Michele A. Manahan

The impact of obesity on breast surgery complications

Background: The increasing prevalence of obesity may worsen surgical outcomes and confound standardized metrics of surgical quality. Despite anecdotal evidence, the increased risk of complications in obese patients is not accounted for in these metrics. To better understand the impact of obesity on surgical complications, the authors designed a study to measure complication rates in obese patients presenting for a set of elective breast procedures. Methods: Using claims data from seven Blue Cross and Blue Shield plans, the authors identified a cohort of obese patients and a nonobese control group who underwent elective breast procedures covered by insurance between 2002 and 2006. The authors compared the proportion of patients in each group who experienced a surgical complication. Using multivariate logistic regression, the authors calculated the odds of developing a surgical complication when obesity was present. Results: There were 2403 patients in the obese group (breast reduction, 80.7 percent; reconstruction, 10.3 percent; mastopexy with augmentation, 1.5 percent; mastopexy alone, 3.5 percent; and augmentation alone, 4.0 percent). The occurrence of complications was compared for each procedure to a nonobese control group of 5597 patients. Overall, 18.3 percent of obese patients had a claim for a complication, compared with only 2.2 percent in the control group (p < 0.001). Obesity status increased the odds of experiencing a complication by 11.8-fold after adjusting for other variables. Conclusions: Obesity is associated with a nearly 12-fold increased odds of a postoperative complication after elective breast procedures. As quality measures are increasingly applied to surgical evaluation and reimbursement, appropriate risk adjustment to account for the effect of obesity on outcomes will be essential. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Massive panniculectomy after massive weight loss.

Background: Massive weight loss, defined as loss of 50 percent of excess weight, often results in laxity and redundancy of the abdominal skin, causing disabling rashes, pain, physical limitation, back strain, and cosmetic deformity. The heavier the panniculus, the more marked the symptoms. Panniculectomy can treat these symptoms, but the approach must be customized because of complex medical and surgical histories related to obesity and the size of the panniculus. The aim of this study was to analyze a series of massive panniculectomies greater than 10 pounds following massive weight loss and to investigate the outcomes achieved. Methods: All patients undergoing massive abdominal panniculectomy by a single plastic surgeon at an academic hospital from October of 2000 to December of 2003 were retrospectively studied. Seven men and 17 women qualified: one woman had a two-stage abdominal panniculectomy, each time with greater than 10-pound abdominal skin resections. All but one patient had gastric bypass. Average weight loss was 171 pounds, with an average maximum body mass index of 70.5 and a minimum body mass index of 43.7 (morbid obesity is defined as a body mass index greater than 40). Patient presentation was regularly complicated by abdominal scars. Abdominal panniculectomy was performed with conservative undermining. Hernias were repaired at the time of surgery. Routine prophylaxis against thromboembolism was performed. Results: Average abdominal skin resection was 16.1 pounds, ranging from 10.3 to 49 pounds. Hernia repair was necessary in 13 patients. Additional surgery performed at the time of panniculectomy included skin reduction surgery of the back (40 percent), chest (32 percent), inner thigh (28 percent), and arm (28 percent). Blood transfusion was necessary in five of the cases (20 percent). Length of stay averaged 3 days. Complications included wounds requiring debridement, dressings, vacuum-assisted closure therapy and/or delayed primary closure (20 percent), and seroma requiring drain replacement or dressings (28 percent). Uncomplicated healing occurred in 44 percent of cases. Conclusion: Massive abdominal panniculectomy is challenging to plan, execute, and manage after surgery. The authors present their approach to these patients, with acceptable results.

A Review of the Surgical Management of Breast Cancer: Plastic Reconstructive Techniques and Timing Implications

The oncologic management of breast cancer has evolved over the past several decades from radical mastectomy to modern-day preservation of chest and breast structures. The increased rate of mastectomies over recent years made breast reconstruction an integral part of the breast cancer management. Plastic surgery now offers patients a wide variety of reconstruction options from primary closure of the skin flaps to performance of microvascular and autologous tissue transplantation. Well-coordinated partnerships between surgical oncologists, plastic surgeons, and patients address concerns of tumor control, cosmesis, and patients’ wishes. The gamut of breast reconstruction options is reviewed, particularly noting state-of-the-art techniques, as well as the advantages and disadvantages of various timing modalities.

Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: Review of a single surgeon's early experience†

The purpose of this study is to describe the early experience of a single surgeon just out of training, including preoperative conditioning, surgical approach, and outcomes in bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction patients.

Increasing age impairs outcomes in breast reduction surgery.

Background: Although multiple breast reduction outcomes studies have been performed, none has specifically identified the impact of advanced age. The authors aimed to study the impact of age on breast reduction outcome. Methods: Medical records for all patients billed for Current Procedural Terminology code 19318 over the past 10 years (1999 to 2009) at a large academic institution were analyzed under an institutional review board–approved protocol. A total of 1192 consecutive patients underwent 2156 reduction mammaplasties performed by 17 plastic surgeons over a 10-year period. Breast reduction techniques included inferior pedicle/Wise pattern in 1250 patients (58.9 percent), medial pedicle/Wise pattern in 360 (16.9 percent), superior pedicle/nipple graft in 305 (14.4 percent), superior pedicle/vertical pattern in 206 (9.7 percent), and liposuction in three (0.14 percent). The average patient age was 36 years. Age groups were divided into younger than 40 years, 40 to 50 years, and older than 50 years. Multiple logistic regression analysis was performed to identify significant relationships. Results: Women older than 50 years more likely experienced infection (odds ratio, 2.7; p = 0.003), with trends toward wound healing problems (odds ratio, 1.6; p = 0.09) and reoperative wound débridement (odds ratio, 5.1; p = 0.07). There was a trend toward infection in women aged 40 to 50 years (odds ratio, 1.7; p = 0.08). Advanced age did not exacerbate fat necrosis or seroma development. Conclusions: Age older than 50 years impairs breast reduction outcomes, particularly infection, and may negatively impact wound healing. Hormonal deficiency may partially account for this finding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

An outcomes analysis of 2142 breast reduction procedures

BackgroundBreast reduction alleviates macromastia symptoms and facilitates symmetrical breast reconstruction after cancer treatment. We investigated a large series of consecutive breast reductions to study important factors that impact outcomes. MethodsAn institutional review board–approved, retrospective review of all breast reductions from 1999 to 2009 in a single institution was performed using the medical record for demographics, medical history, physical examination, intraoperative data, and postoperative complications. Multivariate statistical analysis was performed using Stata 1.0. P ⩽ 0.05 defined significance. ResultsSeventeen surgeons performed 2152 consecutive breast reductions on 1148 patients using inferior pedicle/Wise pattern (56.4%), medial pedicle/Wise pattern (16.8%), superior pedicle/nipple graft/Wise pattern (15.1%), superior pedicle/vertical pattern (11.6%), and liposuction (0.1%) techniques. Complications included discernible scars (14.5%), nonsurgical wounds (13.5%), fat necrosis (8.2%), infection (7.3%), wounds requiring negative pressure wound therapy or reoperation (1.4%), and seroma (1.2%). Reoperation rates were 6.7% for scars, 1.4% for fat necrosis, and 1% for wounds.Body mass index greater than or equal to 35 kg/m2 increased risk of infections [odds ratio (OR), 2.3, P = 0.000], seromas (OR, 2.9, P = 0.03), fat necrosis (OR, 2.0, P = 0.002), and minor wounds (OR, 1.7, P = 0.001). Cardiac disease increased reoperation for scar (OR, 3.0, P = 0.04) and fat necrosis (OR, 5.3, P = 0.03). Tobacco use increased infection rate (OR, 2.1, P = 0.008). Secondary surgery increased seromas (OR, 12.0, P = 0.001). Previous hysterectomy/oophorectomy increased risk of wound reoperations (OR, 3.4, P = 0.02), and exogenous hormone supplementation trended toward decreasing infections (OR, 0.5, P = 0.08). &khgr;2 analysis revealed 7.8% infection risk without exogenous hormone versus 3.8% risk with hormone supplementation (P = 0.02). ConclusionsMorbid obesity, tobacco, cardiac history, and secondary surgery negatively impacted breast reduction outcomes. Hormonal status impacted reoperations and infections.

