Autologous Free Flap Breast Reconstruction Research Articles

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.

Microsurgical autologous breast reconstruction in the midst of a pandemic: A single-unit COVID-19 experience

IntroductionCOVID-19 has disrupted the provision of breast reconstructive services throughout the UK. Autologous free flap breast reconstruction was restarted in our unit on 3 June 2020. We aimed to compare the unit's performance of microsurgical autologous breast reconstruction in the “post-COVID” period compared with the exact time period in the preceding year.MethodsWe retrospectively reviewed prospectively collected data in the “pre-COVID” (from 3 June 2019 to 31 December 2019) and “post-COVID” period (from 3 June 2020 to 31 December 2020). Patient demographics included age, body mass index, co-morbidities, Anaesthesiologists (ASA) grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, reconstruction timing, number of pedicles, contralateral symmetrisation and other procedures.dependant variables were ischaemic time, operative time, mastectomy weight, flap weight, length of stay, return to theatre and complication rates. The number of trainers and trainees present in theatre was recorded and analysed.ResultsFewer DIEP flaps were performed in the “post-COVID” period (45 vs. 29). No significant difference was observed in mastectomy resection weight, but flap weight was significantly increased. No significant difference was found in ischaemic time as well.The postoperative length of stay was significantly reduced. No significant difference was found in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. No cases of venous thromboembolism or flap failures were recorded.The mean number of trainers and trainees, and the trainee-to-trainer ratio was not found to be significantly different between cohorts.ConclusionAlthough fewer cases were performed, autologous breast reconstruction was safely delivered throughout the COVID-19 pandemic in the first wave without affecting training.

Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction.

Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results. A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications. No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation. From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast. Therapeutic, III.

Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes.

The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction. We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q. Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores. System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.

Latest Advancements in Autologous Breast Reconstruction.

After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses. Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.

Propofol-based total intravenous anesthesia decreases the incidence of postoperative nausea and vomiting without affecting flap survival in free flap breast reconstruction.

Postoperative nausea and vomiting (PONV) may cause undesirable effects after microsurgical breast reconstruction. Although total intravenous anesthesia (TIVA) with propofol has been demonstrated to be effective in reducing PONV, it has not been assessed in autologous free flap breast reconstruction. The purpose of this study was to investigate the antiemetic prophylaxis effect and safety of TIVA in microvascular breast reconstruction. Eighty-three patients undergoing microsurgical breast reconstruction with propofol (31 patients) or sevoflurane (52 patients) were retrospectively reviewed. The incidence of PONV was assessed at 2, 6, and 24 hours after surgery. Mean arterial blood pressure (MAP) was compared at T1 (after flap elevation but before transfer), T2 (15 minutes after revascularization), and T3 (at the end of surgery). The incidence of nausea was significantly reduced in the TIVA group over 0 to 2 hours period (P=0.017), and over 2 to 6 hours period (P=0.033). The incidence of vomiting was significantly reduced in the TIVA group over 0 to 2 hours period (P=0.006), and over 2 to 6 hours period (P=0.005). MAP was higher in the TIVA group at T1 (P=0.018), T2 (P=0.005), and T3 (P=0.007). The incidence of flap failure was similar between the two groups (P=0.373). Compared with sevoflurane maintaining anesthesia, propofol-based TIVA improves PONV with less fluctuation of MAP, and did not affect flap survival.

An Individualized Patient-centric Approach and Evolution towards Total Autologous Free Flap Breast Reconstruction in an Academic Setting.

Summary:Advances with newer perforator flaps and complex microsurgical techniques have enabled creative solutions in autologous breast reconstruction. For patients seeking total autologous breast reconstruction without the use of implants, body regions other than the abdomen have emerged to provide a substitute or additional donor tissue. In cases where abdominal perforator flaps are not possible (as with prior abdominoplasty), flaps taken from the lower back or thigh can be used. In situations of inadequate donor tissue in 1 body area, stacked multiple flap reconstruction is possible using donor tissue from multiple areas. In this article, we present our approach for individualizing treatment for breast reconstructive patients seeking to avoid permanent implants. We highlight how free perforator flap selection can not only serve to provide adequate tissue for body-appropriate breast reconstruction but may also be secondarily tailored to provide patient-specific aesthetic body contouring. Our preoperative patient counseling has evolved to involve flap selection based on clinical examination as well as advanced computed tomographic imaging of abdomen, thighs, and lower back. Decision to use 1 or more flaps is based on an assessment of whether the targeted body region(s) provide enough skin and fat for breast reconstruction, if the requisite perforator anatomy is available, and whether the effect of tissue procurement on their individualized aesthetic body contour is optimal.

National Trends in Hospitalization Charges for Autologous Free Flap Breast Reconstruction.

