Introduction to “Advances in Microsurgical Breast Reconstruction”
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PROVIDER: S-EPMC10915425 | biostudies-literature | 2024 Feb
REPOSITORIES: biostudies-literature
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Project description:BackgroundSubspecialization with dedicated perioperative teams has become common practice in some surgical disciplines. While surgeon experience, the number of surgeons involved, and enhanced recovery after surgery (ERAS) pathways are known factors affecting the outcome after microsurgical breast reconstruction, the impact of the perioperative team has not been studied.MethodsWe conducted a retrospective cohort study consisting of a chart review of all patients who underwent microsurgical breast reconstruction from January 2019-April 2020. Surgery was performed by three microsurgeons at two institutions with different perioperative teams-one being a small clinic [private clinic (PC), 33 beds] and the other being a larger hospital [corporate hospital (CH), 335 beds]. Patients were grouped into two cohorts according to the institution where surgery was performed. The primary outcomes studied were frequency of revision surgery, flap loss and patient length-of-stay (LOS).ResultsOne hundred and fifty microsurgical breast reconstructions were performed in 125 patients. Demographic data [age, body mass index (BMI), current tobacco use, donor site] was found statistically comparable between both cohorts. In the PC cohort with fewer perioperative care providers, lower rates of revision surgery and flap loss were observed (P value =0.009 and 0.04, respectively). LOS was not significantly different between the two cohorts (P value =0.44).ConclusionsThe outcome of microsurgical breast reconstruction depends on multiple factors. In this study, fewer flap complications occurred at the small clinic. One reason among others might be the lower number of perioperative care providers involved and hence higher likelihood of sharing microsurgical cases, which facilitates routine and ensures less variability in care. The value of perioperative team subspecialization in microsurgical breast reconstruction needs to be assessed in prospective studies.
| S-EPMC9742050 | biostudies-literature
Project description:BackgroundSurgical and technological advances have resulted in the widespread adoption of microsurgical breast reconstruction. Many comorbidities that potentially might impair vasculature and wound healing are no longer considered contraindications for these procedures. However, some uncertainty still prevails regarding the perioperative management of patients with disorders of hemostasis.MethodsThe authors combined a literature review with a retrospective chart review of patients with disorders of hemostasis who had undergone microsurgical breast reconstruction at the senior author's (J.F.) center between 2015 to 2020. Several disorders associated with thrombotic and/or hemorrhagic complications were identified, and a standardized risk assessment and management strategy was developed in cooperation with a hematologist.ResultsOverall, 10 studies were identified comprising 29 patients who had a defined disorder of hemostasis and underwent microsurgical breast reconstruction. Seventeen microsurgical breast reconstructions were performed on 11 patients at the senior author's (J.F.) center. High factor VIII levels, heterozygous factor V Leiden, and heterozygous prothrombin mutation G20210A were the most common genetic or mixed genetic/acquired thrombophilic conditions. As expected, hereditary antithrombin, protein C, or protein S deficiencies were rare. Among hemorrhagic disorders, thrombocytopenia, platelet dysfunction, and von Willebrand disease or low von Willebrand factor levels were those factors most frequently associated with increased perioperative bleeding.ConclusionsPatients should be screened for elevated risk of thrombosis or bleeding before undergoing microsurgical breast reconstruction, and positive screening should prompt a complete hematologic evaluation. Interdisciplinary management of these disorders with a hematologist is essential to minimize risks and to obtain optimal reconstructive results.Clinical question/level of evidenceRisk, IV.
| S-EPMC10262037 | biostudies-literature
Project description:Background and objectiveBreast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons.MethodsA comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers.Key content and findingsIn this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications.ConclusionsWhile implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.
