Alexander Au

Complications and morbidity following breast reconstruction – a review of 16,063 cases from the 2005–2010 NSQIP datasets

Abstract Post-operative complications pose a significant set-back for patients undergoing breast reconstruction. This study aims to characterize factors associated with postoperative complications following breast reconstruction using the National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005–2010. The 2005-2010 ACS-NSQIP databases were reviewed, identifying encounters for CPT codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominus myocutaneous (TRAM), free TRAM, and latissimus dorsi flap with or without implant). Complications were characterized into three categories: major surgical complications, wound complications, and medical complications. During the study period 16,063 breast reconstructions were performed. Autologous reconstructions were performed in 20.7% of patients and implant-based in 79.3%. The incidence of major surgical complications was 8.4%, whereas the incidence of medical and wound complications was 1.6% and 3.5%, respectively. Independent risk factors for major surgical complications included: immediate and autologous reconstructions, obesity, smoking, previous percutaneous cardiac surgery (PCS), recent weight loss, bleeding disorder, recent surgery, ASA ≥ 3, intra-operative transfusion, and prolonged operative times. Risk factors for medical complications included: autologous reconstruction, obesity, tumor involving CNS, bleeding disorders, recent surgery, ASA ≥ 3, intra-operative transfusion, and prolonged operative times. This study characterizes the incidence of surgical and medical complications following breast reconstruction using a large, prospective multicentre dataset. Key identifiable risk factors associated with both surgical and medical morbidity included: autologous breast reconstruction, obesity, ASA ≥ 3, bleeding disorders, and prolonged operative time. Data derived from this cohort can be used to risk-stratify patients and to enhance perioperative decision-making.

Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction.

Background: Perforator free flaps from the buttock serve as an alternative to abdominally based flaps in autologous breast reconstruction. Microsurgeons often opt to harvest tissue from the gluteal donor site because of a lack of abdominal volume and/or quality. The authors examined the experience of a single surgeon with the inferior gluteal artery perforator (IGAP) flap and provide a quantitative outcomes comparison with the deep inferior epigastric perforator (DIEP) flap. Methods: A retrospective review was performed of patients who underwent IGAP flap surgery for autologous breast reconstruction from August of 2005 to October of 2010 performed by a single surgeon (J.M.S.). Results: Thirty-one inferior gluteal artery perforator flaps were performed on 24 patients. Mean follow-up time was 24.4 months (range, 6 to 65 months). The total flap loss rate was 6.5 percent, and the take-back rate was 13 percent (salvage rate, 75 percent). Vascular complication rates were as follows: intraoperative arterial thrombosis, 13 percent; intraoperative venous thrombosis, 3 percent; delayed arterial thrombosis, 3 percent; and delayed venous thrombosis, 13 percent. Nineteen percent of patients had sensory complaints at the donor site that persisted beyond 3 months postoperatively. In comparison to the DIEP flap, IGAP flaps had a higher rate of intraoperative arterial thrombosis (13 percent versus 2.6 percent, p = 0.024) and delayed venous thrombosis (13 percent versus 1.5 percent, p = 0.008). Conclusions: Review of the IGAP flap reveals some shortcomings of this flap even in the hands of an experienced microsurgeon. Surgeons should be aware of the difficulties and limitations when choosing this flap for reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Increased hospital volume is associated with improved outcomes following abdominal-based breast reconstruction

Abstract Previous studies of outcomes following abdominal-based breast reconstruction largely use data from single-centre/surgeon experience. Such studies are limited in evaluating the effect of operative volume on outcomes. Abdominal-based breast reconstructive procedures were identified in the 2009–2010 HCUP Nationwide Inpatient Sample. Outcomes included in-hospital microvascular complications in free flap cases (requiring exploration/anastomosis revision), procedure-related and total complications in all cases, and length of stay (LOS). High-volume hospitals were defined as 90th percentile of case volume or higher (>30 flaps/year). Univariate and multivariate analyses were performed to identify predictors of outcomes. Of the 4107 patients identified, mean age was 50.7 years; 71% were white, 68% underwent free flap reconstruction, and 25% underwent bilateral reconstruction. The total complication rate was 13.2%, and the microvascular complication rate was 7.0%. Mean LOS was 4.5 days. There were 436 hospitals; 59% of cases were performed at high-volume institutions. Patients at high-volume hospitals more often underwent free flap reconstruction compared to low-volume hospitals (82.4% vs 50.5%, p < 0.001). On unadjusted analysis, microvascular complication rates of 6.4% vs 8.2% were observed for high-volume compared to low-volume hospitals (p = 0.080). After adjusting for case-mix, high-volume hospitals were associated with a decreased likelihood of suffering a microvascular complication (OR = 0.71, p = 0.026), procedure-related complication (OR = 0.79, p = 0.033), or total complication (OR = 0.75, p = 0.004). The majority of cases nationwide are performed at a small number of high-volume hospitals. These hospitals appear to discharge patients earlier and have lower microvascular, procedure-related, and total complication rates when controlling for case-mix.

