A classification system and treatment algorithm for mastectomy flap ischemia in alloplastic breast reconstruction.

BACKGROUND: Mastectomy flap necrosis remains a major cause of failed breast reconstruction with an associated significant financial/psychological burden. Language describing ischemic mastectomy flaps is imprecise as ischemia can result from many causes and can manifest in different ways. Similarly, management of mastectomy flap ischemia varies depending on its etiology. Intraoperative near-infrared imaging (NIR) with indocyanine green (ICG) is an established modality for evaluation of mastectomy flap perfusion. Herein, we define the types of flap ischemia demonstrated via NIR imaging and propose an algorithm for its management. METHOD: A retrospective review was performed of patients who underwent mastectomy and NIR imaging of mastectomy flaps from 2014 to 2017. Patient characteristics, operative details, and outcomes were recorded. Following retrospective review, distinct patterns of ischemia were identified, and a classification system and treatment algorithm were developed. RESULT: Type A; diffuse hypoperfusion can be caused by a number of factors (hypotension, vasoconstrictive agents, etc.). It is best treated with delayed reconstruction. Type B; geographic hypoperfusion may be caused by electro-cautery burn, inaccurate dissection, or retractor injury. It can be treated by resection/primary closure or delayed reconstruction. Type C; marginal/incisional hypoperfusion is best treated with debridement. Type D; diffuse marginal perfusion is seen with overfilled tissue-expanders or an oversized implant within a smaller skin envelope. Management includes deflation/downsizing. An algorithm was developed for treatment of the four ischemia types. CONCLUSION: NIR imaging aides in delineating the type of ischemic injury. Classification of mastectomy flap ischemia allows precise communication between providers and provides a framework for decision-making.

Surgically Treated Hernia following Abdominally Based Autologous Breast Reconstruction: Prevalence, Outcomes, and Expenditures.

BACKGROUND: Donor-site hernia is one of the most feared complications following abdominally based autologous breast reconstruction. The authors aim to assess the incidence of surgically repaired abdominal hernia across different types of abdominally based breast reconstruction, identify predictive perioperative factors, and estimate the health care charges associated with this morbidity. METHODS: Using inpatient and ambulatory surgery data from four states in the United States, the authors identified adult women who underwent pedicled transverse rectus abdominis muscle (TRAM), free TRAM, or deep inferior epigastric perforator (DIEP) flap breast reconstruction between 2008 and 2012. The primary outcome was surgical repair of abdominal hernia within 4 years. Multivariate Cox proportional hazards regression modeling was used to compare outcomes between groups. RESULTS: The final sample included 8246 women who underwent pedicled TRAM (29.2 percent), free TRAM (30.0 percent), or DIEP (40.8 percent) flap reconstruction. The frequency of surgically repaired abdominal hernia following breast reconstruction was highest among the pedicled TRAM flap group (pedicled TRAM, 7.0 percent; free TRAM, 5.7 percent; DIEP, 1.8 percent). A hospital encounter for hernia repair, whether inpatient or ambulatory, generated substantial health care charges (pedicled TRAM, $39,704; free TRAM, $48,378; DIEP, $46,481). On multivariate analysis, patients who developed a surgical-site infection within 30 days of discharge (incidence rate ratio, 1.99; 95 percent CI, 1.44 to 2.75) had a higher incidence of surgically repaired abdominal hernia. CONCLUSIONS: Surgically repaired abdominal hernia is common following abdominally based autologous breast reconstruction and is associated with significant health care expenditures. The authors demonstrate that the amount of rectus muscle sacrificed correlates to the likelihood of developing a surgically repaired abdominal hernia, and identify surgical-site infection as a predictive perioperative factor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Geographic Variation in Access to Plastic Surgeons.

INTRODUCTION: While recent studies project a national shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the current geographic distribution of the plastic surgery workforce across the United States. METHODS: Using the 2013 to 2014 Area Health Resource File, we estimated the number of plastic surgeons at the health service area (HSA) level in 2010 and 2012. The density of plastic surgeons was calculated as a ratio per 100,000 population. The HSAs were grouped by plastic surgeon density, and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. RESULTS: The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7600 plastic surgeons, resulting in a national ratio of 2.42 plastic surgeons/100,000 population. However, over 25 million people lived in 468 HSAs (49.3%) without a plastic surgeon, whereas 106 million people lived in 82 HSAs (8.6%) with 3.0 or more/100,000 population. Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger than 65 years, female, and residing in urban areas. Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density, whereas 15 HSAs lost all plastic surgeons. CONCLUSIONS: Plastic surgeons are asymmetrically distributed across the United States leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact older and rural populations.

Superficial Inferior Epigastric Artery: Learning Curve versus Reality.

BACKGROUND: Breast reconstruction with the superficial inferior epigastric artery (SIEA) free flap continues to gain popularity among reconstructive surgeons. The low risk for abdominal wall morbidity must be weighed against the higher concern for thrombotic events. The aim of this study was to review the authors' recent experience with the SIEA flap and investigate whether their previously published incidences of vessel thrombosis and flap loss were related to their own "learning curve" or whether these adverse events are attributable to inherent qualities of the SIEA flap. METHODS: The authors performed a retrospective chart review of all patients undergoing SIEA flap surgery between January 1, 2008, and July 1, 2014, at their institution. All included operations were performed by the senior author (J.M.S.). The main outcomes of interest included vessel thrombosis and partial/full flap loss. RESULTS: Forty-seven SIEA flaps were performed on 39 patients. Sixty-four percent (n = 30) were immediate reconstructions and 79 percent (n = 37) were bilateral. There were five intraoperative arterial thromboses (10.6 percent) and one intraoperative venous thrombosis (2.1 percent), with eight total thrombotic events (17.0 percent). One total flap loss (2.1 percent) and two partial flap losses (4.3 percent) were experienced. CONCLUSIONS: The authors' recent experience with SIEA-based breast reconstruction shows a similar incidence of thrombotic events and flap loss compared with the authors' early experience. These incidences remain greater than what is seen with other abdominally based autologous breast reconstruction techniques and do not appear to be attributable to an operator learning curve. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.