Autologous Free Flap Breast Reconstruction Research Articles

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

The prevalence of obesity in the United States exceeds 40%, yet perioperative effects of higher body mass index (BMI) in autologous breast reconstruction remain poorly studied. The purpose of this study was to investigate BMI's impact on postop complications in abdominal and gluteal-based autologous breast reconstruction. We conducted a retrospective study using TriNetX, a health care database containing de-identified data from more than 250 million patients. Patients undergoing autologous breast reconstruction were identified by Current Procedural Terminology codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and 35 to 39.99 kg/m2. Outcomes of interest were defined by International Classification of Diseases,Tenth Revision (ICD-10) codes. A two-sample t-test was performed to compare incidence of postoperative complications between cohorts within 3 months of surgery. Patients with a BMI < 24.99 kg/m2 served as the control. Cohorts were balanced on age, race, and ethnicity. We identified 8,791 patients who underwent autologous breast reconstruction. Of those, 1,143 had a BMI < 24.99 kg/m2, 1,867 had a BMI of 25 to 29.99 kg/m2, 1,396 had a BMI of 30 to 34.99 kg/m2, and 559 had a BMI of 35 to 39.99 kg/m2. Patients with a BMI of 25 to 29.99 kg/m2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to 34.99 and 35 to 39.99 kg/m2 had a significantly increased risk of cellulitis, surgical site infection, need for debridement, wound dehiscence, and flap failure. Our study illustrates that there is an increased risk of postoperative complications associated with higher BMI classes. Understanding these data are imperative for providers to adequately stratify patients and guide the procedural decision-making.

Influence of sarcopenia on postoperative complications in patients undergoing autologous microsurgical breast reconstruction: an inverse probability of treatment weighting analysis.

Sarcopenia is characterized by the loss of skeletal muscle mass and power. Preoperative sarcopenia may be associated with an increased risk of postoperative complications after autologous free-flap breast reconstruction surgery; however, this relationship is controversial. This study aimed to determine whether preoperative sarcopenia is associated with a high complication rate in patients undergoing autologous free-flap breast reconstruction. Patients who underwent autologous free-flap breast reconstruction at our hospital between 2019 and 2021 were included in the study. Data on significant complications requiring surgical intervention were retrospectively collected from the medical records. Sarcopenia was defined as having a skeletal muscle index value <41 cm2/m2. The skeletal muscle index was calculated by dividing the sum of the psoas and iliopsoas muscle areas at the level of the third lumbar vertebra by the patient's height in meters squared. The relationship between preoperative sarcopenia and postoperative complications was investigated using an inverse probability of treatment weighting (IPTW) analysis. Among the 203 participants, 90 (44.33%) had preoperative sarcopenia. The general patient characteristics were similar between the sarcopenia and non-sarcopenia groups after IPTW adjustment. Sarcopenia did not significantly increase the risk of flap failure or emergency surgery related to breast reconstruction before IPTW adjustment. However, after IPTW adjustment, the rates of recipient site infection and hematoma were significantly higher in participants with sarcopenia than in those without sarcopenia (p < 0.001 and p = 0.014, respectively). Preoperative sarcopenia may influence certain complications of autologous free-flap breast reconstruction surgery.

A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review.

Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study. The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared. Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05). This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Microsurgical training curriculum in a gynecological breast cancer center: a benefit for patients and surgeons?

PurposeAutologous breast reconstruction improves patient satisfaction and quality of life after mastectomy. In Germany, free flap surgery and implant-based reconstruction is usually separate between reconstructive surgery and gynecology. Cooperation between the specialist disciplines and implementation of microsurgery into breast surgeon training could enhance surgical treatment for breast cancer patients. This evaluation is intended to demonstrate the learning progress within a microsurgical training program and the complication rate in relation to microsurgical experience.MethodsAt the breast cancer center at Klinikum rechts der Isar, TU Munich, a three-stage training program for autologous breast reconstruction and microsurgery for gynecological breast surgeons was developed. Between 2019 and 2022, 74 women received autologous free flap breast reconstruction by a consistent team consisting of a gynecological surgeon in training and an expert microsurgeon. Peri- and postoperative data were collected to analyze the feasibility and safety of a microsurgical training in gynecology.ResultsWithin the training, operative steps of free autologous breast reconstruction were increasingly taken over by the gynecological surgeon in training. The analysis showed a decrease in operating times with consistently low complication rates during the training.ConclusionThis study demonstrated that a training in free autologous breast reconstruction for gynecological surgeons is safely feasible through close cooperation between gynecological and reconstructive surgery.

Patient Perspectives and Quality of Life after Breast Reconstruction and the Impact of Subsequent Revisions.