Factors associated with decision to pursue mastectomy and breast reconstruction for treatment of ductal carcinoma in situ of the breast

BACKGROUND Factors influencing the treatment of ductal carcinoma in situ with mastectomy and reconstruction are poorly understood. METHODS A retrospective cohort study of 196 patients presenting to one institution was performed. RESULTS Forty-seven patients (24.0%) were treated with mastectomy, while 149 (76.0%) underwent breast-conserving surgery. Of the mastectomy patients, 28 (59.6%) elected for reconstruction. On bivariate analysis, patients who opted for mastectomy were younger than those treated with breast-conserving surgery (median age, 51.8 vs. 56.5 years; P = .017) and had higher grade tumors (50.0% vs. 34.6% grade 3, P = .009). Among patients treated with mastectomy, those who opted for reconstruction were younger than those forgoing reconstruction (49.4 vs. 56.9 years, P = .024). Race, ductal carcinoma in situ tumor size, and histologic subtype were not associated with the decision to pursue mastectomy or reconstruction (P > .05 for all). CONCLUSIONS In patients with ductal carcinoma in situ, the decision to pursue mastectomy and reconstruction appears to be driven by younger patient age and higher tumor grade.

Promise and Limitations of Big Data Research in Plastic Surgery.

BackgroundThe use of “Big Data” in plastic surgery outcomes research has increased dramatically in the last 5 years. This article addresses some of the benefits and limitations of such research. MethodsThis is a narrative review of large database studies in plastic surgery. ResultsThere are several benefits to database research as compared with traditional forms of research, such as randomized controlled studies and cohort studies. These include the ease in patient recruitment, reduction in selection bias, and increased generalizability. As such, the types of outcomes research that are particularly suited for database studies include determination of geographic variations in practice, volume outcome analysis, evaluation of how sociodemographic factors affect access to health care, and trend analyses over time. The limitations of database research include data which are limited only to what was captured in the database, high power which can cause clinically insignificant differences to achieve statistical significance, and fishing which can lead to increased type I errors. The National Surgical Quality Improvement Project is an important general surgery database that may be useful for plastic surgeons because it is validated and has a large number of patients after over a decade of collecting data. The Tracking Operations and Outcomes for Plastic Surgeons Program is a newer database specific to plastic surgery. ConclusionsDatabases are a powerful tool for plastic surgery outcomes research. It is critically important to understand their benefits and limitations when designing research projects or interpreting studies whose data have been drawn from them. For plastic surgeons, National Surgical Quality Improvement Project has a greater number of publications, but Tracking Operations and Outcomes for Plastic Surgeons Program is the most applicable database for plastic surgery research.

Coumadin-induced skin necrosis of the breasts: case report.

AbstractA case report of coumadin-induced skin necrosis (CISN) is presented, followed by a topic review of CISN, which reviews presentation, pathophysiology, differential diagnosis, prevention, and management of this disorder. The prevalence of CISN is low (0.01%–0.1% of patients receiving coumadin). However, of those affected, over 50% required some form of surgical debridement or reconstruction. Although skin necrosis secondary to coumadin therapy is rare, it is essential for plastic surgeons to be aware of this clinical entity in order to make the correct diagnosis and provide appropriate treatment.

A novel method of auricular reconstruction.

Seven male patients and 8 total ears underwent composite excision for neoplasm of the auricular helix. Defect size ranged from 2.5 to 4.5 cm exceeding the conventional limit of l.5 cm for wedge excision with primary closure. An incision at the root of the helix released the superior auricular muscle and a portion of the strong supporting anterior auricular tendon. An inferior incision allowed for the advancement of the lobule. The combined release permitted chondrocutaneous mobilization and closure without tension. The cupping deformity was avoided by trimming the concha in a wedge excision. Notching was eliminated with a step cut and close approximation on closure. The superior auriculocephalic sulcus was preserved by altering the fulcrum point of rotation. Ears were reconstructed with favorable esthetic outcome with over 1 year of follow-up in 5 of 7 patients. This technique represents an alternative method of single stage reconstruction of the auricular helix.

