Microvascular Breast Reconstruction Research Articles

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes.

A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. Overall, 137 subjects were identified and 64 met the inclusion criteria (n=28 study, n=36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p<0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5min, p<0.01). A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.

Efficiency in Microvascular Breast Reconstruction

Efficiency in Microvascular Breast Reconstruction

Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction.

Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS's impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0-2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.

The Use of Unlisted Billing Codes for Microsurgical Breast Reconstruction and Implications for Code Consolidation.

Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers. Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes. There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients. Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.

The Value of a Co-surgeon in Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis.

Using a co-surgeon model has been suggested to improve perioperative outcomes and reduce the risk of complications. Therefore, we evaluated if a co-surgeon model compared with a single microsurgeon model could decrease the surgical time, length of stay, rate of complications, and healthcare-associated costs in adult patients undergoing microvascular breast reconstruction (MBR). A comprehensive search was performed across PubMed MEDLINE, Embase, and Web of Science. Studies evaluating the perioperative outcomes and complications of MBR using a single-surgeon model and co-surgeon model were included. A random-effects model was fitted to the data. Seven retrospective comparative studies were included. Ultimately, 1411 patients (48.23%) underwent MBR using a single-surgeon model, representing 2339 flaps (48.42%). On the other hand, 1514 patients (51.77%) underwent MBR using a co-surgeon model, representing 2492 flaps (51.58%). The surgical time was significantly reduced using a co-surgeon model in all studies compared with a single-surgeon model. The length of stay was reduced using a co-surgeon model compared with a single-surgeon model in all but one study. The log odds ratio (log-OR) of recipient site infection (log-OR = -0.227; P = 0.6509), wound disruption (log-OR = -0.012; P = 0.9735), hematoma (log-OR = 0.061; P = 0.8683), and seroma (log-OR = -0.742; P = 0.1106) did not significantly decrease with the incorporation of a co-surgeon compared with a single-surgeon model. Incorporating a co-surgeon model for MBR has minimal impact on the rates of surgical site complications compared with a single-surgeon model. However, a co-surgeon optimized efficacy and reduced the surgical time and length of stay.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

Background: Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center. Methods: The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls. Results: The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P &lt; 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P &lt; 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P &lt; 0.0001). ERAS had a lower pain average on POD 0–3; however, this finding was not statistically significant. Conclusion: Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Surgical Outcomes of Autologous Breast Reconstruction in Low BMI Patients; Beyond the Gold Standard DIEP Flap.

Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low Body Mass Index (BMI). However, the gold standard of microvascular breast reconstruction, the Deep Inferior Epigastric Perforator (DIEP) flap, can be challenging to achieve due to the paucity of adnominal bulk in these patients. This study compares operative outcomes in women with BMIs less than 23.5 following reconstruction after one of three free flap methods: The DIEP flap, alternative flaps (I.e., lumbar artery perforator flap (LAP) or profounda artery perforator flap (PAP)), and stacked flaps. A retrospective study was conducted on thin patients (BMI < 23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (NTH, SST) at a single institution. One hundred and fifteen patients were divided into three reconstructive groups. Flap weights, complication rates, secondary revisions, and fat grafting in each group were then compared. The success rate in all three groups was 100%, with only one partial flap loss in the stacked group. There was a significant difference in overall minor complications and donor complications between the three groups, with alternative flaps experiencing the most. All three groups had similar incidences of recipient breast complications, medical complications, need for secondary revisions, and amount of fat grafted. Autologous breast reconstruction in low BMI patients yields successful and durable results. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the gold standard DIEP flap.

