ASRM Scientific Paper Presentations: Breast Sunday, January 14, 2018, 1:15pm – 3:30pm

1:15 PM - 1:20 PM RM 16. Recovery from Mastectomy: Qualifying Survivorship through Patient-Centered Outcomes University of Virginia School of Medicine, Charlottesville Presenter: Kasandra Hanna, MD Kasandra Hanna, MD University of Virginia School of Medicine, Charlottesville, VA

1:20 PM - 1:25 PM RM 17. Is Adjuvant Radiotherapy Associated with a Difference in Patient Reported Outcomes One Year After Immediate DIEP/SIEA Based Breast Cancer Reconstruction? Presenter: Julian Diaz-Abele, MD A L Cooke, MD(1), Julian Diaz-Abele, MD(1), Kim R. Dalke, MSc(1), Pascal Lambert, Msc(2), Tom Hayakawa, MD(1) and Ed Buchel, MD(1) (1)University of Manitoba, Winnipeg, MB, Canada, (2)Cancer Care, Winnipeg, MB, Canada

Background: There has been a long-standing debate pertaining the timing (immediate or delayed). Despite the benefits of immediate breast reconstruction, many studies still express concerns regarding radiation of the immediate autologous breast reconstruction. The purpose of this study was to determine if adjuvant radiotherapy is associated with a difference in patient reported outcomes in patients undergoing immediate DIEP/SIEA autogenous breast reconstruction.

Methods: Patient reported outcomes of the local prospective cohort from the larger MROC database was studied. All patients underwent treatment in out hospital center, immediate DIEP/SIEA breast reconstruction, were operated between 2012 and 2015, had unilateral reconstruction only, were diagnosed with breast cancer, and did not have previous breast cancer surgery, reconstruction or radiation. We compared demographics, radiation, and MROC questionnaires in 125 patients (65 radiated and 61 non-radiated). The questionnaires consisted of EORTC QLQ-BR23, NPRS, Breast-Q, PROMIS-29, MPQ-SF, GAD-7, and PHQ-9; and evaluated a total of 24 different domains. Power analysis was performed prior to the study, Bonferroni correction was followed, baseline data was controlled with multivariable analysis, and both parametric and non-parametric tests were used.

Results: Demographics were not statistically different between groups. Cancer stage and treatment were different between groups; the radiated group had more frequently a higher tumor stage (T 2, 3, 4 80 vs 16% of patients), positive nodes (86 vs 5% of patients), number of nodes removed (11 vs 2 nodes), and chemotherapy (97 vs 38% of patients). Of the 24 domains 23 had no statistical difference between radiated and non-radiated groups. The EORTC breast symptom domain was the only statistically different domain between groups (higher in the radiated group; 16/100 vs 8/100, p<0.0001) in a normalized ordinal scale where 0 was no symptoms and 100 was very severe symptoms.

Conclusion: There was no difference in 23/24 patient reported outcome domains. Despite a statistical difference in breast symptoms between radiated and non-radiated patients, the difference was small (8/100) and the radiated groups still scored numerically low on the 100-point symptomatology scale. The difference between the two groups may be related to a higher degree of axillary disease (11 vs 2 nodes removed) and/or the well-recognized adverse effects of radiation. Overall, our study found minimal difference in patient reported outcomes between radiated and non-radiated immediate autologous breast cancer reconstruction. Based on these results, we believe immediate autologous breast reconstruction followed by radiation may be a successful approach for patients with breast cancer.

1:25 PM - 1:30 PM RM 18. Trends in Physician Payments for Breast Reconstruction Memorial Sloan Kettering Cancer Center, New York Presenter: Hinaben Panchal, MD MPH Hinaben Panchal, MD MPH(1), Clifford Sheckter, MD(2), Day Yi, MS(1), Shantanu N. Razdan, MD, MSPH(1), Claudia R. Albornoz, MD MSc.(1), Peter G Cordeiro, MD(1), Joseph J Disa, MD(1), Babak J Mehrara, MD(3) and Evan Matros, MD MMSc MPH(1) (1)Memorial Sloan Kettering Cancer Center, New York, NY, (2)Stanford University, Stanford, CA, (3)Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY

Background: Breast reconstruction (BR) rates have steadily increased in the U.S. over the past two decades, with a notable rise in prosthetic relative to autologous techniques. Physician payments compared to the effort required for autologous reconstruction has been reported as one barrier underlying these trends. Single institution data suggest that physician reimbursement for prosthetic reconstruction has increased, while for autologous reconstruction, it has plateaued. No national claims analysis of plastic surgeon payment for the common methods of breast reconstruction exists. The study aim is to assess national payment trends for tissue expanders (TE) and free flaps (FF). The hypothesis is that there are increasing payment disparities between TE and FF.