Patients undergoing mastectomy with immediate implant-based or autologous free-flap breast reconstruction from 2008 to 2020 were reviewed. These patients were categorized by revisions (0-1, 2-3, and 4+) and surveyed on QoL metrics using BREAST-Q and Was It Worth It? (WIWI) questionnaires. BREAST-Q QoL, satisfaction, and WIWI metrics between revision groups were evaluated. Among 252 patients, a total of 150 patients (60%) underwent zero to one revisions, 72 patients (28%) underwent two to three revisions, and 30 patients (12%) underwent four or more revisions. Median follow-up was 6 years (range, 1-11 years). BREAST-Q satisfaction among patients with four or more revisions was significantly lower (P = 0.03), while core QoL domains (chest physical, psychosocial, and sexual well-being) did not significantly differ. Analysis of unplanned reoperations due to complications and breast satisfaction showed no significant difference in QoL scores between groups (P = 0.08). Regarding WIWI QoL metrics, four or more revisions were associated with a higher rate of worse QoL (P = 0.035) and worse overall experience (P = 0.001). Most patients in all revision groups felt it was worthwhile to undergo breast reconstruction (86%), would choose breast reconstruction again (83%), and would recommend breast reconstruction to others (79%). Overall, a majority of patients undergoing revisions after breast reconstruction still have a worthwhile experience. Although reoperations after breast reconstruction do not significantly impact long-term BREAST-Q QoL domains, patients undergoing four or more revisions have significantly lower breast satisfaction, worse QoL, and a postoperative experience worse than expected.

Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction.

Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase. The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point. A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively. Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI. Risk, II.

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

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). 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%). 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.

Trends of Autologous Free Flap Breast Reconstruction and Safety During the COVID-19 Pandemic.

Autologous free flap breast reconstruction (ABR) is a valuable surgical option for patients following mastectomy. The COVID-19 pandemic has led to a myriad of factors that have affected access to care, hospital logistics, and post-operative outcomes. This study aims to identify differences in patient selection, hospital course and severity, and post-operative outcomes for patients who underwent ABR during and prior to the COVID-19 pandemic. Patients undergoing ABR from the ACS-NSQIP 2019-2020 database were analyzed to compare sociodemographics, hospital course, and outcomes over the first post-operative month. Multivariable logistic regression was used to identify factors predictive of complications based on operative year. 3,770 breast free flaps were stratified into two groups based on the timing of reconstruction (pre-pandemic and pandemic groups). Patients with a diagnosis of disseminated cancer were significantly less likely to undergo ABR during the COVID-19 pandemic. On univariate analysis, there were no significant differences in post-operative complications between the two groups. When controlling for potentially confounding sociodemographic and clinical risk factors, the COVID-19 group was significantly more likely to undergo reoperation compared to the pre-pandemic group (p< 0.05). When comparing outcomes for patients who underwent ABR prior to and during the COVID-19 pandemic, we found a significant increase in the odds of reoperation for those who had ABR during the pandemic. Debridement procedures and exploration for postoperative hemorrhage, thrombosis or infection increased from the pre-pandemic group to the COVID-19 group. Notably, operative times decreased.

D100. Radiate The Flap or Expander? The Impact of Post-Mastectomy Radiation Timing on Overall Outcomes after Autologous Free Flap Breast Reconstruction

PURPOSE: Optimal timing of post-mastectomy radiation therapy (PMRT) in autologous breast reconstruction is controversial. Our study compares overall reconstructive outcomes in patients requiring post-mastectomy radiation therapy where either the expander or the free flap was radiated. METHODS: A single-center retrospective review was performed for patients who underwent free flap breast reconstruction and post-mastectomy radiation from January 2004 through January 2021. Demographic, intraoperative, and post-operative variables were recorded. RESULTS: 452 free flaps were identified, and 82 underwent PMRT. 59.8% were radiated with an expander prior to free flap surgery (PreDIEP), and 40.2% flaps underwent PMRT (PostDIEP). PostDIEP patients were significantly younger (43.0 vs 47.9years, p=0.016). Radiation was performed 454.0±231.3 days prior to DIEP, versus 220.3±325.9 days after DIEP (p=0.000). There were no significant differences in free flap outcomes between the two cohorts including thrombosis, venous congestion, flap loss, takebacks, fat necrosis, seroma, or infection. However, there were significantly more total reconstructive complications, including infection and wound breakdown, experienced by the PreDIEP cohort (46.9% versus 24.2%, p=0.038). Mean follow up after DIEP was 1.9 years. CONCLUSION: Timing of PMRT did not impact free flap outcomes, but those who had the expander radiated experienced significantly more complications overall. For the 30.6% of patients in the preDIEP group who always intended to undergo autologous reconstruction, radiation after flap may have improved their overall outcomes. As added complications cause delays in cancer therapy and final reconstruction, our results suggest that PMRT of the flap when possible may improve the overall experience for breast cancer patients.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data.

