Antibiotic Prophylaxis and Resistance in Surgical Site Infection After Immediate Tissue Expander Reconstruction of the Breast.

BACKGROUND: A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI. METHODS: An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed. RESULTS: In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin). CONCLUSIONS: Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.

Patient-Reported Quality of Life After Breast Reconstruction: A One-Year Longitudinal Study Using the WHO-QOL Survey.

BACKGROUND: Patient-reported quality of life (QOL) is an important measure of the impact that breast reconstruction has on postmastectomy patients. This study seeks to describe psychosocial outcomes after breast reconstruction and to identify factors that influence them. METHODS: All patients who underwent immediate postmastectomy reconstruction by the senior author between 2009 and 2011 were offered participation in this study. Patients completed the World Health Organization QOL-BREF questionnaire preoperatively and 1-year postoperatively. Change scores were compared across reconstructive techniques, as well as across various demographic and clinical variables. RESULTS: One hundred twenty-nine women completed the preoperative questionnaire, and 60 patients completed the follow-up questionnaire at 1 year (response rate, 46.5%). Compared to the preoperative baseline, overall QOL was unchanged, general satisfaction with health improved significantly, and QOL in physical, psychological, social, and environmental domains decreased (P < 0.05 for all but social domains). On bivariate analysis, being in a relationship at the time of reconstruction was associated with a decline in overall QOL, as well as the quality of social relationships and environment. Educational level impacted how physical and psychological wellness evolved after surgery. Patients with a higher cancer stage reported a decrease in satisfaction with health at 1 year. Type of reconstruction, development of a complication, and need for additional surgery did not influence any of these outcomes. CONCLUSIONS: At 1-year follow-up from postmastectomy reconstruction, breast cancer survivors report a similar overall QOL, but significant decrements in physical, psychological, and environmental QOL. Satisfaction with health improved. The type of breast reconstruction did not influence any of these outcomes.

Prevalence of Body Dysmorphic Disorder Among Patients Seeking Breast Reconstruction.

BACKGROUND: Body dysmorphic disorder (BDD) is characterized by a preoccupation with a slight or imagined defect in physical appearance. It has significant implications for patients who desire breast reconstruction, because patient satisfaction with the aesthetic outcome is a substantial contributor to the success of the procedure. OBJECTIVES: The authors estimated the prevalence of BDD among women seeking breast reconstruction by surveying patients with the previously validated Dysmorphic Concerns Questionnaire (DCQ). METHODS: One hundred eighty-eight women who presented for immediate or delayed breast reconstruction completed the DCQ anonymously, during initial consultation with a plastic surgeon. Two groups of respondents were identified: those who desired immediate reconstruction and those who planned to undergo delayed reconstruction. The prevalence of BDD among breast reconstruction patients was compared between the 2 groups, and the overall prevalence was compared with published rates for the general public. RESULTS: Body dysmorphic disorder was significantly more prevalent in breast reconstruction patients than in the general population (17% vs 2%; P < .001). It also was much more common among patients who planned to undergo delayed (vs immediate) reconstruction (34% vs 13%; P = .004). CONCLUSIONS: Relative to the general public, significantly more women who sought breast reconstruction were diagnosed as having BDD. Awareness of the potential for BDD will enable clinicians to better understand their patients' perspectives and discuss realistic expectations at the initial consultation. Future studies are warranted to examine the implications of BDD on patient satisfaction with reconstructive surgery. LEVEL OF EVIDENCE: 3.

An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction.

BACKGROUND: Intraoperative angiography is a useful tool for predicting both tissue perfusion during postmastectomy breast reconstruction and mastectomy flap and free flap survival. OBJECTIVES: The authors determine whether the routine use of laser-assisted indocyanine green (ICG) fluorescence angiography (SPY Imaging; LifeCell Corp, Branchburg, New Jersey) in breast reconstruction decreases the incidence of complications and whether this new technology is cost-effective. METHODS: A retrospective review was conducted for 184 consecutive patients who underwent breast reconstruction using intraoperative ICG angiography from April 2009 to December 2011 at Emory University (Atlanta, Georgia). The incidence of complications (including mastectomy skin necrosis, flap necrosis, fat necrosis, unexpected reoperations, infections, and dehiscence) among these patients was compared with data for 184 consecutive patients who underwent breast reconstruction at Emory University from October 2007 to April 2009, prior to the introduction of ICG angiography. Patient data recorded included age, body mass index, smoking status, and history of preoperative radiation as well as the timing and type of reconstruction, along with complications. The cost of unexpected reoperations for perfusion-related complications and associated hospital stays was calculated. RESULTS: The 184 patients who underwent procedures using ICG angiography imaging had a lower incidence of mastectomy skin necrosis (13% vs 23.4%; P = .010) and unexpected reoperations for perfusion-related complications (5.9% vs 14.1%, P = .009). The 184 patients who underwent procedures without ICG angiography had a higher mean degree of severity of mastectomy skin necrosis (2.22 vs 1.83 on a scale of 1-3; P = .065). There were no significant differences in the degree of flap necrosis, nipple necrosis, fat necrosis, dehiscence, infection, implant exposure, flap loss, seroma, hematoma, or the number of overall complications between the 2 groups. The use of ICG angiography saved patients an average of $610. CONCLUSIONS: The use of ICG angiography during postmastectomy breast reconstruction decreased the incidence and severity of mastectomy skin necrosis as well as the incidence of unexpected reoperations for perfusion-related complications. The technology was found to be cost-effective.

