The financial impact of COVID-19 on a surgical department: The effects of surgical shutdowns and the impact on a health system.

BACKGROUND: The COVID-19 pandemic resulted in sweeping shutdowns of surgical operations to increase hospital capacity and conserve resources. Our institution, following national and state guidelines, suspended nonessential surgeries from March 16 to May 4, 2020. This study examines the financial impact of this decision on our institution's health system by comparing 2 waves of COVID-19 cases. METHODS: The total revenue was obtained for surgical cases occurring during the first wave of the pandemic between March 1, 2020 and July 31, 2020 and the second wave between October 1, 2020 and February 29, 2021 for all surgical departments. During the same time intervals, in the prepandemic year 2019, total revenue was also obtained for comparison. Net revenue and work relative value units per month were compared to each respective month for all surgical divisions within the department of surgery. RESULTS: Comparing the 5-month first wave period in 2020 to prepandemic 2019 for all surgical departments, there was a net revenue loss of $99,674,376, which reflected 42% of the health system's revenue loss during this period. The department of surgery contributed to a net revenue loss of $58,368,951, which was 24.9% of the health system's revenue loss. Within the department of surgery, there was a significant difference between the net revenue loss per month per division of the first and second wave: first wave median -$636,952 [interquartile range: -1,432,627; 26,111] and second wave median -$274,626 [-781,124; 396,570] (P = .04). A similar difference was detected when comparing percent change in work relative value units between the 2 waves (wave 1: median -13.2% [interquartile range: -41.3%, -1.8%], wave 2: median -7.8% [interquartile range: -13.0%, 1.8%], P = .003). CONCLUSION: Stopping elective surgeries significantly decreased revenue for a health system. Losses for the health system totaled $234,839,990 during the first wave, with lost surgical revenue comprising 42% of that amount. With elective surgeries continuing during the second wave of COVID-19 cases, the health system losses were substantially lower. The contribution surgery has to a hospital's cash flow is essential in maintaining financial solvency. It is important for hospital systems to develop innovative and alternative solutions to increase capacity, offer comprehensive care to medical and surgical patients, and prevent shutdowns of surgical activity through a pandemic to maintain financial security.

The Impact of a Single Dual-Trained Surgeon in the Management of Mastectomy and Reconstruction.

BACKGROUND: Oncoplastic breast surgery is typically performed using a two-surgeon, two-team approach. The authors present their experience with patients undergoing mastectomy and immediate reconstruction performed by a single, dual-trained breast surgical oncologist and plastic and reconstructive microsurgeon. METHODS: Patients who underwent mastectomy and/or immediate reconstruction performed by the senior author between 2015 and 2019 were divided into single-surgeon or dual-surgeon cohorts, and matched by age, body mass index, reconstruction type, and cancer stage. RESULTS: The authors included 158 patients in their analysis (single-surgeon, n = 45; dual-surgeon, n = 113). Single-surgeon patients underwent surgery 13.2 days earlier than dual-surgeon patients (p < 0.01), and required significantly fewer preoperative (1.9 versus 3.4; p < 0.01) and postoperative visits (6.8 versus 10.7; p < 0.01). Operative duration was comparable (single-surgeon, 245 minutes; dual-surgeon, 245 minutes; p = 0.99). The authors found no significant difference in surgical-site infection, seroma, hematoma, abdominal donor-site healing, or flap and prosthesis loss between the groups. The authors did find that dual-surgeon patients had a significantly higher rate of mastectomy flap necrosis (20 percent versus 4 percent; p = 0.01), which held true on logistic regression when controlling for other variables. BREAST-Q data demonstrated that single-surgeon patients had significantly higher overall scores (p = 0.04), and were significantly more satisfied with their outcomes, surgeon, and the information provided (p = 0.03, p = 0.03, and p = 0.01, respectively). CONCLUSIONS: The single-surgeon approach has the potential to decrease patient burden by requiring fewer preoperative and postoperative visits without compromising surgical outcomes or oncologic safety. Further investigation is warranted into the financial implications and patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate Breast Reconstruction for Inflammatory Breast Cancer: Trends in Use and Clinical Outcomes 2004-2016.