While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality. The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed. A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified. Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

Google Search Popularity as a Reflection of Medical Literacy and Interest in Breast Reconstruction

Objective: Reconstructive breast procedures have been on the rise over the past decades, implant-based approaches being more popular than autologous techniques. Google search engine remains one of the most utilized sources for medical knowledge about breast reconstruction among patients. This study aims to discover Google search popularity as a reflection of patient’s interest in breast reconstruction options over time. Methods: This study utilized Google Trends (GT), a powerful online tool that analyzes changes in Google search popularity over time and geographical regions. This study searched for breast reconstruction related terms across the United States from January 2007 to January 2022. Search terms included: “breast reconstruction,” “implant reconstruction,” “breast expanders,” “implant after mastectomy,” “DIEP flap,” and “TRAM flap.” Searches terms in Spanish were also included. The data were collected from the GT platform and search terms were compared using best fit linear trend lines. Results: Google search popularity for breast reconstruction has slightly decreased over time, while searches for DIEP flaps have increased. Searches for implant-based reconstruction options and related terms showed relatively low interest and no change overtime. DIEP flap searches consistently rose over time as TRAM flap searches gradually decreased in popularity over time. Significant number of searches for TRAM flap were only available in New York, Texas, and California, while DIEP flap was popular in 35 states. Conclusion: Amongst autologous breast reconstruction options, DIEP flaps are gaining popularity while TRAM flaps are decreasing in popularity across the United States. Patients are increasingly interested in autologous free flap breast reconstruction options. Corresponding Author: Neej Patel, 411 E 2nd St Apt#112 Flint, MI 48503, [email protected], 7343064487

Breast Free-Flap Reconstruction and Flap Monitoring Times for Microvascular Complications: is there a Set Rule? A Retrospective Study from a High-volume Tertiary Centre

Introduction: Autologous free-flap breast reconstruction accounts for 30% of reconstruction following mastectomy. However there is no consensus regarding immediate post-operative monitoring protocols. We report the time periods and salvage rates for free-flaps which were returned-to-theatre at a high-volume practice. Materials and Methods: The prospectively collected electronic records for patients undergoing breast free-flap reconstruction between January 2015 and August 2019 were reviewed retrospectively. All free-flaps were reviewed by nurses using the standardised hospital protocol until discharge. Primary end-points evaluated include free-flaps which were returned-to-theatre for full free-flap loss, complication type and free-flap salvage. Results: We identified 679 autologous breast free-flap reconstructions. Fifteen (2.2%) were returned-to-theatre for surgery-related complications during inpatient stay. Eight (1.2%) developed microvascular complications; seven (1.0%) were successfully salvaged and we encountered one free-flap loss (0.1%) due to an arterial complication developing 72-hours postoperatively. Six of the eight microvascular complications (75%) occurred within the first 24 hours from surgery. Surgical time in the takeback population was statistically significantly longer than in the non-takeback population (539 minutes vs. 406 minutes, p=0.00585). Conclusion: Majority of microvascular complications occurred within the first 24-hours in our cohort and these were successfully identified and salvaged at our high-volume practice. We believe all free-flaps should be closely monitored in the first 24-hours. Beyond this period, protocols should be suited to each institution based on their patient demographic, facilities available for free-flap monitoring and case-volume.

The Impact of Breast Cancer Type, Staging, and Treatment on Vascular Complications of Immediate Free-Flap Breast Reconstruction.

Patients with advanced cancer staging have a greater risk of developing venous thromboembolism than noncancer patients. The impact of breast cancer stage and treatment on outcomes after autologous free-flap breast reconstruction (ABR) is not well-established. The objective of this retrospective study is to determine the impact of breast cancer characteristics, such as cancer stage, hormone receptor status, and neoadjuvant treatments, on vascular complications of ABR. A retrospective review was conducted examining patients who underwent ABR from 2009 to 2018. Breast cancer stage, cancer types, hormone receptor status, and treatments were collected in addition to demographic data. Intraoperative vascular concerns, postoperative vascular concerns, and flap loss were analyzed. Univariate analysis and fixed-effects models were used to associate breast cancer characteristics with outcomes. Neoadjuvant hormone therapy was associated with increased risk for intraoperative vascular concern (odds ratio, 1.059 [ P = 0.0441]). Neoadjuvant trastuzumab was associated with decreased risk of postoperative vascular concern (odds ratio, 0.941 [ P = 0.018]). Breast cancer stage, somatic genetic mutation, receptor types, neoadjuvant chemotherapy, and neoadjuvant radiation had no effect on any vascular complications of ABR. Autologous free-flap breast reconstruction is a reliable reconstructive option for patients with all stages and types of breast cancer. There is potentially increased risk of intraoperative microvascular compromise in patients who have neoadjuvant hormone therapy. Trastuzumab is potentially protective against postoperative microvascular compromise. Patients should feel confident that, despite higher stage cancer, they can pursue their desired reconstructive option without fear of vascular compromise.

