Brady Sieber

Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps.

Background: Free tissue transfer is standard for postoncologic reconstruction, yet it entails a lengthy operation and significant recovery. The authors present their longitudinal experience of free tissue breast reconstructions with an emphasis on predictors of major surgical and medical complications. Methods: The authors reviewed their prospectively maintained free flap database and identified oncologic breast reconstruction patients from 2005 to 2011. Factors associated with surgical and medical complications were identified using univariate analyses and logistic regression to determine predictors of complications. Results: Complications included major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)]. Obesity (p = 0.034), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with immediate complications. Similarly, delayed surgical complications were associated with obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), and prior radiation therapy (p = 0.06). Regression analysis demonstrated that flap choice (p = 0.024) was independently associated with major immediate complications, and patient comorbidities such as chronic obstructive pulmonary disease (p = 0.001) and obesity (p < 0.0001) were associated with delayed complications. Patients who developed an immediate surgical complication experienced longer hospital stays (p < 0.0001), higher operating costs (p < 0.001), and greater hospital costs (p < 0.001). Conclusions: Early major complications are related to flap selection, whereas late major complications are associated with patient comorbidities. Overall, major surgical and medical complications are associated with increased hospital length of stay and greater cost in autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions.

Background: The authors’ institution has seen an increase in obese and morbidly obese patients seeking autologous breast reconstruction. The authors provide a comprehensive outcome analysis of patients undergoing abdominally based autologous breast reconstruction. Methods: The authors identified obese patients receiving free tissue transfer for breast reconstruction. World Health Organization body mass index criteria were used: nonobese (body mass index, 20 to 29.9 kg/m2), class I (30 to 34.9 kg/m2), class II (35 to 39.9 kg/m2), and class III (>40 kg/m2). Patient comorbidities, body mass index, complications (medical and surgical), and hospital resource use were examined. Results: Eight-hundred twelve patients undergoing 1258 free tissue transfers for breast reconstruction were included. Overall, 66.5 percent (n = 540) were considered nonobese, 22.9 percent (n = 186) had class I obesity, 5.0 percent (n = 41) had class II, and 5.7 percent (n = 45) had class III. Obesity was associated with a significant increase in minor (p = 0.001) and major (p = 0.013) complications. Morbidly obese patients had significantly higher rates of total flap loss (p = 0.006) and longer operative times (p = 0.0002). Complications translated into greater cost and resource consumption (p < 0.001). Muscle-sparing transverse rectus abdominis myocutaneous flap experienced a significantly higher rate of hernia compared with other flaps (p = 0.02), without a difference in flap loss rate (p = 0.61). Conclusions: Increasing obesity is associated with increased perioperative risk in free abdominally based autologous breast reconstruction, which translated into greater perioperative morbidity, higher hospital cost, and increased health care resource consumption. Higher body mass index is directly related to intraoperative technical difficulty, flap loss, donor-site morbidity, and cost use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients.

Background: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions. Methods: A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs. Results: One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively). Conclusions: The authors’ analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Transfusions in autologous breast reconstructions: an analysis of risk factors, complications, and cost.

PurposeFree tissue transfer requires lengthy operative times and can be associated with significant blood loss. The goal of our study was to determine independent risk factors for blood transfusions and transfusion-related complications and costs. MethodsWe reviewed our prospectively maintained free flap database and identified all patients undergoing breast reconstruction receiving blood transfusions. These patients were compared with those not receiving a postoperative transfusion. We examined baseline patient comorbidities, preoperative and postoperative hemoglobin (HgB) levels, intraoperative and postoperative complications, and blood transfusions. Factors associated with transfusion were identified using univariate analyses, and multivariate logistic regression was used to determine independently associated factors. ResultsA total of 70 (8.2%) patients received postoperative blood transfusions. Multivariate analysis revealed associations between length of surgery (P = 0.01), intraoperative arterial thrombosis [odds ratio (OR), 6.75; P = 0.01], major surgical complications (OR, 25.9; P < 0.001), medical complications (OR, 7.2; P = 0.002), and postoperative HgB levels (OR, 0.2; P < 0.001). Transfusions were independently associated with higher rates of medical complications (OR, 2.7; P = 0.03). A significantly lower rate of medical complications was observed when a restrictive transfusion (HgB level, <7 g/dL) was administered (P = 0.04). A cost analysis demonstrated that each blood transfusion was independently associated with an added

Outcome analysis of 244 consecutive flaps for managing complex groin wounds

1,500 in total cost. ConclusionsSeveral key perioperative factors are associated with allogenic transfusion, including intraoperative complications, operative time, HgB level, and postoperative medical and surgical complications. Blood transfusions were independently associated with greater morbidity and added hospital costs. Overall, a restrictive transfusion strategy (HgB level, <7 g/dL or clinically symptomatic) may help minimize medical complications. Level of EvidencePrognostic/risk category, level III.