INTRODUCTION: National guidelines specify against immediate breast reconstruction (IBR) among inflammatory breast cancer (IBC) patients. However, limited data exist regarding this practice. We report practice patterns and oncologic outcomes among nonmetastatic IBC patients receiving trimodality therapy, with or without IBR. METHODS: Using the National Cancer Database, we identified nonmetastatic IBC patients treated with trimodality therapy from 2004 to 2016. Primary outcome was overall survival (OS), assessed on unadjusted analysis using Kaplan-Meier estimates and on adjusted analysis using multivariable Cox proportional hazards and inverse probability weighting (IPW) models. OS analysis was also conducted with propensity score matched (PSM) cohorts. Secondary outcomes included IBR utilization rates, time to postmastectomy radiotherapy (PMRT), and surgical outcomes. RESULTS: 6589 women were included, including 5954 (90.4%) non-reconstructed and 635 (9.6%) IBR. Among IBR recipients, 250 (39.4%) underwent autologous reconstruction, 171 (26.9%) underwent implant-based reconstruction, and 214 (33.7%) unspecified. IBR utilization increased from 6.3% to 10.1% from 2004 to 2016 at a 4% average annual growth rate (P < 0.001). Median follow-up was 43 and 45 months for IBR and non-reconstructed patients, respectively (P = 0.29). On Cox multivariable analysis, IBR was associated with improved OS (HR 0.63, 95% CI 0.44-0.90, P = 0.01), but this association was not significant on IPW analysis (P = 0.06). In PSM cohorts, this association remained significant (HR 0.60, 95% CI 0.40-0.92, P = 0.02). Margin status, time to PMRT, 30-day readmission, and 30-/90-day mortality did not differ between groups (all P > 0.05). CONCLUSION: Although not endorsed by national guidelines, IBR is increasing among IBC patients; however, more granular data are needed to determine oncologic safety.

Oncoplastic partial breast reconstruction: concepts and techniques.

Immediate oncoplastic breast reconstruction performed at the time of breast conserving surgery for the treatment of breast cancer merges the therapeutic goals of complete oncologic extirpation with preservation of breast form and function. A constellation of surgical techniques that employs breast volume displacement and/or replacement methods of varying complexity levels have emerged, thus broadening the potential applications for breast conservation therapy to include cases with increased tumor-to-native breast-volume ratios, multicentric or multifocal disease, and/or previous margin-positive resections. This review describes the various reconstructive methods, including the use of local tissue rearrangement, oncoplastic reduction-mastopexy, and locoregional flaps. Classification of the surgical options into levels I and II volume-displacement and volume-replacing techniques is made. Additionally, we explore the oncologic safety and effectiveness of this treatment paradigm by summarizing existing supportive evidence regarding associated risk of surgical complications, rate of margin-positive resection, implications for radiographic surveillance, local recurrence rates, and patient-reported outcomes. In conclusion, surgeons may use a wide variety of oncoplastic techniques for partial breast reconstruction at the time of segmental mastectomy to deliver effective breast conserving treatment for women with breast cancer. A growing body of literature affirms the oncologic safety of this approach. Future directions for research include long-term follow-up data with emphasis on outcomes from patient perspectives.

An Analysis of Specialty-Specific Microsurgical Head and Neck Reconstruction: A Look at a Single Institution and National Trends Over a Decade.