An Evaluation of the Impact of Mental Illness on Postoperative Breast Reconstruction Revision Surgery.

A commercially available database of 91 million unique patients, PearlDiver, was used to identify patients with breast cancer who underwent autologous free flap breast reconstruction. An average number of revisions were calculated from each group of patients-those with a history of anxiety and/or depression and patients without a history of anxiety and/or depression. A logistic regression was performed to determine risk factors associated with patients undergoing revision surgery. A total of 39,683 patients with a history of breast cancer underwent autologous breast reconstruction between 2010 and 2020, of which 6308 (15.9%) patients had a history of GAD and/or depression before autologous reconstruction. A total of 13,422 (33.8%) patients received at least one revision surgery. Patients with GAD only, depression only, and concomitant GAD and depression received 1.40 revisions each with no significant differences between the control and any of the study groups (P = 0.956). Logistic regression did not find psychiatric history to be associated with patients undergoing revision surgery (OR, 0.94; 95% CI, 0.89-1.00). Patients who underwent autologous reconstruction for breast cancer demonstrated no difference in rates of secondary surgical revision, regardless of a concurrent mental health history.

Complications in microsurgical breast reconstruction: thrombosis prevention and management

Breast reconstruction is one of the largest components of plastic and reconstructive surgery. Autologous free flap breast reconstruction continues to grow due to exceptionally high flap success rates. It provides patients with a durable and natural reconstruction with high patient satisfaction. A patent microvascular anastomosis is a key component to a successful autologous free flap breast reconstruction. Thrombus within the vascular anastomosis or the distal flap microcirculation is the most common cause of flap failure. This review aims to discuss microsurgical techniques including atraumatic handling of vessels, appropriate magnification, suture styles, anastomotic techniques, recipient vessel selection, the role of anticoagulation and antiplatelet therapy used to minimize the risk of thrombotic events. When microvascular thrombus occurs, early reoperation and reperfusion is imperative to flap survival. This review will discuss specific maneuvers and intraoperative interventions to maximize flap salvage.

The effect of immediate postoperative intravenous administration of ferric carboxymaltose after autologous free-flap breast reconstruction

Intravenous ferric carboxymaltose (IV-FCM) can effectively correct perioperative anemia in patients undergoing major surgeries. However, its efficacy and side effects in patients undergoing free flap-based breast reconstruction are yet to be investigated. At our institution, from year 2020, patients with breast cancer undergoing abdominal free flap-based breast reconstruction were injected 500 mg of IV-FCM immediately post-operation. Propensity-matched 82 IV-FCM injected (study group) and 164 historical control group patients were retrospectively analyzed for transfusion rates, changes in hematological parameters, and flap or donor-site related complications. The major and minor complication rates related to the operation site were similar between the two groups. There was no significant difference in the transfusion rate between the two groups (control 29.9% vs. study 32.9%, p = 0.71). However, the total amount of transfusion required was significantly higher in the historical control group (control—53.2% 1 pack, 42.6% 2 packs, 4.3% 3 packs of RBC vs. Study—66.7% 1 pack, 33.3% 2 packs, p = 0.02) than in the study group. Additionally, the historical control group showed a significantly higher drop in red blood cell count, hemoglobin, and hematocrit levels from postoperative days 1–2 and 2–3 compared to the study group. Immediate postoperative use of IV-FCM in free flap-based breast reconstruction was well tolerated by patients and reduced overall transfusion volume.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients

Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions. We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data. A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference. We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