Predictors of nipple ischemia after nipple sparing mastectomy.

Nipple sparing mastectomy (NSM) has become an accepted approach in selected cases of breast cancer and prophylactic mastectomy. Various surgical techniques have been described and nipple ischemia has been a common complication. Potential risk factors for nipple ischemia after NSM are examined. To examine predisposing factors for nipple ischemia after NSM. Prospective evaluation of 71 consecutive NSM in 45 patients from 2009 to 2011 was performed. There were 40 mastectomies for cancer (56.3%), and 31 (43.7%) prophylactic mastectomies. In cases of cancer, the ducts were excised from the undersurface of the nipple. Reconstructive methods included: expander 58, latissimus flap/expander 2, implant 10, and free TRAM flap 1. Various patient and technical factors were examined for impact on nipple ischemia. Partial nipple necrosis occurred in 20 cases (28.2%). Nineteen cases healed uneventfully and one required secondary nipple reconstruction. Operations for cancer (OR 10.54, CI 1.88-59.04, p = 0.007) and periareolar incisions (OR 9.69, CI 1.57-59.77, p = 0.014) predisposed to nipple ischemia. Periareolar incisions and dissection of the nipple ducts for cancer have a higher risk of nipple necrosis after NSM.

The effects of breast size in unilateral postmastectomy breast reconstruction.

BACKGROUND: Postmastectomy breast reconstruction is offered to women with breast cancer regardless of body habitus and breast size. The decision regarding technique for breast reconstruction includes patient preference, risk factors, and physical characteristics. The purpose of this study was to determine whether there is a relationship between preoperative breast size and choice of reconstruction, choice of contralateral breast symmetry procedure, and incidence of complications. METHODS: A retrospective review of 355 patients who underwent unilateral breast reconstruction at Emory University from 2005 to 2009 was performed. Patients were stratified into 3 groups based on mastectomy specimen weight with small breasts defined as less than 500 g, medium breasts as 500 to 1000 g, and large breasts as more than 1000 g. Patient demographics were queried including age and risk factors. Additional data points included type of reconstruction, contralateral procedure, and complications. RESULTS: There were 144 patients with small breasts (40.5%), 150 with medium breasts (42.1%), and 62 with large breasts (17.4%). Women with small breasts were equally likely to undergo tissue expander (34%), latissimus dorsi flap (32%), or TRAM/DIEP flap (34%) reconstruction. Women with medium breasts were most likely to undergo TRAM/DIEP reconstruction (47%), whereas women with large breasts were most likely to undergo latissimus dorsi reconstruction (37%; P = 0.134). Small-breasted women were more likely to undergo contralateral augmentation (P < 0.0001), which varied based on the type of reconstruction. Women with medium-sized breasts were more likely to undergo mastopexy (P = 0.033), and large-breasted women were more likely to undergo reduction (P < 0.0001). Women with complications had a greater mean mastectomy weight than women without complications (744 g compared with 620 g, P = 0.0062), and there was an increasing incidence of postoperative wound infections with increasing breast size (18% of large breasts, 7% of medium breasts, and 3% of small breasts; P = 0.0003). CONCLUSIONS: Preoperative breast size does play a role when choosing the most appropriate reconstructive option and symmetry procedure. Being able to adjust the contralateral breast, however, brings the extremes of breast size toward the middle, making most options available regardless of initial size and shape. There are noticeable trends in technique and outcome when stratified by breast size.

Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients.