INTRODUCTION: Head and neck free flap (HNFF) reconstructions have historically utilized a multidisciplinary approach between otolaryngology head and neck surgery (OHNS) and plastic surgery (PS). However, there seems to be a trend toward both the extirpative and reconstructive portions being performed by OHNS. We aimed to elucidate the volume trend in HNFF reconstruction over the last decade. METHODS: Data were collected by 3 modalities: electronic medical record search of patients who underwent HNFF surgery at our institution (2013-2018), survey data from microsurgery fellowship programs (2007-2017), and National Surgical Quality Improvement Program (NSQIP) query of cases receiving designated HNFF Current Procedural Terminology codes (2011-2016). Data were analyzed with trends in HNFF reconstruction as our primary outcome. RESULTS: At our institution, HNFF reconstructions increased 4-fold (59-227). Percentage of cases by PS decreased from 18.6% to 6.0%, whereas that of OHNS increased 81.4% to 94.0% (P = 0.009). Survey data, completed by microsurgery fellowship program directors (23/81 [27.2%]), revealed the number of OHNS programs in 2007 performing 100 or more HNFF cases compared with PS was 40% (6/15) to 12.5% (1/8) (P = 0.172). By 2016, that number increased significantly for OHNS to 73.3% (11/15), whereas that of PS remained stagnant at 12.5% (1/8) (P = 0.005). According to NSQIP data, the percentage of cases performed by PS in 2011 was 52%, which was greater than OHNS's share of 43%. The other 5% was allotted to either orthopedic, oral and maxillofacial surgery, or general surgery. In 2013, those numbers reached a peak for PS at 55% and a nadir for OHNS at 36%. However, by 2016, the percentage of HNFF cases reversed. where 58% of cases were performed by OHNS and only 38% by PS. When comparing the 2011 data to the 2016 data, OHNS had a 134% increase, whereas PS had a 27% decrease (P = 0.003). CONCLUSIONS: Head and neck free flap reconstruction has grown dramatically over the last 10 years. Plastic surgeons are performing fewer cases, whereas otolaryngology head and neck surgeons perform more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data.

Locoregional Cancer Recurrence after Breast Reconstruction: Detection, Management, and Secondary Reconstructive Strategies.

BACKGROUND: Locoregional recurrence of the previously reconstructed breast poses a diagnostic and operative challenge. This study examines detection, management, and reconstructive strategies of locoregional recurrence following postmastectomy breast reconstruction. METHODS: A retrospective review of records was performed on patients treated within the health system for breast cancer from January of 2000 to July of 2014. Of these patients, descriptive factors and operative details were collected for those that developed locoregional recurrence. Subsequent reconstructive operations were also examined. Using a multidisciplinary team, a surveillance/management algorithm was generated. RESULTS: A total of 41 patients with locoregional recurrence were identified (mean time to recurrence, 4.6 years). Two- and 5-year survival following locoregional recurrence was 88 percent and 39 percent, respectively. Locoregional recurrence was found to occur in the following tissue planes: subcutaneous (27 percent), subcutaneous/pectoralis (24 percent), chest wall (37 percent), and axillary (12 percent). The most frequent method of detection was patient concern leading to examination. Older age at the time of locoregional recurrence (p = 0.028), increased time to recurrence/detection (p = 0.024), and chemotherapy before locoregional recurrence (p = 0.014) were associated with the need for a secondary salvage flap. Patients who experienced a subcutaneous recurrence were far less likely to undergo a secondary flap (p = 0.011). Factors associated with loss of the index reconstruction included lower body mass index (p = 0.009), pectoralis invasion (p = 0.05), and implant reconstruction (p = 0.03). CONCLUSIONS: Detection and management of locoregional recurrence requires appropriate physical examination and imaging. Significant factors associated with failure to salvage the initial reconstruction included body mass index, plane of recurrence, and type of initial reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Function and Strength after Free Abdominally Based Breast Reconstruction: A 10-Year Follow-Up.

