Currently, one published study documented operative time (OT) as a predictor for postoperative outcomes in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstructions. No literature has investigated this in unilateral DIEP flaps. We aimed to determine the relationship between unilateral OT, postoperative complications, unplanned reoperations (UR), and extended length-of-stay (eLOS).Patients who underwent elective unilateral DIEP reconstruction from 2018 to 2023 at a tertiary centre in London, United Kingdom, were retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive covariates, including procedural complexity, was recorded and used in univariable and multivariable regression models.The final cohort contained 173 patients. After risk-adjustment, ≥421-minute operations led to a significantly higher overall complication rate (HR: 2.14, 95% CI: 1.26, 3.64, p = 0.005) relative to <421 min. Significantly higher odds of eLOS were observed in the ≥460-minute group (OR: 2.07, 95% CI: 1.07, 3.99, p = 0.03) compared to <460 min. There was no significant effect on the rate of postoperative UR across any OT group.We confirmed OT was an independent predictor for postoperative outcomes in the DIEP flap, and demonstrated this in unilateral reconstructions. A clinical maximum threshold of 7 h was derived based on this cohort to help guide future surgical practice. Efficiency can be achieved by meticulous preoperative planning and process standardisation, multiple senior surgeons working per flap, and smooth teamwork between specialities and intraoperative staff. 

Prolonged operative time is a risk factor for adverse postoperative outcomes in the unilateral deep inferior epigastric perforator (DIEP) flap surgery: a retrospective cohort study

BACKGROUND: In recent years, follow-up after breast reconstruction with silicone implants and the detection of complications have been relieved by the possibility of improved diagnostic methods. METHODS: Between January 2015 and December 2019 a total of 40 patients (29-84 years) with silicone implants were included in this retrospective study. The implants were examined clinically and with modern imaging: general ultrasound imaging (US), magnetic resonance imaging (MRI), high resolution computed tomography (CT) and positron emission tomography - computed tomography (PET-CT). If necessary, a histological/cytological sample was taken. The breast implants were assessed by three radiologists specialized in breast imaging. The grade of capsular contracture was classified according to the Baker classification. RESULTS: All 40 women obtained a clinical examination and an US diagnostic to identify early and more common complications such as implant folding and capsular fibrosis. Depending on the clinical examination and ultrasound findings additional MRI (n = 10), CT (n = 9) and/or PET-CT (n = 2) were performed. 16 patients had implants folding proven with US (n = 16), MRI (n = 6) and CT (n = 1). The grade of capsular fibrosis was determined according to the Baker classification. The following results were obtained in our study: 25 breast implants with Baker grade I and eleven breast implants with Baker grade II, both proven with US; one breast implants with Baker grade III and one breast implant with Baker grade IV, proven with US (n = 2), MRI (n = 1) and CT (n = 1). One patient had intracapsular rupture and one patient had extracapsular rupture, both detected on CT and surgically proven. No patient had a silicone accumulation in the lymph nodes. One patient had pathologically enlarged axillary lymph nodes, which were evaluated as inflammatory changes in PET-CT. Long-term complications such as the development of malignant breast tumors could not be observed. CONCLUSION: To detect early complications after breast implant surgery, a regular clinical examination is indispensable. Imaging methods complement each other and if they are used multimodal, it is easier to identify early complications. Modern diagnostic modalities like ultrasound and magnetic resonance imaging expand the spectrum and improve diagnostic safety.

Imaging of breast implant and implant-associated complications: Capsular contracture and intra- or extracapsular rupture.

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor’s letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy. 

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

Introduction The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. Methods Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. Results Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p<0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p<0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p<0.05). Conclusions Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment After DIEP Flap Breast Reconstruction.

With the emergence of state-of-the art implant technology and advanced surgical techniques, plastic surgeons face challenging problems, such as identification of a specific type of a device and diagnosis of postoperative complications, in managing patients undergoing implant-based augmentation mammaplasty. In this article, the authors introduce a novel method for characterizing a breast implant based on diverse factors (eg, filler properties, type of pocket, surface topography, shape type, and manufacturer of the device) and detecting the presence and scope of rupture using high-resolution ultrasound. 