UNLABELLED: The latissimus dorsi flap (LDF) remains a widely used technique for postmastectomy autologous tissue breast reconstruction. The purpose of this study was to evaluate the effect of body mass index (BMI) on flap and donor-site complications in patients undergoing LDF reconstruction. METHODS: All patients at Emory University Hospital between 2005 and 2010 who underwent an LDF for breast reconstruction were included. Demographics were queried, and patients were stratified into 3 groups according to BMI: normal weight (NL; BMI, <25 kg/m), overweight (OW; BMI, 25-29.9 kg/m), and obese (OB; BMI, ≥30 kg/m). Flap and donor-site complications were compared among the groups. RESULTS: There were 277 patients included in the review: NL (n = 102), OW (n = 72), and OB (n = 103). Overall postoperative complication rates for flaps and donor sites were 33.5% and 22.3%, respectively. The incidence of donor-site complications was similar among BMI groups (22.5% vs 19.4% vs 24.2% for NL, OW, and OB groups, respectively). Flap-related complications occurred in 28.4% (NL), 33.3% (OW), and 38.8% (OB). When stratified by type of complication, no statistically significant difference was found in the incidence of seromas and tissue necrosis at the LDF site. Obese patients were more likely to develop mastectomy skin flaps necrosis (21.3%) compared to the NL group (9.8%, P = 0.042) and less likely to have capsular contracture and hematomas (P = 0.009 and 0.023, respectively). No difference was observed in the incidence of seroma, hematomas, infection, and skin necrosis of the donor site among BMI groups. Patients reconstructed with an LDF and tissue expander tended to have more flap-related complications compared to LDF alone (36.1% vs 25.3%, P = 0.11). CONCLUSIONS: The incidence of both flap and donor-site complications after LDF was not significantly different in overweight and obese patients compared to the normal weight population. The use of LDFs in overweight and obese patients results in an acceptable incidence of postoperative complications and can be safely used in this category of patients.

Time to completion of nipple reconstruction: what factors are involved?

BACKGROUND: Nipple reconstruction is often used as a marker for completion of the breast reconstructive process. The purpose of this study was to determine the average time to nipple reconstruction and the factors that influence this process. METHODS: All patients who underwent postmastectomy breast reconstruction at Emory University between 2005 and 2011 were reviewed. Only those who had completed nipple reconstruction were included. Variables recorded were body mass index, age, smoking history, surgeon, presence of preoperative or postoperative chemotherapy or radiation therapy, type of reconstruction, timing of reconstruction, unilateral or bilateral reconstruction, and complication history. Time to completion of nipple reconstruction was calculated and comparisons were made. RESULTS: A total of 451 patients completed nipple reconstruction (128 implant reconstructions, 120 latissimus plus implant reconstructions, 23 latissimus only reconstructions, and 180 transverse rectus abdominus myocutaneous flap [TRAM] or deep inferior epigastric perforator flap [DIEP] reconstructions). Average time to nipple reconstruction was 12.25 months. Patients who underwent TRAM or DIEP flaps completed reconstruction on average earlier than implant-based reconstruction and latissimus-only reconstruction (8.67 vs 11.2 and 11.3 months, respectively, P = 0.0016). Patients who underwent postoperative chemotherapy or radiation therapy were delayed compared to those that did not (11.3 vs 9.33 and 13.87 vs 9.87 months, P = 0.0315 and P = 0.0052). Timing of completion was also dependent on attending surgeon (9.8 and 11.43 months for the 2 senior surgeons, P = 0.0135) and presence of complications (10.3 compared to 9.77 months for patients without complications, P = 0.0334). Body mass index, smoking history, preoperative chemotherapy or radiation therapy, timing of reconstruction, and unilateral versus bilateral reconstruction did not affect time to nipple reconstruction. CONCLUSIONS: Type of reconstruction, surgeon, presence of complications, and need for postoperative chemotherapy or radiation therapy all affect timing to completion of breast reconstruction. Patients should be counseled as to these factors at the initial consultation to set appropriate expectations.

Patient motivations for choosing postmastectomy breast reconstruction.

INTRODUCTION: The number of women who undergo postmastectomy breast reconstruction is reported to be around 40% and, although increased from previous decades, seems lower than expected. The purpose of this report is to investigate and improve our understanding of women's motivations for choosing reconstruction. METHODS: We prospectively surveyed consecutive patients referred for possible reconstructive surgery at Emory University Hospital between December 2008 and September 2010. A Likert-scale (1-5) questionnaire was used evaluating body image, femininity and sexuality, and influences regarding reconstruction. Demographic information was collected and analyzed. A PubMed search was also performed evaluating national rates of reconstruction, the demographic disparities, and the decision-making process behind undergoing reconstruction. RESULTS: Among the 155 women surveyed, most (63%, n = 99) were 40 to 60 years old, 54.8% (n = 85) were African American, and 41.3% (n = 64) were white. Overall, patients agreed more strongly with questions related to body image as a motivating factor for breast reconstruction than they did with questions related to sexuality or femininity (mean score, 2.85 vs 3.26). When asked about their primary motivation for breast reconstruction, 76% of women agreed it was to maintain a balanced appearance, 34% agreed it was to continue to feel feminine, and 7.7% agreed it was to maintain sexual functioning. When asked about outside influences in pursuing breast reconstruction, the 51.6% of patients reported that they were urged by their referring physician to consider it, and most of the patients (58%) discussed the surgery with other breast cancer patients considering breast reconstruction. CONCLUSIONS: Women pursuing breast reconstruction are motivated more by concerns of body image than issues of sexuality or femininity, which is independent of any demographic characteristics. It is important for referring physicians to recognize their role in initiating the discussion on reconstruction, and women would benefit from being referred to support groups to discuss their treatment and reconstruction with other breast cancer patients.