BACKGROUND: The long-term impact of abdominally based free flap breast reconstruction is incompletely understood. The aim of this study is to provide long-term, subjective and objective health data on abdominally based free flap breast reconstruction patients, with specific attention to the effects of laterality, flap type, and obesity. METHODS: Patients were enrolled in this prospective study between 2005 and 2010 and completed preoperative, early (<1 year), and long-term (5 to 10 years) evaluations. Objective examination included an assessment of upper and lower abdominal function and a functional independence measure. Patient-reported outcomes included the 36-Item Short-Form Health Survey and the BREAST-Q abdominal well-being module. Scores were compared by laterality (unilateral versus bilateral), flap type (muscle-sparing free transverse rectus abdominis musculocutaneous versus deep inferior epigastric artery perforator), and presence of obesity. RESULTS: Fifty-one patients were included, with an average 8.1-year follow-up. Overall, 78.8 percent of patients had stable or improved scores across the upper and lower abdominal function and functional independence measures, and minimal objective differences across flap laterality or types were observed. Postoperative scores improved for 36-Item Short-Form Health Survey physical health (p < 0.001) and mental health (p < 0.001), and did not differ based on laterality or flap type. Obesity negatively impacted physical health (p = 0.002) and mental health (p = 0.006). CONCLUSIONS: Abdominally based autologous breast reconstruction is associated with significant improvements in long-term quality of life across key domains of physical and mental health with little functional impairment and no long-term differences across flap type or laterality. Obese patients, however, may be at risk for subjective physical and mental health impairment, perhaps unrelated to the surgery itself.

5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes.

BACKGROUND: The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. METHODS: A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. RESULTS: The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. CONCLUSIONS: Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sifting through the Evidence: A Comprehensive Review and Analysis of Neurotization in Breast Reconstruction.

BACKGROUND: An untoward outcome following breast reconstruction is diminished or complete loss of sensation. As the reconstructive paradigm continues to evolve, sensory restoration following reconstruction remains a research focus. Despite the multitude of published outcomes, there is marked heterogeneity across studies, thus confounding published outcomes. This study critically appraises the literature to summarize outcomes and establish a framework to guide clinical practice and future research. METHODS: A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in an effort to perform a meta-analysis. The Ovid MEDLINE, PubMed, Embase, Scopus, Cochrane, and ClinicalTrials.gov online databases were queried to capture all publications between 1990 and 2017 that investigated postreconstruction breast sensation. The primary outcome of interest was breast sensation following both implant-based and autologous reconstruction with or without neurotization. Secondary outcomes of interest included time to sensory testing and patient-reported outcomes. RESULTS: Overall, 503 titles were screened, from which 37 articles were ultimately included for analysis, accounting for 1299 patients. There was major methodologic variability and inconsistent measurable outcomes across studies. It can be deduced that postoperative sensation returns spontaneously and unpredictably, neurotization enhances the magnitude and rapidity of sensory restoration when compared to nonneurotized reconstruction, and a sensate reconstruction improves patient-reported outcomes. CONCLUSIONS: Significant study design discrepancies exist, making it difficult to combine data and assess results. To effectively study breast sensation and the impact of neurotization, future investigation will depend on standardizing the way in which breast sensation is measured.

Autologous breast reconstruction in the postbariatric patient population.

BACKGROUND: Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution. METHODS: Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts. RESULTS: Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00). CONCLUSIONS: As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile.

BACKGROUND: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. METHODS: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. RESULTS: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. CONCLUSION: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction.

BACKGROUND: As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. METHODS: In an effort to expand on Nahabedian's 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. RESULTS: The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. CONCLUSION: With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.

Academic Productivity, Knowledge, and Education in Plastic Surgery: The Benefit of the Clinical Research Fellow.

BACKGROUND: Academic research productivity is limited by strenuous resident and faculty schedules but nevertheless is imperative to the growth and success of our discipline. The authors report institutional experience with their clinical research fellowship model, providing two positions per year. METHODS: A critical analysis of research productivity was performed for all trainees, faculty, and research fellows from 2000 to 2015. Academic productivity was determined by the number of peer-reviewed publications, podium presentations, and h-index. Academic fate of previous research fellows was also noted. During the 16-year timeframe, 484 articles were published in print. Notably, 92 articles were published from 2000 to 2007 and 392 articles were published from 2008 to 2015 (p = 0.0066), demonstrating linear growth after instituting the research fellowship. In addition, 33 articles were published from 2002 to 2004 before leadership change, 47 from 2005 to 2007 after leadership change but before fellowship, and 58 from 2008 to 2010 in the first few years of the fellowship (p = 0.0204). RESULTS: Overall, 39.9 percent of publications appeared in Plastic and Reconstructive Surgery, with a total of 77 different peer-reviewed journal inclusions. American Association of Plastic Surgeons, American Society of Plastic Surgeons, and Northeastern Society of Plastic Surgeons podium presentations totaled 143 between 2005 and 2015. Of the eight previous fellows who applied into integrated and independent programs, 100 percent have matched. CONCLUSION: Incorporation of a formalized research fellowship into a plastic surgery program can drastically increase clinical research contribution in a reproducible fashion.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction.

