eligible. Patient data were extracted from electronic medical records. Data regarding COVID-19 infection was collected through a questionnaire. The primary outcome was complication rate.

RESULTS

The ABR, IBR and PBR groups consisted of 113 (12 COVID-positive), 41 (2 COVID-positive) and 113 (10 COVID-positive) patients. In the ABR and PBR groups, postoperative complications occurred significantly more often in patients with perioperative COVID-infection. Especially impaired wound healing occurred significantly more often in the ABR and PBR breasts, but also at the donor site of ABR patients with perioperative COVID.

CONCLUSION

Perioperative COVID-infection increases susceptibility to complicated wound healing after reconstructive breast surgery. A possible explanation lies in the dysregulation of haemostasis by the virus, and its direct effects on microvasculature. A hypercoagulable state results. We recommend to postpone elective breast surgery for 4-6 weeks after COVID-19 infection. Also, precautionary measures remain important to minimize the risk of perioperative COVID-19 infection.

The impact of using the internal mammary artery as a recipient vessel on medial mastectomy skin flap perfusion in autologous breast reconstruction: An observational study using indocyanine green

BACKGROUND

The internal mammary artery (IMA) is the preferred recipient vessel for microvascular anastomosis in immediate autologous breast reconstruction following skin-sparing mastectomy (SSM). Although the IMA accounts for approximately 60% of the blood supply to the breast, the exact contribution to the mastectomy skin flap perfusion is unclear. The aim of this observational study was to investigate the impact of using the IMA as a recipient vessel on medial mastectomy skin flap perfusion assessed with indocyanine green angiography (ICGA).

METHODS

This observational study included ten consecutive women who underwent immediate autologous breast reconstructions following SSM. Two intraoperative indocyanine green (ICG) assessments were performed to assess tissue perfusion of the upper and lower part of the medial mastectomy skin flap: the first following the SSM and the second after clamping the IMA. During a 120-second angiography, three additional images were made after 60, 90, and 120 s. The ICG inflow time and mean, minimum, and maximum fluorescence intensities (FIs) were obtained.

RESULTS

Four unilateral and six bilateral autologous breast reconstructions were included. There was no difference in tissue perfusion when comparing the inflow time (24.1 s vs. 23.0 s, P = 0.348), the mean FI (131.4 vs. 124.0, P = 0.126), minimum FI (28.6 vs. 33.4, P = 0.086), and maximum FI (253.1 vs. 247.6, P = 0.166) before and after clamping the IMA.

CONCLUSION

According to this study, the use of the IMA as a recipient vessel does not reduce medial mastectomy skin flap perfusion in patients undergoing immediate autologous breast reconstructions following SSM.

Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions

Purpose

As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions.

Methods

For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded.

Results

A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59–5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14–11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27–3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052).

Conclusions

This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4695-0) contains supplementary material, which is available to authorized users.

Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: A multicentre study

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is the first choice for autologous breast reconstruction. The aim of this retrospective cohort study was to analyse the recipient- and donor-site complications and compare them between unilateral and bilateral DIEP flap breast reconstructions.

METHODS

Between January 2010 and December 2014, 530 DIEP flap reconstructions were performed in 426 consecutive patients in three Dutch hospitals. Major and minor complications were categorised into recipient- and donor-site complications. Post-operative flap re-explorations were recorded.

RESULTS

Of the total 530 DIEP flap reconstructions performed (322 unilateral, 104 bilateral), recipient-site complications were major in 9.8% and minor in 20.2%. The patients developed fat necrosis (unilateral 14.0% vs. bilateral 7.7%; OR 1.950; 95% CI 1.071-3.550; p = 0.027) and infection (unilateral 5.6% vs. bilateral 1.9%; OR 3.020; 95% CI 1.007-9.052; p = 0.039) at the recipient site significantly more frequently in the unilateral DIEP flap reconstructions. The donor-site complications were major in 0.9% and minor in 19.5% of the cases. Body mass index (BMI) was significantly associated with complications (donor site: OR 1.137; 95% CI 1.075-1.201; p < 0.001, recipient site: OR 1.073; 95% CI 1.009-1.142; p = 0.026). Flap re-explorations were performed in 5.7% (n = 30) of the cases. Total flap loss occurred in 3.0% (n = 16) of the cases.

CONCLUSIONS

Bilateral DIEP flap breast reconstructions can be performed with the same percentage of complications and re-explorations as unilateral reconstructions and even result in less fat necrosis and infection at the recipient site. Higher BMIs are significantly associated with recipient- and donor-site complications.