6. Breast Flap Neurotization After Autologous Free Flap Breast Reconstruction: A Prospective Trial

Purpose: Restoration of breast sensation is an important factor to consider following autologous breast reconstruction (ABR). Flap neurotization may result in improved sensation after ABR, but current literature regarding both patient-reported outcomes and quantitative sensation after neurotization is inadequate and heterogenous. We present a prospective trial investigating the long-term outcomes of flap neurotization regarding breast sensation. Methods: 98 patients (n = 166 flaps) were prospectively evaluated for breast sensation and quality-of-life 1-5 years after ABR. This included 55 neurotized patients (n=97 neurotized breast flaps) and 44 non-neurotized patients (n=71 non-neurotized breast flaps). Evaluation consisted of the validated patient-reported questionnaire (BREAST-Q), a sensation-specific patient-reported questionnaire, and pressure-specified sensation testing at 9 locations on the breast using the AcroVal pressure-specified sensory device. Continuous variables were compared using independent t-tests. Categorical variables were compared using chi-squared analyses. Results: Non-neurotized patients were significantly more likely to report breast sensation was affecting their daily lives due to pain or discomfort, while neurotized patients were more likely to report they did not notice a difference in breast sensation after ABR or that the change in sensation was not affecting their daily lives (p= 0.035). While there was no significant difference in quantitative sensation between neurotized and non-neurotized patients at 1 year after ABR, neurotized patients were significantly more sensate at 4 of 9 testing locations on the breast (0.011<p<0.039) when evaluated 2-5 years after ABR. Conclusion: Breast sensation affects the daily lives of breast reconstruction patients and is an important long-term outcome to consider following ABR. Neurotization is associated with improved protective sensation as well as reduced pain and discomfort in the long-term after ABR.

Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer (PRADA): a multicentre, prospective, non-randomised, feasibility study.

Radiotherapy before mastectomy and autologous free-flap breast reconstruction can avoid adverse radiation effects on healthy donor tissues and delays to adjuvant radiotherapy. However, evidence for this treatment sequence is sparse. We aimed to explore the feasibility of preoperative radiotherapy followed by skin-sparing mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction in patients with breast cancer requiring mastectomy. We conducted a prospective, non-randomised, feasibility study at two National Health Service trusts in the UK. Eligible patients were women aged older than 18 years with a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy radiotherapy, who were suitable for DIEP flap reconstruction. Preoperative radiotherapy started 3-4 weeks after neoadjuvant chemotherapy and was delivered to the breast, plus regional nodes as required, at 40 Gy in 15 fractions (over 3 weeks) or 42·72 Gy in 16 fractions (over 3·2 weeks). Adverse skin radiation toxicity was assessed preoperatively using the Radiation Therapy Oncology Group toxicity grading system. Skin-sparing mastectomy and DIEP flap reconstruction were planned for 2-6 weeks after completion of preoperative radiotherapy. The primary endpoint was the proportion of open breast wounds greater than 1 cm width requiring a dressing at 4 weeks after surgery, assessed in all participants. This study is registered with ClinicalTrials.gov, NCT02771938, and is closed to recruitment. Between Jan 25, 2016, and Dec 11, 2017, 33 patients were enrolled. At 4 weeks after surgery, four (12·1%, 95% CI 3·4-28·2) of 33 patients had an open breast wound greater than 1 cm. One (3%) patient had confluent moist desquamation (grade 3). There were no serious treatment-related adverse events and no treatment-related deaths. Preoperative radiotherapy followed by skin-sparing mastectomy and immediate DIEP flap reconstruction is feasible and technically safe, with rates of breast open wounds similar to those reported with post-mastectomy radiotherapy. A randomised trial comparing preoperative radiotherapy with post-mastectomy radiotherapy is required to precisely determine and compare surgical, oncological, and breast reconstruction outcomes, including quality of life. Cancer Research UK, National Institute for Health Research.

Seldom one and done: Characterizing rates of reoperation with direct-to-implant breast reconstruction after mastectomy

BackgroundLimited data exist outlining reoperations after direct-to-implant (DTI), tissue expander (TE) and autologous free-flap breast reconstruction. MethodsPatients undergoing mastectomy with reconstruction from 2008 to 18 were reviewed. Patient factors, surgical techniques, planned, unplanned, and total reoperations were analyzed. ResultsAmong 544 total patients, the majority underwent DTI (294, 54%) or TE (176, 32%); 74 (14%) received autologous free-flaps. Majority of DTI patients (55%) underwent subsequent reoperations. Compared to autologous tissue, DTI had less patients undergo additional surgery (76% vs. 55%, P = 0.001). Incidence of total unplanned reoperations did not significantly differ between reconstructive groups. The rate of unplanned reoperations due to complications was lowest for DTI (39%) when compared to TE (48%) and autologous (55%, P = 0.015). Compared to TE, DTI carried a lower risk for ≥2 total reoperations (OR = 0.21, 95% CI 0.13–0.33, P < 0.001). ConclusionsSeldom “one and done,” additional surgery after DTI remains significant.