Use of High-resolution Ultrasound in Characterizing a Breast Implant and Detecting a Rupture of the Device Before Reoperation in Women Receiving Augmentation Mammaplasty

The deep inferior epigastric perforator flap for breast reconstruction is associated with lengthy operative times that remain an issue for plastic surgeons today. The main objective of this study was to determine if a 2-stage deep inferior epigastric perforator flap reconstruction resulted in a shorter total plastic surgeon operative time compared with an immediate reconstruction. Methods A retrospective chart review was conducted on all patients who underwent deep inferior epigastric perforator flap breast reconstruction from February 2013 to July 2020 by the senior author. Patient demographics, medical comorbidities, mastectomy characteristics, expander placement, reconstructive procedures, operative time, and complications were tabulated. Results The study included a total of 128 patients. For immediate/1-stage flap reconstruction, average operative times for the plastic surgeon were 427.0 minutes for unilateral procedures, and 506.3 minutes for bilateral procedures. For delayed/2-stage reconstruction, average combined plastic surgeon operative times were 351.1 minutes for unilateral expander followed by flap reconstruction (75.9 minutes shorter than immediate unilateral, P = 0.007), and 464.8 minutes for bilateral reconstruction (41.5 minutes shorter than immediate bilateral, P = 0.04). Total patient time under anesthesia was longer for 2-staged bilateral reconstruction (P = 0.0001), but did not differ significantly for unilateral reconstruction. Complications between immediate and delayed groups were not significantly different. Conclusions We found that staged reconstruction over 2 procedures resulted in a significant reduction in operative time for the plastic surgeon for both unilateral and bilateral reconstruction. With amenable breast surgeons and patients, the advantages of controlling scheduling and the operating room may encourage plastic surgeons to consider performing free flap reconstruction in a delayed fashion.

Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

Silicone gel implants are widely used for cosmetic and reconstructive breast surgery. There has been a paradigm shift with increased utilization of implant-based breast reconstruction compared to autologous reconstruction in the United States over the past couple of decades. Implant rupture is a known complication of silicone gel implants with variable incidence and increased propensity with the age of the implant. Usually, the clinical findings suggestive of implant rupture are not obvious to the patient and surgeon. Intracapsular implant rupture, when the shell of the implant ruptures but the fibrous capsule formed by the breast remains intact, occurs in the majority of cases. While extracapsular rupture, which denotes silicone leakage extending beyond the capsule, is less common. In rare cases, silicone migrates beyond the capsule to distant sites, regional sites, and lymph nodes, leading to a variety of symptoms. Following mastectomy with lymph node dissection, the disruption of normal breast lymphatic drainage may result in aberrant drainage to internal mammary nodes and contralateral axillary lymph nodes. We present a unique case of axillary silicone lymphadenopathy due to contralateral breast intracapsular implant rupture in a patient with no previous ipsilateral breast surgery. The condition was found during a routine breast cancer screening. We also engage in a review of the relevant literature.

/pdf/becker-implant-intracapsular-rupture-with-contralateral-39h9fg47u2.pdf

Becker Implant Intracapsular Rupture with Contralateral Axillary Silicone Lymphadenopathy in an Asymptomatic Patient: A Case Report and Literature Review.

Intraneural lipomas are rare soft-tissue tumors that can occur particularly within the median nerve. Even fewer cases have been reported of their occurrence within the ulnar nerve. These masses can cause compression neuropathies. In this report, we present the first documented case of an intraneural lipoma of an ulnar digital nerve.

Intraneural Lipoma of the Digital Nerve: A Case Report and Literature Review.

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Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

Becker Implant Intracapsular Rupture with Contralateral Axillary Silicone Lymphadenopathy in an Asymptomatic Patient: A Case Report and Literature Review.

Intraneural Lipoma of the Digital Nerve: A Case Report and Literature Review.