Methods: The Blue Health Intelligence (Blue Cross/Blue Shield), a national claim-based database encompassing 42 States, was queried for 2009-2013. Women 18 and older with claims for BR after mastectomy for breast cancer were identified using Current Procedural Terminology codes. Trends and variations in the volume of surgery and physician reimbursement were analyzed by procedure type and year. Reimbursement variation was calculated by the standard deviation as a percentage of the mean payment, termed the coefficient of variation (CV). Longitudinal trends were assessed with Poisson and linear regression analyses.

Results: 21,259 women underwent BR. The overall five-year trend demonstrated a significant rise in the incidence of TE (p<0.001; Table-1). Bilateral procedures for both TE and FF trended up 16% annually (p<0.001; Table-1). In contrast, the incidence of unilateral TE increased 1% (p=0.047), whereas, that of unilateral FF decreased 4% annually (p=0.03; Table-1). Linear modeling of physician payments (per case-year) revealed a significant upward trend for TE reimbursements only (p<0.009;Table-2), whereas FF payments were level (p=0.165; Table-2). There was substantially greater payment variation for FF (108%) compared to TE (59%). Adjusted median physician payments increased with the rise in TE volume (p=0.010;Figure-1). No correlation was noted for FF procedural volume and payment.

Conclusion: Breast reconstruction volume continues to rise with a significant increase in bilateral cases. Mean physician payments have increased for prosthetic, but not autologous techniques. While macroeconomic principles, such as supply and demand, may explain payment trends for implants, the situation is less clear for flaps. The relationship between payment and number of autologous procedures performed may run in either direction, so additional analysis is needed to determine causality. Regardless, the relatively greater variation in physician payments for FF compared to TE suggests potential room for negotiation with insurers.

1:33 PM - 1:38 PM RM 19. Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction Without Liposomal Bupivacaine: Should it Become the Standard of Care? Vanderbilt University Medical Center, Nashville Presenter: Christodoulos Kaoutzanis, MD Christodoulos Kaoutzanis, MD(1), Nishant Ganesh Kumar, MD(2), Dillon C O'Neill, BA(1), Blair Wormer, MD(1), Julian Winocour, MD(1), John Layliev, MD(1), Stephane A Braun, MD(1) and Kent Higdon, MD(1) (1)Vanderbilt University Medical Center, Nashville, TN, (2)University of Michigan, Ann Arbor, MI

Background: Enhanced Recovery Pathway (ERP) programs have demonstrated improved perioperative care and shorter length of hospital stay (LOS) in several surgical disciplines. The purpose of this study was to compare the outcomes of patients undergoing autologous tissue-based breast reconstruction (ABR) before and after implementation of the ERP without liposomal bupivacaine.

Methods: We retrospectively reviewed consecutive patients who underwent ABR by two surgeons before and after the implementation of the ERP at a university center over a three-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-ERP) and ERP patients using two-tailed Student’s t-test, Fisher exact test, or Pearson chi-square test. Multivariate logistic regression was performed to identify risk factors for LOS. Cost analysis was performed.

Results: Between April 2014 and January 2017, 100 consecutive women were identified; 50 in each group. Both groups had similar demographics, co-morbidities, and reconstruction types. Postoperatively, the ERP cohort used significantly less total morphine equivalent and more acetaminophen when compared to the pre-ERP cohort (Table 1). The median LOS was shorter with ERP than pre-ERP (3 vs. 4 days, p<0.01), which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342 (Table 1). Participation in an ERP program and lower total morphine equivalent use were independent predictors for decreased LOS. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were low and similar between the groups (Table 1).

Conclusion: ERP program implementation should be considered as the standard approach for perioperative care in ABR since it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased LOS leading to downstream healthcare cost savings.