There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Previous studies hypothesize that factors like length of stay and hospital volume are key drivers of cost; however, how these factors have affected cost have not been well studied. Our study analyzes the factors influencing hospital charges relating to these procedures and their trends over a multiyear time frame. The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2009 to December 2014. All female patients who were diagnosed with breast cancer or at a high risk for breast cancer who underwent autologous free flap breast reconstruction were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear models were used to examine associations between selected variables and the hospitalization charges, as well as trends in these factors over the years included. There were 659,220 female patients diagnosed with breast cancer or had a high risk of breast cancer between 2009 and 2014. Of these patients, 20,050 (3.0%) received autologous free flap breast reconstruction and were included. The mean total hospital charge was US $98,839.33 (SD = US $61,532.04). Regression analysis showed that the proportion of procedures to the total population of potential patients significantly increased over the selected time frame (P = 0.02). The average total charges also increased significantly (P < 0.01), despite a decrease in length of stay (P = 0.05). Procedures performed in the west were associated with significantly higher charges when compared with other regions (US $147,855.42, P < 0.001). Higher hospital charges were also associated with urban hospitals, regardless of teaching status. The overall demand for the autologous free flap breast reconstruction is increasing within the patient population, in conjunction with increasing associated hospital charges. This increase in cost is seen despite an overall decrease in length of stay, originally thought to be the main contributor to regional cost variation. Further studies should be done to develop strategies to better target increased hospitalization charges, because the overall health care burden of this procedure is expected to rise if current trends continue.

“Three-dimensional evaluation of breast volume changes following autologous free flap breast reconstruction over six months”

ObjectivesTo date, little is known about postoperative changes in breast volume after autologous breast reconstruction. The purpose of this retrospective study was to investigate breast volume changes following autologous free flap reconstruction and the factors affecting flap volume. Materials and methodsPatients who underwent deep inferior epigastric perforator, superficial inferior epigastric artery and profunda artery perforator flaps between December 2016 and January 2019 were included. Exclusion criteria were breast complications requiring surgical debridement, and the absence of at least two suitable three-dimensional images postoperatively. Three-dimensional stereophotogrammetry volume measurements were performed at the time of standard surgical check-ups. Changes in breast volume were modeled using a quartic polynomial curve function in a nested mixed effects model. Results136 breasts in 101 patients were included. An average decrease of predicted breast volume was found from 637.8 cc (95%-CI [624.4, 651.1]) at two weeks to 566.6 cc (95%-CI [535.1, 598.0]) after three and 567.6 cc (95%-CI [515.9, 617.6]) after six months postoperatively. Reconstruction timing and first postoperatively measured breast volume showed a statistically significant difference in initial reconstructed breast volume and in the shape of the relationship between time and breast volume, whereas autologous technique and BMI only showed a statistically significant difference in initial reconstructed volume and mastectomy indication in the shape of the relationship. ConclusionThe final overall flap volume decreased to 88.9% of its original volume after six months. Gaining more insight into the factors influencing flap volume is of crucial importance to facilitate predictable surgical outcomes.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery. Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.

Salvaging Breast Reconstruction: Profunda Artery Perforator Flaps Using Thoracodorsal Vessels.

Background:Over the years, the choice of recipient vessels for free flap autologous breast reconstruction has shifted from the thoracodorsal to the internal mammary vessels due to ease of flap inset and predictability of anatomy. However, thoracodorsal vessels are still great recipient vessels, and can be useful, especially in the previously failed or staged autologous breast reconstruction. In this study, we present our experience using thoracodorsal or serratus vessels for profunda artery perforator flaps.Methods:Of the 792 autologous free flap breast reconstruction performed, we identified 12 patients (21 flaps) who underwent reconstruction using thoracodorsal or serratus vessels from 2012 to 2017. Flap, patient characteristics, and demographic data and perioperative details were collected.Results:Twenty-one flaps were used to reconstruct 14 breasts in 12 patients. The mean age of patients was 49.6 years old (range, 42–54), the mean flap weight was 354.7 g (range, 170–540 g), the mean body mass index was 28 (range, 23.2–34.4), and the average operative time was 496.1 minutes (266–680). Majority of these patients underwent additional staged free flap reconstruction (following previous deep inferior epigastric perforator flaps) for severe breast contour defects (58%) and for failed previous breast reconstruction (42%). The anastomosis was performed using thoracodorsal (43%), serratus (43%), and profunda artery perforator side branch (14%) vessels.Conclusion:Determining appropriate flap and recipient vessels in a previously failed or staged breast reconstruction is very challenging. Thoracodorsal and serratus vessels are excellent recipient vessels in patients who already have exhausted internal mammary vessels for previous breast reconstruction.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Abstract: Thromboelastography and Intraoperative Anticoagulation during Reconstructive Microsurgery