BACKGROUND: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure. METHODS: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014. RESULTS: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459). CONCLUSIONS: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction.

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction.

OBJECTIVE: The purpose of this study was to critically examine intraoperative vasopressor usage as it relates to free flap perfusion and its effect on perioperative complications in autologous breast reconstruction. METHODS: A retrospective cohort study was performed involving all free autologous breast reconstructions at a single institution over a 5 year period. Data collection focused on perioperative care, specifically fluid administration, urine output (UOP), use of vasopressors, and case duration. Outcomes included major intraoperative and postoperative complications. Patients who received intraoperative vasopressors were compared to all patients who did not. The use, type, and timing of the vasopressor agent were assessed with standard statistical analyses and regression modelling. RESULTS: Six hundred and eighty-two patients reconstructed with 1039 flaps were included. Of these, 475 (69.6%) patients received vasopressors. The vasopressor cohort was older (p = 0.001), with higher rates of hypertension (p = 0.02). They had a greater number of hypotensive episodes (2.3 vs 0.8, p < 0.0001) and received a greater volume of fluid (4653.0 vs 4291.7 ml, p = 0.004). Examining complications, no increase in intraoperative thrombotic events (arterial or venous) or flap loss was noted with vasopressor administration. A higher rate of minor complications was, however, noted (53.1% vs 43.0%, p = 0.016). CONCLUSIONS: This study demonstrates that the use of intraoperative vasopressor agents in the anaesthetic care of free flap breast reconstruction patients is common, but likely does not impact thrombotic events or flap loss. Minor complications may, however, be more common in these patients.

Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: A novel anticoagulation protocol.

BACKGROUND: Hypercoagulable conditions are often considered relative contraindications to free flap reconstruction. This paper presents and critically examines a novel anticoagulation regimen developed to address this disease state. METHODS: Hypercoagulable patients who underwent free tissue transfer between 2007 and 2015 were identified. From 2011, all such patients were subjected to a novel anticoagulation protocol involving an intravenous bolus of 2000 U of unfractionated heparin prior to microvascular pedicle anastomosis, followed by a heparin infusion at 500 U/h, which was postoperatively increased to therapeutic levels. Patients were discharged on full anticoagulation for 1 month. Patients prior to 2011 received only subcutaneous heparin. Outcomes in patients receiving this novel anticoagulation protocol were compared to those of patients receiving standard therapy (postoperative subcutaneous heparin). RESULTS: Twenty-three hypercoagulable patients underwent reconstruction with 32 flaps. Eleven patients were administered the novel protocol. No thromboses were noted in the novel protocol cohort, while three thrombotic events occurred in the control cohort (0% vs. 17.6%, p = 0.23). No flaps were salvaged after thrombosis. All losses occurred in the control cohort (0% vs. 17.6%, p = 0.23). The novel protocol cohort was more likely to have postoperative red blood cell transfusions (72.6% vs. 16.7%, p = 0.007), hematomas (26.7% vs. 0%, p = 0.04), and lower mean hemoglobin nadirs [6.9 (1.0) vs. 8.9 ± 1.8 g/dL, p = 0.01]. CONCLUSION: The key approach to hypercoagulable patients is likely prevention over treatment. Patients who received prophylactic heparin infusions had clinically lower rates of thrombotic events and flap loss. However, this encouraging finding must be balanced with the increased risk for postoperative bleeding complications.