1:38 PM - 1:43 PM RM 20. Patient-Reported Outcomes Two Years after Immediate Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium (MROC) Study University of Michigan, Ann Arbor Presenter: Katherine Bernadette Santosa, M.D. Katherine Bernadette Santosa, M.D.(1), Ji Qi, MS(1), Jennifer B Hamill, MPH(1), Hyungjin M Kim, ScD(1), Edwin G. Wilkins, MD, MS(1) and Andrea L Pusic, MD, MHS(2) (1)University of Michigan, Ann Arbor, MI, (2)Memorial Sloan Kettering Cancer Center, New York, NY

Background: Previous outcome studies have been limited by short-term follow-up and lack of patient-reported outcome (PRO) measures. The objective of this multicenter prospective study was to evaluate PROs in women undergoing immediate post-mastectomy implant-based or autologous reconstruction at one and two years following reconstruction.

Methods: Patients were recruited as part of the Mastectomy Reconstruction Outcomes Consortium (MROC) study from eleven institutions (57 providers) across North America. Included in the analysis were women undergoing immediate, implant-based or autologous tissue procedures following mastectomies for cancer treatment or prophylaxis. All patients had at least one-year follow-up after reconstruction. Patients completed the BREAST-Q questionnaire prior to and at one and two years after surgery. A separate mixed-effects regression model was used to compare PRO scores between procedure types over time, controlling for baseline and a range of demographic and clinical covariates. A paired-samples t-test was performed to compare preoperative and two-year post-operative physical well-being of the abdomen scores among autologous patients.

Results: A total of 2,397 patients (1,789 implant, 608 autologous) were studied, of whom 1,702 (71%) completed the questionnaire at one-year after reconstruction. Additionally, of the 2,034 patients who reached two-year follow-up, 1,220 (60%) responded to the questionnaire. Autologous patients consistently reported higher satisfaction with breasts, (mean difference 8.21, p<0.001), greater psychosocial well-being (mean difference 3.05, p=0.006), physical well-being of the chest (mean difference 2.00, p=0.017), and sexual well-being (mean difference 6.05, p<0.001) compared to implant patients. However, in a separate univariate analysis, autologous patients reported significantly lower physical well-being of the abdomen scores at two-years as compared to their initial baseline scores prior to reconstruction (mean difference= -11.2, p<0.001).

Conclusion: Patients who underwent autologous reconstruction were more satisfied with their breasts and reported higher sexual well-being scores than women who underwent implant-based procedures over the two-year postoperative period. However, autologous patients reported lower physical well-being of the abdomen scores two years after reconstruction as compared to their baseline preoperative scores. These findings have the potential to assist breast reconstruction patients and providers navigate through this important shared decision-making process.

1:43 PM - 1:48 PM RM 21. Upper Extremity Morbidity Following Implant-Based Breast Reconstruction: A Pilot Study University of Michigan, Ann Arbor Presenter: Daniel A. Lyons, MD Daniel A. Lyons, MD(1), Joshua Leonardis, MS(1), Thomas Olinger, MD(1), Aviram Giladi, MD, MS(1), David Lipps, PhD(1) and Adeyiza O. Momoh, MD(2) (1)University of Michigan, Ann Arbor, MI, (2)Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI

Background: Studies assessing upper extremity morbidity following implant-based breast reconstruction have yielded mixed results, providing insufficient understanding of the effects that these procedures have on the neuromuscular control of the extremity. Our pilot study aims to utilize robot-assisted biomechanical measures to assess upper extremity morbidity and shoulder instability following breast reconstruction.

Methods: Patients were identified via chart review and recruited into the following cohorts: latissimus dorsi muscle flap plus implant, sub-pectoral implant-only, and mastectomy-only without reconstruction (control group). Functional and health-related quality of life outcomes were assessed using multiple validated patient reported outcome (PRO) questionnaires: QuickDASH, SPADI, PROMIS and SF-12. Robot-assisted biomechanical measures of shoulder stiffness – a function of extremity strength and neuromuscular control – were acquired. A single-axis rotary motor applied small, stochastic perturbations (0.06 rad) over 60 second trials (12 total trials per subject) while measuring resultant shoulder torques (Fig. 1). Patients were examined with their arm elevated 90 degrees while relaxed or actively producing torques scaled to ±10% of their isometric strength in the horizontal and vertical directions. Correlation between PRO and shoulder biomechanical measures were performed using univariate regression analysis.