Comparing microsurgical breast reconstruction outcomes following postoperative monitoring techniques: a systematic review and meta-analysis of 2529 patients

Aims: This paper aims to assess the existing evidence regarding oximetry and thermography by comparing postoperative rates of complications following microsurgical breast reconstruction. Methods: A systematic review of PubMed, Web of Science, and Cochrane was completed. A qualitative and quantitative analysis of all included studies was then performed. Results: Fourteen studies were included with a total population of 2,529 female patients who underwent microvascular breast reconstruction, ultimately totaling 3,289 flaps. The mean age for the cohorts included in this study ranged from 48.9 to 57 years of age. A total of 15 complete flap losses were reported. Furthermore, this meta-analysis of proportion showed that total flap loss experienced was 0% (95%CI 0%-100%) for patients monitored with thermography compared to 0% (95%CI 0%-1%) for those monitored with oximetry. Partial flap loss occurred at a frequency of 1% [95% confidence interval (CI) 0%-73%] for patients monitored with thermography compared to 1% (95%CI 0%-2%) for those monitored with oximetry. Furthermore, the results of this study showed that thermography prompted a return to the operating room (OR) in 1% (95%CI 0%-73%) of the patients compared to 5% (95%CI 3%-9%) for oximetry. Lastly, the overall complication rate was 12% (95%CI 1%-54%) for patients monitored with thermography compared to 10% (95%CI 4%-21%) for those monitored with oximetry. Conclusion: Ultimately, this meta-analysis concludes that while oximetry monitoring currently has strong evidence for improving flap outcomes, trends in the current data indicate that further studies may demonstrate that thermography may be comparable to oximetry in achieving similar patient outcomes.

Utilization of the internal mammary perforators as the recipient vessels for microsurgical breast reconstruction: A systematic review and meta-analysis of the literature.

The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels. A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery). Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%. With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction.

Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. Ninety-one patients (with 119 free flaps) were followed up between 6 and 12months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps

The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.

ASO Visual Abstract: Long-Term Surgical and Patient-Reported OutcomesComparingSkin-Preserving, StagedVersusDelayedMicrovascularBreast Reconstruction.

ASO Visual Abstract: Long-Term Surgical and Patient-Reported OutcomesComparingSkin-Preserving, StagedVersusDelayedMicrovascularBreast Reconstruction.

Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction.

Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (β - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p=0.042), seroma (OR 0.42, p=0.036), and hematoma (OR 0.24, p=0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (β - 1.15, p<0.001) and operative time (β - 97.0, p<0.001) and lower odds of 30-days readmission (OR 0.29, p=0.005) and infection (OR 0.33, p=0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improvedflap outcomes and similar patient-reported quality of life to that of delayed reconstruction.

D122. The Impact of Tamoxifen Therapy on Thrombotic Flap Complications: A Nationwide Analysis

PURPOSE: Perioperative tamoxifen practices in microvascular breast reconstruction vary widely. However, no prior literature has investigated this issue from a national standpoint. Thus, this study investigated: (1) the impact of tamoxifen therapy on microvascular flap outcomes using nationwide data, and (2) amongst those on tamoxifen therapy, the impact of perioperative tamoxifen use on flap outcomes. METHODS: This was a retrospective cohort investigation using Truven MarketScan Databases (2014-2017). All women who underwent microvascular breast reconstruction were included; prescriptions claims data was used to identify those on tamoxifen. Outcomes were compared between tamoxifen/non-tamoxifen cohorts. Subgroup analyses in the tamoxifen cohort were undertaken to investigate whether perioperative tamoxifen use impacted outcomes. RESULTS: Overall, 5,832 women were included, of whom 1,983 (34%) were on tamoxifen. There were no differences in flap-related adverse events between tamoxifen and non-tamoxifen cohorts (OR: 1.00; 95%CI: 0.79-1.31; p=0.38). However, amongst patients determined to be at high risk for thrombotic complications, those on tamoxifen therapy had a significantly higher risk of 90-day postoperative venous thromboembolism (OR: 1.15; 95%CI: 1.01-1.28; p=0.04). There were no significant differences in flap failure between those who held tamoxifen versus those who continued tamoxifen into the perioperative period. CONCLUSION: Upon review of national data, preoperative tamoxifen therapy did not significantly increase flap complications/failure after microvascular breast reconstruction. However, patients on tamoxifen therapy with thrombotic risk factors as determined by the Caprini risk score were found to have greater risk for postoperative venous thromboembolism- such patients may need special consideration for postoperative chemoprophylaxis.