| S-EPMC11399014 | biostudies-literature
Project description:BackgroundCommercial payments for implant-based breast reconstruction have increased within the past decade, whereas reimbursements have stagnated for microsurgical techniques. The physician payment-to-work relative value unit ratio allows for standardization when comparing procedures of differing complexity. This study aimed to characterize payment per work relative value unit for common breast and nonbreast microsurgical procedures.MethodsThe Massachusetts All-Payer Claims Database was queried from 2010 to 2014 for Current Procedural Terminology (CPT) codes related to microsurgical and breast reconstruction. International Classification of Diseases codes were further used to categorize procedures by anatomical region, including head and neck, breast, trunk, and extremities. Physician payments, both commercial and governmental, were aggregated by anatomical region and CPT code. Payment distributions were described with means and medians and compared using statistical tests.ResultsAmong 3435 commercial claims, distributions of physician payments per work relative value unit for microsurgical and common breast procedures differed only for breast free flaps billed through S codes (p < 0.001). Microsurgical breast procedures (CPT code 19364) had significantly greater median payments per work relative value unit compared to microsurgery of the head and neck, trunk, and upper extremities (p = 0.004). Payment per work relative value unit for common breast and nonbreast microsurgical procedures did not differ significantly among governmental claims (p = 0.103).ConclusionsAdjustment of physician payments by work relative value units did not show significant variability across common breast procedures, except for S codes, suggesting that payments are mostly driven by differences in work relative value units and individual contractual negotiations. Lower payments per work relative value unit for other regions compared to breast suggests an opportunity for negotiation with commercial payers.
| S-EPMC8415094 | biostudies-literature
Project description: Not available
| S-EPMC9906097 | biostudies-literature
Project description:Autologous reconstruction using abdominal flaps remains the most popular method for breast reconstruction worldwide. We aimed to evaluate a prediction model using machine-learning methods and to determine which factors increase abdominal flap donor site complications with logistic regression. We evaluated the predictive ability of different machine learning packages, reviewing a cohort of breast reconstruction patients who underwent abdominal flaps. We analyzed 13 treatment variables for effects on the abdominal donor site complication rates. To overcome data imbalances, random over sampling example (ROSE) method was used. Data were divided into training and testing sets. Prediction accuracy, sensitivity, specificity, and predictive power (AUC) were measured by applying neuralnet, nnet, and RSNNS machine learning packages. A total of 568 patients were analyzed. The supervised learning package that performed the most effective prediction was neuralnet. Factors that significantly affected donor-related complication was size of the fascial defect, history of diabetes, muscle sparing type, and presence or absence of adjuvant chemotherapy. The risk cutoff value for fascial defect was 37.5 cm2. High-risk group complication rates analyzed by statistical method were significant compared to the low-risk group (26% vs 1.7%). These results may help surgeons to achieve better surgical outcomes and reduce postoperative burden.
| S-EPMC7946880 | biostudies-literature
Project description:Defect reconstruction after radical oncologic resection of malignant chest wall tumors requires adequate soft tissue reconstruction with function, stability, integrity, and an aesthetically acceptable result of the chest wall. The purpose of this article is to describe possible reconstructive microsurgical pathways after full-thickness oncologic resections of the chest wall. Several reliable free flaps are described, and morbidity and mortality rates of patients are discussed.
| S-EPMC3140233 | biostudies-other
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| S-EPMC8489888 | biostudies-literature
Project description:Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.
| S-EPMC9900030 | biostudies-literature
Project description:BackgroundSarcopenia is characterized by the loss of skeletal muscle mass and power. Preoperative sarcopenia may be associated with an increased risk of postoperative complications after autologous free-flap breast reconstruction surgery; however, this relationship is controversial.ObjectivesThis study aimed to determine whether preoperative sarcopenia is associated with a high complication rate in patients undergoing autologous free-flap breast reconstruction.MethodsPatients who underwent autologous free-flap breast reconstruction at our hospital between 2019 and 2021 were included in the study. Data on significant complications requiring surgical intervention were retrospectively collected from the medical records. Sarcopenia was defined as having a skeletal muscle index value <41 cm2/m2. The skeletal muscle index was calculated by dividing the sum of the psoas and iliopsoas muscle areas at the level of the third lumbar vertebra by the patient's height in meters squared. The relationship between preoperative sarcopenia and postoperative complications was investigated using an inverse probability of treatment weighting (IPTW) analysis.ResultsAmong the 203 participants, 90 (44.33%) had preoperative sarcopenia. The general patient characteristics were similar between the sarcopenia and non-sarcopenia groups after IPTW adjustment. Sarcopenia did not significantly increase the risk of flap failure or emergency surgery related to breast reconstruction before IPTW adjustment. However, after IPTW adjustment, the rates of recipient site infection and hematoma were significantly higher in participants with sarcopenia than in those without sarcopenia (p < 0.001 and p = 0.014, respectively).ConclusionPreoperative sarcopenia may influence certain complications of autologous free-flap breast reconstruction surgery.
| S-EPMC10652871 | biostudies-literature