INTRODUCTION: Maintaining optimal coagulation is vital for successful microvascular flap transfer. Hypercoagulate states are risk factors for pedicle thrombosis and flap loss.1 Therefore, identifying patients who are at risk for such events is paramount. The viscoelastic Thromboelastography (TEG) is a modern method to assess a patient’s coagulation status and in the past, it has predominantly been used in critical care, cardiac or trauma surgery.2 The aim of our study was to evaluate its diagnostic capabilities, its role compared to classic coagulation tests, and the effect of low-dose heparin in reconstructive breast microsurgery. METHODS: After approval from the institutional review board, clinic charts of our senior author were analyzed for all patients between 2012 and 2016 who underwent autologous free flap breast reconstruction and received perioperative TEG. Patient demographics, their medical history, clinical and operative details were documented. All coagulation studies, such as thrombocyte count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and the numerous TEG parameters were gathered for baseline, the intraoperative, and the first two postoperative days (POD1, POD2). Statistical calculations sought to determine any risk factors associated with adverse outcomes of reconstructive microsurgery. RESULTS: 100 patients were subsequently identified who underwent 172 abdominal-based free flaps for breast reconstruction. Intraoperatively, 91 patients received unfractioned heparin (UFH) as their TEG-G values were significantly more hypercoagulable at baseline and again on POD1 and POD2. Intraoperative TEG-G was indifferent and borderline hypocoagulate for both the 91 heparin and the 9 non-heparin patients. PT/aPTT showed no changes perioperatively. Thrombocytes slightly decreased due to blood dilution. Within a mean follow-up of 17.4 ± 11.1 months, 3 bleeding, 6 wound/infection, and 6 thrombotic complications occurred. Of the latter group, 2 resulted in flap loss (1.2%). Intraoperative bleeding was related to high aPTT (0.029). Wound complications were related to high BMI (p = 0.022) and diabetes (0.028). The 6 thrombotic events had much steeper increases of TEG-G between surgery and POD2 (p = 0.003). Both flap losses occurred in 2 patients with a history of abdominal surgery despite intraoperative UFH. CONCLUSION: TEG is more dynamic and accurate to show the effects of intraoperative anticoagulation than conventional coagulation tests. Our applied heparin regimen was successful to avoid significant detrimental outcomes. The 2 flap losses were associated with previous abdominal surgery and scarring. Reference Citations: 1. Wang TY, Serletti JM, Cuker A, et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg. 2012;129:443–453. 2. Bolliger D, Seeberger MD, Tanaka KA. Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfus Med Rev. 2012;26:1–13.

Comparison of risk factors and complications in patients by stratified mastectomy weight: An institutional review of 1041 consecutive cases.

This study aims to investigate the specific complication rates, reconstructive differences, and delineate the pertinent independent risk factors in patients with different mastectomy weights. A retrospective chart review of consecutive patients undergoing mastectomy between 2010 and 2015 was performed. Patient demographics, comorbidities, and intraoperative and postoperative outcomes were collected. Patients were divided into three groups: those with mastectomy weight <500, 500-1000, and >1000 g. During the study period, a total of 704 consecutive patients and 1041 total mastectomy surgeries had complete mastectomy specimen weight data. Of these, 437 breasts were in the <500 g specimen group, 425 were included in the 500-1000 g group and 179 in the >1000g group. The rate of overall complications between the three mastectomy weight groups (<500, 500-1000, and >1000 g) was statistically significant (14.0%, 17.6%, and 25.7%; P = 0.002, respectively) and were higher with increased mastectomy weights. Notably, in patients with breast mastectomy weight >1000 g, autologous reconstruction had significantly reduced rates of overall complications (AOR = 0.512, P = 0.048). Complication rates were lower in women with larger breast weights undergoing autologous reconstruction, warranting potential use of autologous free flap breast reconstruction in women with large mastectomy specimen weights when possible.

A Nationwide Analysis of Cost Variation for Autologous Free Flap Breast Reconstruction