D142. Concurrent Co-surgeon DIEP Flap Breast Reconstructions: Feasibility and Clinical Outcomes

PURPOSE: A co-surgeon model has been shown to be a favorable approach for microvascular breast reconstruction, but concurrent co-surgeon DIEP flap cases have not been well-studied. The authors hypothesize that performing two concurrent co-surgeon bilateral DIEP flap reconstructions would increase productivity and result in non-inferior clinical outcomes. METHODS: A single-institution, retrospective cohort study was designed utilizing electronic medical record review to identify all cases of co-surgeon free flap breast reconstructions over a 38-month period. Subsequently, study patients who specifically underwent concurrent bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-concurrent reconstruction within the same, preceding, or following month of those in the study group. Primary outcome variables were minor and major complications within 90-days postoperatively. Secondary outcome variables were operating time and length of hospital stay. Descriptive statistics, univariate analysis, and multivariate regression analysis were performed. RESULTS: 137 subjects were identified, and 64 met inclusion criteria (n=28 study group, n=36 control). There was no statistically significant difference between the groups in age, BMI, radiation, trainee experience, or immediate/delayed reconstruction. There was no statistically significant difference in minor and major complications including anastomosis revision, takeback to operating room, or readmission. Operative time was longer in the study group (540.5 vs. 451.7 minutes, p<0.0001). There was no statistically significant difference in length of hospital stay. CONCLUSION: Concurrent co-surgeon approach to bilateral DIEP flap breast reconstruction increases productivity and does not result in a higher complication rate, compared to non-concurrent operations.

ASO Author Reflections: Skin-Preserving Staged Microvascular Breast Reconstruction Results in Surgical and Patient-Reported Outcomes Comparable to Delayed Reconstruction.

ASO Author Reflections: Skin-Preserving Staged Microvascular Breast Reconstruction Results in Surgical and Patient-Reported Outcomes Comparable to Delayed Reconstruction.

Operative Time Is an Independent Predictor of Postoperative Outcomes in Bilateral DIEP Flap Breast Reconstruction: A Multivariate Analysis of 1000 Flaps

Introduction: Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT’s impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in Deep Inferior Epigastric Artery Perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds. Materials and Methods: Patients who underwent bilateral DIEP flaps from 2010-2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. 1000 flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. Results: After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all p<0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (p=0.050), 5-7 hours had comparable odds (p=0.540), and 7-9 hours had 5.5 times lower odds than procedures ≥ 9 hours (p<0.001). Lastly, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 x OT (hours) (R2=0.308; p<0.001). Conclusion: Operative time (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 hours and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.

Analysis of Breast Aesthetic Revision Procedures after Unilateral Abdominal-based Free-flap Breast Reconstruction: A Single-center Experience with 1251 Patients.

A retrospective review of all unilateral abdominal-based free-flap breast reconstructions performed from 2000 to 2014 was undertaken at a tertiary academic center. Overall, 1251 patients were included in the analysis. The average number of breast revision procedures was 1.1 ± 0.9, and 903 patients (72.2%) underwent at least one revision procedure. Multiple logistic regression analysis demonstrated that younger age, higher body mass index, and prior oncologic surgery on the reconstructed breast were factors associated with increased likelihood of undergoing a revision procedure. The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m2) increase in a patient's body mass index. Multiple Poisson regression modeling demonstrated that younger age, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were significant factors associated with undergoing a greater number of revision procedures. Most patients who undergo unilateral autologous breast reconstruction require at least one additional operation to optimize their breast aesthetic results. Young age and obesity increase the likelihood of undergoing additional operations. These findings can aid reconstructive microsurgeons in counseling patients and establishing patient expectations prior to their undergoing microvascular breast reconstruction.

Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis.

Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons (N.T.H. and S.S.T.) with standardized surgical and postoperative protocols were retrospectively reviewed. One thousand flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all P < 0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (P = 0.050), 5-7 hours had comparable odds (P = 0.540), and 7-9 hours had 5.5 times lower odds than procedures ≥ 9 hours (P < 0.001). Last, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 × OT (hours) (R2 = 0.308; P < 0.001). OT (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.