Abdominally based free flap planning in breast reconstruction with computed tomographic angiography: systematic review and meta-analysis.

Background: Computed tomographic angiography is often used for preoperative mapping. The authors aimed to systematically assess breast reconstruction outcomes after abdominally based free flaps planned with preoperative computed tomographic angiography versus Doppler ultrasonography. Methods: A search of the PubMed, EMBASE, and Scopus databases and an additional hand-search of relevant articles until June of 2012 rendered 442 English-language citations. Three authors independently reviewed these citations and included all the studies comparing preoperative computed tomographic angiography versus Doppler ultrasonography with regard to short-term postoperative outcomes and operative times. A meta-analysis was performed to evaluate the incidence of flap-related complications (seven studies), donor-site morbidity (four studies), and operative times (five studies) between preoperative computed tomographic angiography and Doppler ultrasonography. A pooled relative risk was calculated using a random-effect model to compare complication rates between the computed tomographic angiography and Doppler ultrasonography groups. Results: A total of 13 studies met inclusion criteria. Preoperative computed tomographic angiography was associated with significantly fewer flap-related complications (relative risk, 0.87; 95 percent CI, 0.78 to 0.97), reduced donor-site morbidity (relative risk, 0.84; 95 percent CI, 0.76 to 0.94), and shorter reconstruction operative time by 87.7 minutes (mean difference, 87.7 minutes; 95 percent CI, 78.3 to 97.1 minutes). Conclusions: The use of preoperative computed tomographic angiography reduces the operative time, postoperative flap-related complications, and donor-site morbidity compared with Doppler ultrasonography. Preoperative computed tomographic angiography has the potential to reduce operative cost and increase efficiency in the operating room. Thus, preoperative mapping by computed tomographic angiography should be strongly considered for abdominally based free flap breast reconstruction.

Three-dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction†

Background: Three‐dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free‐flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested. Methods: Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights. Results: The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the “middle half” of the patients, was 91–109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70–133%). Conclusion: 3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patients lower abdomen.

Pilot study of breast sensation after breast reconstruction: Evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery

Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation.

Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction

Background. Many studies demonstrate direct patient benefits from use of preoperative computed tomography angiograms (CTA) for abdominal tissue‐based breast reconstruction. We present a novel classification schema to translate imaging results into further clinical relevance. Methods. Each hemiabdomen CTA was classified into a schema that addressed findings of expected anatomy, anatomy that necessitates a change in operative technique and anatomy that suggests less morbid procedures may be considered. Results. Eighty‐six patients (172 hemiabdomens) were available for study. Of the reconstructions performed in this time period, 40 (47%) were bilateral and 46 (53%) unilateral. Based on perforator size and location, relative perimuscular anatomy, and continuity of vessels, five categories were defined: type I “Traditional” anatomy (n = 150, 87%), type II “Highly Favorable” anatomy (n = 11, 6.4%), type III “Altered‐Superiorly Translocated” anatomy (n = 9, 5.2%), type IV “Superficial Dominant” anatomy (n = 26, 15%), and type V “Hostile” anatomy (n = 4, 2.3%). The additive total is greater than 100%, because vessels may fall into more than one category. Discussion. In providing the microsurgeon with a preoperative vascular map that has the potential to influence the preoperative, operative, and postoperative course, abdominal CTAs should be considered a worthy adjunct to the diagnostic armamentarium of the reconstructive surgeon. These classifications and their clinical impacts become even more important in centers performing increasing numbers of bilateral reconstructions. We believe that our simple schema can facilitate effective use of this powerful tool, aiding in overall care of the breast reconstruction patient.