Cost variation among hospitals has been demonstrated for surgical procedures. Uncovering these differences has helped guide measures taken to reduce health care spending. To date, the fiscal consequence of hospital variation for autologous free flap breast reconstruction is unknown. To investigate factors that influence cost variation for autologous free flap breast reconstruction. A secondary cross-sectional analysis was performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010. The dates of analysis were September 2016 to February 2017. The setting was a stratified sample of all US community hospitals. Participants were female patients who were diagnosed as having breast cancer or were at high risk for breast cancer and underwent autologous free flap breast reconstruction. Variables of interest included demographic data, hospital characteristics, length of stay, complications (surgical and systemic), and inpatient cost. The study used univariate and generalized linear mixed models to examine associations between patient and hospital characteristics and cost. A total of 3302 patients were included in the study, with a median age of 50 years (interquartile range, 44-57 years). The mean cost for autologous free flap breast reconstruction was $22 677 (interquartile range, $14 907-$33 391). Flap reconstructions performed at high-volume hospitals were significantly more costly than those performed at low-volume hospitals ($24 360 vs $18 918, P < .001). Logistic regression demonstrated that hospital volume correlated with increased cost (Exp[β], 1.06; 95% CI, 1.02-1.11; P = .003). Fewer surgical complications (16.4% [169 of 1029] vs 23.7% [278 of 1174], P < .001) and systemic complications (24.2% [249 of 1029] vs 31.2% [366 of 1174], P < .001) were experienced in high-volume hospitals compared with low-volume hospitals. Flap procedures performed in the West were the most expensive ($28 289), with a greater odds of increased expenditure (Exp[β], 1.53; 95% CI, 1.46-1.61; P < .001) compared with the Northeast. A significant difference in length of stay was found between the West and Northeast (odds ratio, 1.25; 95% CI, 1.17-1.33). There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Experience, as measured by a hospital's volume, provides quality health care with fewer complications but is more costly. Longer length of stay contributed to regional cost variation and may be a target for decreasing expenditure, without compromising care. In the era of bundled health care payment, strategies should be implemented to eliminate cost variation to condense spending while still providing quality care.

Seguridad y complicaciones en reconstrucción mamaria autóloga con colgajo DIEP: una revisión sistemática

Autologous free flap breast reconstruction may be associated with complications related to the flap and the donor site. Our objective was to evaluate the reported evidence on safety, complications and risk factors in patients undergoing deep inferior epigastric artery perforator flap (DIEP) breast reconstruction. A systematic review was conducted based on a Medline search for studies published between September 1995 and September 2015. Demographic data, flap dimensions and complication rates were recorded including total flap necrosis, partial flap necrosis and fat necrosis. A total of 34 clinical studies including 35 case series, 2,761 patients and 3,927 DIEP flaps were identified. The mean body mass index was higher than 24.5kg/m2 whereas the obesity rate was above 14.5%. None of the articles reported flap weight, area or volume after molding. Total and partial flap necrosis rates were 1.9% (75/3,811) and 2.6% (68/2,575), respectively. Fat necrosis was diagnosed in 8.2% (308/3,746) of flaps with a standard deviation of 6.9. Reoperation was required in 5.5% (107/1,940) of the flaps. The incidence of hematoma in the recipient site and abdominal hernia or bulge formation was 3% (59/1,952 flaps and 52/1,725 patients). In conclusion, the occurrence of complications in breast reconstruction by autologous DIEP flap was low, although the occurrence of fat necrosis ranged widely.

Radiation Therapy Versus No Radiation Therapy to the Neo-breast Following Skin-Sparing Mastectomy and Immediate Autologous Free Flap Reconstruction for Breast Cancer: Patient-Reported and Surgical Outcomes at 1 Year—A Mastectomy Reconstruction Outcomes Consortium (MROC) Substudy

To determine whether adjuvant radiation therapy (RT) is associated with adverse patient-reported outcomes and surgical complications 1year after skin-sparing mastectomy and immediate autologous free flap reconstruction for breast cancer. We compared 24 domains of patient-reported outcome measures 1year after autologous reconstruction between patients who received adjuvant RT and those who did not. A total of 125 patients who underwent surgery between 2012 and 2015 at our institution were included from the Mastectomy Reconstruction Outcomes Consortium study database. Adjusted multivariate models were created incorporating RT technical data, age, cancer stage, estrogen receptor, chemotherapy, breast size, body mass index, and income to determine whether RT was associated with outcomes. At 1year after surgery, European Organisation for Research and Treatment of Cancer (EORTC) Breast Cancer-Specific Quality of Life Questionnaire breast symptoms were significantly greater in 64 patients who received RT (8-point difference on 100-point ordinal scale, P<.0001) versus 61 who did not receive RT in univariate and multivariate models. EORTC arm symptoms (20-point difference on 100-point ordinal scale, P=.0200) differed on univariate analysis but not on multivariate analysis. All other outcomes-including Numerical Pain Rating Scale, BREAST-Q (Post-operative Reconstruction Module), Patient-Report Outcomes Measurement Information System Profile 29, McGill Pain Questionnaire-Short Form (MPQ-SF) score, Generalized Anxiety Disorder Scale, and Patient Health Questionnaire-were not statistically different between groups. Surgical complications were uncommon and did not differ by treatment. RT to the neo-breast compared with no RT following immediate autologous free flap reconstruction for breast cancer is well tolerated at 1year following surgery despite patients undergoing RT also having a higher cancer stage and more intensive surgical and systemic treatment. Neo-breast symptoms are more common in patients receiving RT by the EORTC Breast Cancer-Specific Quality of Life Questionnaire but not by the BREAST-Q. Patient-reported results at 1year after surgery suggest RT following immediate autologous free flap breast reconstruction is well tolerated.