Increased Lower Extremity Venous Stasis May Contribute to Deep Venous Thrombosis Formation after Microsurgical Breast Reconstruction-An Ultrasonographic Study.

Background Despite guideline-compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant-based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. Methods An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Results Eighteen patients with a mean age and body mass index of 52.7 years (range, 29-76 years) and 31.3 kg/m2 (range, 21.9-43.4 kg/m2) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (p < 0.0001). Similarly, a 24.3 and 69.9% increase in CFV circumference (p = 0.0007) and area (p < 0.0001) were noted, respectively. These correlated with a 28.4% decrease in maximum flow velocity in the CFV (p = 0.0001). Of note, none of these parameters displayed significant changes for the IJV, thus indicating that observed changes in the CFV were not the result of changes in perioperative fluid status. Conclusion Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.

Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection.

BACKGROUND: Microvascular free tissue transfer has become the main technique used for head and neck reconstruction. We assessed the cost-effectiveness of free flap reconstruction for head and neck defects after oncologic resection for squamous cell carcinoma (SCC). METHODS: We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of reconstruction with free tissue transfer compared with locoregional flaps. Health state probabilities and quality of life scores were determined from literature. Costs were determined from institutional experience. Outcomes included quality-adjusted life years, costs, and incremental cost-effectiveness ratio. RESULTS: Free flap reconstruction was more costly than pedicled flap but associated with greater quality of life with no survival benefit. A value <$50,000 per quality-adjusted life-year (QALY) was defined as cost-effective. The incremental cost-effectiveness for head and neck free flap reconstruction was below the threshold and, therefore, free flap reconstruction is cost-effective. Reconstruction was more cost-effective for patients with lower stage cancers: $4643 per QALY for stage I SCC, $8226 for stage II, $17,269 for stage III, and $23,324 for stage IV. Univariate sensitivity analysis showed the cost-effectiveness would remain <$50,000 for all stages of SCC for all variables except for QALY after locoregional reconstruction without complications. CONCLUSION: Microsurgical head and neck reconstruction is cost-effective compared with locoregional flaps, even more so in patients with early-stage cancer. This finding supports the current practice of free flap head and neck reconstruction. Screening and early detection are important to optimize costs. © 2016 Wiley Periodicals, Inc. Head Neck 39: 541-547, 2017.

Reliable prediction of postmastectomy lymphedema: The Risk Assessment Tool Evaluating Lymphedema.

BACKGROUND: Breast cancer-related lymphedema remains a significant complication post mastectomy. Identifying patients at highest risk may better inform targeted healthcare resource allocation and improve outcomes. This study aims to identify lymphedema predictors after mastectomy to develop a simple, accurate risk assessment tool. METHODS: An institutional retrospective review identified all women with breast cancer undergoing mastectomy between January 2000 and July 2013 with postmastectomy lymphedema as the primary outcome. Stepwise multivariate Cox regression identified independent predictors of lymphedema. A simplified risk assessment tool was derived and composite risk estimated for each patient. RESULTS: Of 3,136 patients included, 325 (10.4%) developed lymphedema after a follow-up of 4.2 years. Significant predictors included invasive cancer diagnosis (hazard ratio [HR] = 2.25), postmastectomy radiation (HR = 2.05), age over 65 years (HR = 1.90), and axillary dissection (HR = 1.79). Stratified lymphedema risk by group was defined as follows: low 6.2%, moderate 10.0%, high 16.4%, and extreme 36.4%. The model demonstrated excellent risk discrimination (C = .78). CONCLUSIONS: Postmastectomy lymphedema incidence was 10.4%. Invasive cancer diagnosis, chemoradiation, and axillary dissection imparted significant risk. The Risk Assessment Tool Evaluating Lymphedema offers accurate risk discrimination ranging from 6.2% to 36.4%. Selective treatment approaches may improve outcomes and delivery of cost-effective healthcare.