Emily C. Cleveland

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.

Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 national surgical quality improvement program data sets.

Background: The authors assess the risk and safety profiles of both implant and autologous breast reconstructions in the morbidly obese population using the National Surgical Quality Improvement Program data sets. Methods: The authors reviewed the 2005 to 2010 National Surgical Quality Improvement Program databases, identifying encounters for Current Procedural Terminology codes including either implant-based reconstruction or autologous reconstruction. Patients were classified and compared based on World Health Organization obesity criteria. Complications were divided into three categories: major surgical complications, wound complications, and medical complications. Results: During the study period, 15,937 breast reconstructions were identified. The incidence of obesity was 27.1 percent, with 4.0 percent defined as class III (morbidly) obese. Morbidly obese patients had significantly higher rates of almost all complications compared with nonobese patients, including major surgical complications (p < 0.001), medical complications (p < 0.001), respiratory complications (p = 0.015), venous thromboembolism (p = 0.001), and wound complications (p < 0.001). These patients also were more likely to require a return to the operating room both for any reason (p < 0.001) and specifically for prosthesis/flap failure (p < 0.001). Morbid obesity was found to be an independent predictor of wound complications (OR, 2.1; p < 0.001), surgical complications (OR, 1.6; p < 0.001), medical complications (OR, 1.6; p = 0.01), and return to the operating room (OR, 1.5; p < 0.001). There was no significant difference in the 30-day surgical complication rates between implant and autologous reconstructions in the morbidly obese (p = 0.23). Conclusion: Morbid obesity is associated with a significantly increased risk of perioperative complications that translates into progressive, higher rates of overall morbidity, regardless of reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction.

PURPOSE Complex lower extremity wounds present a significant challenge to the reconstructive surgeon. We report a consecutive experience of free tissue transfers for lower extremity reconstruction with a focus on outcomes and flap selection. METHODS A retrospective review of all free tissue transfers for lower extremity reconstruction between 2006 and 2011 was performed. Minor complications were defined as nonoperative complications (infection, seroma, hematoma, wound breakdown, and partial loss). Major complication required a surgical intervention (total flap loss, thrombosis, nonunion, amputation, and hematoma). RESULTS A total of 119 free flaps were performed in 114 patients. Reconstructed defects were most commonly derived from acute traumatic (N = 40) or chronic traumatic (N = 34) wounds, oncologic (N = 14), or diabetic (N = 8). Flap loss occurred at a rate of 5.9% and the overall lower extremity salvage rate was 93%. Complications were significantly higher for free tissue transfers to the region of the distal tibia (p = 0.04). Major complications were significantly higher in patients with chronic obstructive pulmonary disease (p = 0.02) and in patients who experienced intraoperative technical difficulties (p = 0.014). Flap loss was significantly higher when the rectus abdominis flap was used (p = 0.02) and when a delayed venous thrombotic event occurred (p = 0.001). CONCLUSION Patient comorbidities and defect location can be associated with higher rates of complications; flap selection and delayed venous thrombotic events appear to be associated with flap failure.Level of Evidence Prognostic/risk category, level III.

Roll, Spin, Wash, or Filter? Processing of Lipoaspirate for Autologous Fat Grafting: An Updated, Evidence-Based Review of the Literature.

Background: The use of autologous adipose tissue harvested through liposuction techniques for soft-tissue augmentation has become commonplace among cosmetic and reconstructive surgeons alike. Despite its longstanding use in the plastic surgery community, substantial controversy remains regarding the optimal method of processing harvested lipoaspirate before grafting. This evidence-based review builds on prior examinations of the literature to evaluate both established and novel methods for lipoaspirate processing. Methods: A comprehensive, systematic review of the literature was conducted using Ovid MEDLINE in January of 2015 to identify all relevant publications subsequent to the most recent review on this topic. Randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation. Results: Nine articles comparing various methods of processing human fat for autologous grafting were selected based on inclusion and exclusion criteria. Five compared established processing techniques (i.e., decanting, cotton gauze rolling, centrifugation, and washing) and four publications evaluated newer proprietary technologies, including washing, filtration, and/or methods to isolate stromal vascular fraction. Conclusions: The authors failed to find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician’s ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.

Complications Following Reduction Mammaplasty

BACKGROUND Reduction mammaplasty is an established and effective technique to treat symptomatic macromastia. Variable rates of complications have been reported, and there is a continued need for better outcome assessment studies. OBJECTIVE The authors investigate predictors of postoperative complications following reduction mammaplasty using the National Surgery Quality Improvement Program (NSQIP) data sets. METHODS The 2005-2010 American College of Surgeons NSQIP databases were reviewed to identify primary encounters for reduction mammaplasty using Current Procedural Terminology code 19318. Two complication types were recorded: major complications (deep infection and return to operating room) and any complication (all surgical complications). Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. A multivariate regression analysis was used to identify independent predictors of complications. RESULTS A total of 3538 patients were identified with an average age of 43 years and body mass index of 31.6 kg/m(2). Most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes. The incidence of overall surgical complications was 5.1%. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01). The incidence of major surgical complications was 2.1%. Factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). CONCLUSIONS This study demonstrates overall incidence of complications in 1 in 20 patients and a 1 in 50 incidence of a major surgical complication. Noteworthy findings include the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. These data can assist surgeons in preoperative counseling and enhance perioperative decision making.

The virtual-patient pilot: testing a new tool for undergraduate surgical education and assessment.

BACKGROUND The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients. METHODS Three VP cases were developed using commercially available software to simulate common surgical scenarios. Surgical clerks volunteered to complete VP cases. Upon case completion, an individual performance score (IPS, 0-100) was generated and a 16-item survey was administered. Surgery shelf exam scores of clerks who completed VP cases were compared with a cohort of students who did not have exposure to VP cases. Descriptive statistics were performed to characterize survey results and mean IPS. RESULTS Surgical clerks felt that the VP platform was simple to use, and both the content and images were well presented. They also felt that VPs enhanced learning and were helpful in understanding surgical concepts. Mean IPS at conclusion of the surgery clerkship was 69.2 (SD 26.5). Mean performance on the surgery shelf exam for the student cohort who had exposure to VPs was 86.5 (SD 7.4), whereas mean performance for the unexposed student cohort was 83.5 (SD 9). DISCUSSION The VP platform represents a new educational tool that allows surgical clerks to direct case progression and receive feedback regarding clinical-management decisions. Its use as an assessment tool will require further validation.

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets.

BACKGROUND This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR). METHODS We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3). RESULTS Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism. CONCLUSIONS Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.

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

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.