Optimizing the fascial closure: an analysis of 1261 abdominally based free flap reconstructions.

BACKGROUND Complex groin wounds present a significant challenge to the reconstructive surgeon. We present a large experience of flaps for managing complex groin wounds. The purpose of our study was to assess outcomes with respect to flap selection and indication (prophylactic versus salvage). PATIENTS AND METHODS A retrospective review of all patients receiving flaps for complex groin wounds between 2005 and 2011 was performed. Two types of procedures were evaluated: prophylactic muscle flaps (PMFs) and salvage flaps. We performed an outcome analysis of complications based on flap timing and selection. RESULTS A total of 244 flaps were performed during the study period: 146 flaps for salvage and 98 for prophylaxis. Flaps included: sartorius muscle flap (SMF) (N=132), rectus femoris flap (RFF) (N=99), and antero-lateral thigh (ALT) (N=13). Salvaged wounds had higher rates of major wound dehiscence compared to prophylactic wounds (P=0.002). The SMF (N=132) and RFF (N=99) cohorts were similar with respect to patient and operative characteristics, however, the RFF cohort tended to be obese (P=0.002), used for salvage (P=0.0005), endarterectomy procedures (P=0.018), and culture positive wounds (P=0.09). Major limb related complications (graft loss, limb loss, and reoperation) were significantly lower in the RFF group (P=0.03). CONCLUSIONS Muscle flaps for complex groin wounds can be safely performed with excellent outcomes. We suggest use of the SMF in the prophylactic setting and for smaller salvage wounds. The RFF may be better suited to address larger, more complex wounds. PMFs in select, high-risk patients optimize wound healing relative to patients undergoing groin wound salvage. LEVEL OF EVIDENCE Prognostic/risk category, level III.

A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications.

BackgroundDonor-site morbidity continues to be a significant complication in patients undergoing abdominally based breast reconstruction. The purposes of our study were to critically examine abdominal donor-site morbidity and to present our algorithm for optimizing donor site closure to reduce these complications. MethodsWe performed a retrospective cohort study examining all patients undergoing abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at our institution. Data were analyzed for overall donor site morbidity, as defined by hernia/bulge or reoperation for debridement and/or mesh removal and for hernia/bulge alone. ResultsA total of 812 patients underwent 1261 free tissue transfers. Fifty-three patients (6.5%) experienced donor-site morbidity, including 27 hernias/bulges (3.3%). No significant difference in overall abdominal morbidity was found between unilateral and bilateral reconstructions (P = 0.39) or the use of muscle in the flap (P = 0.11 unilateral msfTRAM, P = 0.76 bilateral). Prior lower abdominal surgery was associated with higher rates of donor-site morbidity (P = 0.04); hypertension (P = 0.012) and multiple medical comorbidities (P < 0.001) were also significantly more common in these patients. Obesity was the only patient characteristic associated with higher rates of hernia/bulge (P = 0.04). Delayed abdominal would healing was associated with hernia/bulge (P < 0.001); these patients were significantly more likely to develop this complication (odds ratio = 6.3, P < 0.001). ConclusionsParticular attention must be provided to donor-site closure in obese patients and those with hypertension and multiple medical comorbidities. Low rates of abdominal wall morbidity result from meticulous fascial reconstruction and reinforcement and careful attention to tension-free soft tissue closure.

Impact of obesity on outcomes in breast reconstruction: A systematic review protocol

PURPOSE Large, complex scalp defects represent a significant reconstructive challenge, thus a variety of free tissue transfer techniques have been employed to optimally provide soft tissue coverage. The aim of this study is to determine factors associated with complications. METHODS A retrospective cohort study was performed on patients undergoing free tissue transfer for scalp defects from 1997 to 2011. Patients were compared with respect to demographics, defect characteristics, intraoperative factors, flap choice, and postoperative complications. RESULTS Forty-three flaps were performed in 37 patients with a success rate of 97.7%. Multivariate regression demonstrated that defect characteristics (size of defect) and patient-related factors (age and smoking) were associated with wound complications in scalp reconstruction. Outcomes were similar between the latissimus dorsi (LD) and anterolateral thigh (ALT) groups and the immediate cranioplasty patients with respect to all forms of complications. CONCLUSIONS We report a 98% success rate using free tissue transfer for complex scalp defects and identify defect size, patient age, and smoking as factors associated with wound complications. Patient comorbidities were associated with major complications. We report equal efficacy in using the ALT and LD, as well as immediate cranioplasty. LEVEL OF EVIDENCE Prognostic/risk, level III.

Impact of Obesity on Outcomes in Breast Reconstruction: A Systematic Review and Meta-Analysis

Highlights • Summarise the risks related to breast reconstruction among obese women.• Both implant based and autologous reconstruction will be investigated.• Determine optimal methods of breast reconstruction.• Refine patient selection for each procedure.