Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation

 

by Asaad, Malke; Slovacek, Cedar; Mitchell, David; Liu, Jun; Selber, Jesse C.; Clemens, Mark W.; Chu, Carrie K.; Mericli, Alexander F.; Butler, Charles E. 

 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1080e-1089e

 

Background: 

Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable.

Methods: 

The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.

Results: 

A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).

Conclusions: 

Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.

 

An Analysis of the Modified Five-Item Frailty Index for Predicting Complications following Free Flap Breast Reconstruction

 

by Magno-Pardon, David A.; Luo, Jessica; Carter, Gentry C.; Agarwal, Jayant P.; Kwok, Alvin C. 

 

Plastic and Reconstructive Surgery: January 2022 - Volume 149 - Issue 1 - p 41-47

 

Background:

The modified five-item frailty index is a validated and effective tool for assessing risk in surgical candidates. The authors sought to compare the predictive ability of the modified five-item frailty index to established risk factors for complications in free flap breast reconstruction.

Methods:

The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for free flap breast reconstructive procedures. Univariate and multivariate regression analysis models were used to assess how modified five-item frailty index and factors commonly used to risk stratify (age, body mass index, American Society of Anesthesiologists classification, and history of smoking) were associated with complications.

Results: Of the total 10,550 cases, 24.1 percent experienced complications. A high modified five-item frailty index score is associated with a higher overall rate of postoperative complications (p < 0.001). This significant trend was demonstrated in both surgical (p < 0.001) and medical (p < 0.001) complications. When controlling for other risk factors commonly used for risk stratification such as age, body mass index, American Society of Anesthesiologists classification, and history of smoking, the modified five-item frailty index was significantly associated with medical (OR, 1.75; 95 percent CI, 1.37 to 2.22; p = 0.001) and any complications (OR, 1.58; 95 percent CI, 1.29 to 1.93; p < 0.001) and had the largest effect size. Assessing for specific complications, the modified five-item frailty index is the strongest independent predictor of reoperation (OR, 1.41; 95 percent CI, 1.08 to 1.81; p = 0.009).

Conclusion: The modified five-item frailty index is a useful predictor of postoperative outcomes in patients undergoing free flap breast reconstruction when compared to other historically considered risk factors for surgical complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

 

A Comparison of Surgical Complications in Patients Undergoing Delayed versus Staged Tissue-Expander and Free-Flap Breast Reconstruction

 

by Shammas, Ronnie L.; Cason, Roger W.; Sergesketter, Amanda R.; Glener, Adam D.; Broadwater, Gloria; Hollins, Andrew; Le, Elliot; Marks, Caitlin; Atia, Andrew N.; Orr, Jonah P.; Hollenbeck, Scott T. 

 

Plastic and Reconstructive Surgery: September 2021 - Volume 148 - Issue 3 - p 501-509

 

Background: Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement (“delayed-immediate” reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear.

Methods: The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications.

Results: Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875).

Conclusions: The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. 

Clinical Question/Level of Evidence: Therapeutic, III.

 

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

 

by N. Gort, B.G.I. van Gaal, H.J.P. Tielemans, D.J.O. Ulrich, S. Hummelink 

 

The Breast: August 19, 2021

 

Background

Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.

Materials en methods

The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.

Results

152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).

Conclusion

An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

 

 

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

 

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

 

by Rose, Jessica F.; Doval, Andres F.; Zavlin, Dmitry; Ellsworth, Warren A.; Echo, Anthony; Spiegel, Aldona J

 

Plastic and Reconstructive Surgery: June 2021 - Volume 147 - Issue 6 - p 1271-1277

Background: 

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.

Methods: 

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.

Results: 

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.

Conclusions: 

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.

CLINICAL QUESTION/LEVEL OF EVIDENCE: 

Therapeutic, III.

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

1 Plastic and Reconstructive Surgery - Most Popular Articles by Frey, Jordan D.; Stranix, John T.; Chiodo, Michael V.; Alperovich, Michael; Ahn, Christina Y.; Allen, Robert J.; Choi, Mihye; Karp, Nolan S.; Levine, Jamie P.  

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 1086–1093

Background: Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. Methods: Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. Results: Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). Conclusion: Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors’ technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.