Reece, Edward

Abstract Abdominally based free flaps are commonly utilized in the context of breast reconstruction. Historically, postoperative care of these patients involved liberal amounts of intravenous fluid administration; however, overadministration of fluids puts patients at risk of developing flap edema via fluid shifts, electrolyte imbalances, wound dehiscence, and other sequelae. The purpose of this study is to assess fluid administration trends in this cohort at the authors' institution and assess its impact on patient outcomes. A retrospective review was performed on patients who underwent free-flap breast reconstruction. Patient demographics and hospitalization data were collected, and type of abdominal flap and reconstruction timing was noted. Perioperative fluid administration volumes were tracked, and primary outcomes included complication rate and type (e.g., acute blood loss anemia [ABLA], partial/total flap loss, etc.). Multivariable logistic regression was performed to assess the impact of fluid volume on patient outcomes. A total of 115 patients (mean age of 51.3 ± 10.5 years) underwent 188 abdominally based free flaps. Deep inferior epigastric artery perforator flaps were performed most often (n = 91), followed by muscle-sparing transverse rectus abdominis flaps (n = 88). Multivariable logistic regression demonstrated that high perioperative fluid administration (≥9,000 mL) was associated with increased odds of medical complications (odds ratio [OR] = 21.7; confidence interval [CI]: 5.54–84.5; p < 0.001). Patients with high fluid administration volumes experienced an increased (but nonstatistically significant) flap complication rate (OR = 2.96; CI: 0.89–9.88; p = 0.08) and developed ABLA at a higher rate (OR = 15.86; CI: 5.30–46.4; p < 0.001). High-volume resuscitation (≥9,000 mL) was associated with increased odds of ABLA as well as a greater likelihood of medical and flap complications in patients undergoing abdominally based free flaps for breast reconstruction. These data should be used to guide the development of protocols within institutions, which perform free flaps for breast reconstruction.

Abstract Robots have been used effectively in plastic and reconstructive surgery (PRS) for reconstruction. The utilization of robotics in all surgical specialties is expanding with the goal of offering the most appropriate patient-centered care possible, especially in complex multidisciplinary cases. Despite the safety, efficiency, and reproducibility of robotics in PRS, there is a paucity of required and formalized training in PRS residency programs. The ACGME and industry published guidelines were investigated. Robotic surgery case logs of Mayo Clinic Arizona General Surgery residents were analyzed with attention to equivalency certification (EQ). Over the past 5 years, the equivalency certification from Intuitive (Sunnyvale, CA) was obtained by 30% of all general surgery residents at our institution (range, 0–100). The case numbers to obtain the equivalence certification are industry recommendations, and proficiency is determined by the program director. The ACGME does not mandate robotics training in general surgery residency. According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), trainees must complete 20 console cases and 10 bedside cases to become industry certified. With respect to training and advancing the field, PRS residents could successfully obtain certification in their residency programs. The minimum case requirement recommended by SAGES is not burdensome and can ensure robotic privileges in PRS practice immediately following graduation. By improving the training for minimally invasive robotic surgery in plastic surgery, patients and healthcare systems benefit from improved quality of life outcomes and decreased postoperative length of stay, which results in less strain on our entire medical system.

Abstract Background The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap. Methods CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap. Results A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm3 (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm3 (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm3 (SD = 62.40). Conclusion The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

BACKGROUND: Although the overall psychosocial benefits and body image gains of postmastectomy breast reconstruction are well-established, there is limited information on how postoperative complications affect patient quality of life (QOL). STUDY DESIGN: A single-institution cross-sectional survey analysis was performed on patients who underwent postmastectomy breast reconstruction between 2008 and 2020. QOL was assessed using the BREAST-Q and the Was It Worth It questionnaires. The results were compared among patients who had major complications, minor complications, and no complications. Responses were compared using 1-way ANOVA and chi-square tests as appropriate. RESULTS: A total of 568 patients met inclusion criteria, and 244 patients responded (43% response rate). Most patients did not have any complications (n = 128; 52%), 41 had minor complications (17%), and 75 had major complications (31%). There were no differences in any of the BREAST-Q well-being metrics based on degree of complication. Across all 3 groups, patients reported that surgery was worthwhile (n = 212; 88%), they would choose reconstruction again (n = 203; 85%), and they would recommend it to a friend (n = 196; 82%). Overall, 77% reported that their overall experience either met or exceeded expectations, and 88% of patients had unchanged or improved overall QOL. CONCLUSIONS: Our study demonstrates that QOL and well-being are not negatively impacted by postoperative complications. Although patients who had no complications had an overall more positive experience, nearly two-thirds of all patients, no matter the degree of complication, stated that their overall experience either met or exceeded their expectations.

Abstract Goals/Purpose Perioperative management of estradiol therapy varies considerably among plastic surgeons performing aesthetic surgeries. This study aimed to review available literature regarding perioperative management of estradiol therapy in aesthetic surgery patients, and the risk it poses for developing VTE in the perioperative period. Methods/Technique A literature search was performed using online databases to identify studies evaluating VTE in aesthetic surgery patients taking oral contraceptives (OCPs) or hormone replacement therapy (HRT), and transgender patients on feminizing hormone therapy undergoing non-flap feminization surgery (facial feminization and breast augmentation procedures). Reported outcomes were extracted from these studies and summarized. Results/Complications A systematic review of the literature yielded 225 studies. Five of these studies met inclusion criteria. One study that was excluded, referenced an article that met inclusion criteria, which was ultimately included in our review for a total of six studies, representing 3,635 patients. Conclusion Data regarding perioperative management of estrogen therapy is limited in the literature, and standardized guidelines for aesthetic surgery patients have not been elucidated. This has led to inconsistencies in how estrogen is managed for elective, cosmetic procedures. Further research is needed to determine standardized practice guidelines. In the meantime, case-by-case evaluation of surgical appropriateness should continue. Surgeons should also consider risk-mitigating strategies, such as a focus on patient education, more intentional patient questioning regarding estrogen-containing product use, a preoperative coagulability workup for patients with a personal or family history indicative of possible coagulopathy, and specialty-wide efforts to create an aesthetics database and evidence-based guidelines.