Barbed Sutures and Tendon Repair—a Review

IntroductionTraumatic tendon lacerations are a common problem encountered by hand surgeons worldwide. Although the use of barbed suture to repair tendon lacerations has gained theoretical popularity in recent years, there is little information available regarding the safety, efficacy, longevity, or complications encountered when used in tenorraphy. In this study, we review the available literature on the use of barbed suture in tendon repair.MethodsStudies conducted between 1980 and 2014 were identified using several databases, including EMBASE, SCOPUS, MEDLINE, and Web of Science. Keywords used to search for appropriate studies included the following: barbed, v loc, quill, tendon, tendon injuries, suture, tenorraphy, injury, and laceration, in various combinations.ResultsOur initial literature search identified 47 articles, and 8 were deemed appropriate for review after applying our exclusion criteria. The data from each of the articles is reviewed for the following major categories:1.Maximum load to failure2.Mode of failure3.Load to 2-mm gap4.Change in cross-sectional area5.Type of repairConclusionsBarbed suture tenorraphy has a myriad of theoretical advantages, supported by varying ex vivo studies, as compared to traditional techniques. However, due to the non-uniformity in current studies and the lack of available data in a live model, we are unable to argue for or against barbed suture tenorraphy. We believe our review provides the most in-depth analysis of barbed suture tenorraphy to date, illuminates the potential advantages of using barbed sutures, and highlights the need for further investigation into this technique.

A Comparison of Superomedial versus Inferior Pedicle Reduction Mammaplasty Using Three-Dimensional Analysis.

A COMPARISON OF SUPEROMEDIAL VERSUS INFERIOR PEDICLE REDUCTION MAMMOPLASTY USING THREE-DIMENSIONAL ANALYSIS. Victor Z. Zhu, Ajul Shah, Rachel Lentz, Tracy Sturrock, Alexander F. Au, Stephanie L. Kwei. Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, CT. Reduction mammoplasty using the inferior pedicle (IP) technique continues to be more commonly performed than the superomedial pedicle (SMP). This study uses three-dimensional (3D) imaging to compare postoperative linear and volumetric changes in SMP and IP breast reductions. Reduction mammoplasty was performed using either a SMP or IP, with a Wise-pattern skin incision. Patients in each cohort were matched based on total postoperative breast size, BMI, and age. Postoperative 3D photographs were taken at 1-3 months and 6-12 months. Measurements included: sternal notch to nipple distance, areola surface area, total breast volume, breast projection, proportion superior pole volume, proportion medial pole volume, and tissue shifting over time. There were 13 SMP patients (26 breasts) and 14 IP patients (28 breasts). There were significant differences at 1-3 months between the cohorts in sternal notch to nipple distance (21.6+0.4cm SMP vs. 24.1+0.3cm IP, p<0.01), and proportion superior pole volume (53.9+1.2% SMP vs. 57.3+1.1% IP, p=0.04). The sternal notch to nipple distance (21.6+0.4cm SMP vs. 24.6+0.4cm IP, p<0.01) remained different between the two cohorts at 6-12 months; however, there was no difference in superior pole fullness at this time point. There was a significant difference in proportion medial pole volume (38.1+2.0% SMP vs. 45.8+1.4% IP, p<0.01). There were changes in volumetric distribution over time in both cohorts, with decreased proportion medial pole volume in the SMP cohort, and increased proportion medial pole volume in the IP cohort (p<0.01) over time. Areola surface area increased significantly more over time in the IP cohort than the SMP cohort (2.87+0.77cm IP vs. 0.01+0.57cm SMP, p<0.01). There is no difference between the SMP and IP technique in proportion superior pole volume or breast projection within the 12-month postoperative period; however, the IP technique demonstrated greater proportion medial pole volume and increased areolar surface area over time.

Abstract 14. Should Nerve Coaptation Be Routine? Breast Sensation Following Mastectomy +/- Reconstruction

METHOD: Nationwide Inpatient Sample (2006–2011) was queried to identify bilateral breast reduction cases. Patients with rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome, Raynaud’s syndrome, psoriatic arthritis, or scleroderma were identified. Demographic factors, comorbidities, and postoperative complications were compared to patients without CTD using student t-test, chi-square, and risk-adjusted multivariate logistic regression.