Results: Sixty patients meeting inclusion criteria completed the study: 20 patients with latissimus dorsi, 20 patients with implant-only, and 20 patients with mastectomy alone. Patients having undergone latissimus flap reconstructions exhibited significantly less shoulder stiffness than patients with mastectomy alone in both vertical adduction and active horizontal directions (p<0.001). Patients with implant-only reconstructions exhibited less passive and active horizontal shoulder stiffness compared to patients undergoing mastectomy alone (p<0.003). There was no significant difference in shoulder stiffness patients who had undergone latissimus dorsi flap and implant-only reconstructions. A significant correlation between passive shoulder stiffness in the vertical direction with QuickDASH and PROMIS questionnaires (p=0.002 and p=0.001, respectively), as well as between active shoulder stiffness during horizontal abduction and SPADI questionnaire scores (p=0.007) was found on univariate regression analyses. There were no significant differences in PRO scores between the reconstruction groups.

Conclusion: We identified significant differences in shoulder stiffness (and, hence, upper extremity neuromuscular control) between patients with latissimus dorsi flap and implant-only reconstructions compared to mastectomy alone. These differences in stiffness correlated with functional outcomes from QuickDASH, PROMIS and SPADI questionnaires. Understanding these potential deficits will allow for improved preoperative counseling and informed decisions on reconstructive options, as well as guide post-operative therapy and rehabilitation protocols.

1:51 PM - 1:56 PM RM 22. Wise-Pattern Skin Reduction in Nipple-Sparing Mastectomy: A Comparison of Reconstructive Outcomes between Concomitant and Staged Techniques NYU Hansjörg Wyss Department of Plastic Surgery, New York Presenter: Ara A. Salibian, MD Ara A. Salibian, MD(1), Jordan D. Frey, MD(2), Mihye Choi, MD(1) and Nolan S. Karp, MD(1) (1)NYU Langone Medical Center, New York, NY, (2)Plastic Surgery, NYU Langone Medical, New York, NY

Background

The use of wise-pattern mastectomy skin incisions has been well-described for large volume breast reconstruction. This technique has demonstrated good results with skin-sparing mastectomies; however, reconstructive techniques and outcomes for nipple-sparing mastectomy (NSM) remain to be fully elucidated. Furthermore, there are no comparisons between techniques utilizing skin reduction at the time of NSM and staged breast reduction prior to NSM.

Methods

A retrospective chart review was performed of all cases of breast reconstruction after NSM with a concomitant or prior wise-pattern reduction. Cases were divided into two cohorts: breast reconstruction after NSM with wise-pattern mastectomy incisions and no prior history of breast reduction/mastopexy, and cases with intentional staged breast reduction with wise-pattern skin resection prior to NSM. Cohorts were compared with regards to patient demographics, operative techniques and reconstructive outcomes.

Results

Twenty-six cases (14 patients) underwent NSM with concomitant wise-pattern skin reduction and 14 cases (7 patients) underwent NSM with prior, staged breast reduction. Patients that underwent concomitant skin reduction had a higher BMI than staged patients (27.3 versus 23.8, respectively; p=0.079), greater mastectomy specimen weights (720.9 versus 535.7, respectively; p=0.0304, and more post-operative chemotherapy (30.8% verse 0%, respectively, p=0.0024). There were no differences in smoking history, diabetes, the number of obese patients, neoadjuvant therapies, mastectomy indication or reconstructive technique between the two cohorts (Table 1). Average time between NSM and breast reduction in the staged group was 7.6 months.

There was a significantly higher rate of major mastectomy flap necrosis in patients undergoing concomitant skin reduction compared to staged skin reduction with prior breast reduction (46.2% versus 0%, respectively; p=0.0024). Other complications including minor flap necrosis, partial and full nipple-areola complex necrosis, infection and reconstructive failure were similar between the two groups.

Conclusion

Patients undergoing NSM with wise-pattern skin reduction mastectomy incisions have a significantly higher rate of major mastectomy flap necrosis compared to those with staged breast reductions prior to NSM. Staged breast reduction may allow optimization of nipple-sparing candidates in patients with large or ptotic breasts to minimize ischemic complications.

1:56 PM - 2:01 PM RM 23. Check the Record; Remote CT Scans for Breast Flap Perforator Mapping: Is CT Angiography necessary? Duke University Medical Center, Durham Presenter: Amanda R. Sergesketter, B.S. Amanda R. Sergesketter, B.S., Bryan Pyfer, MD, Brett Phillips, MD, MBA and Scott T. Hollenbeck, MD Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC

Background

Perforator mapping with computed tomography angiography (CTA) before breast flap reconstruction is widely used to reduce donor-site morbidity and operative time. However, pre-operative imaging adds significant time, radiation, and economic burden. The aim of this study was to evaluate whether pre-existing CT scans could identify dominant perforators in patients undergoing autologous breast reconstruction.

Methods

Female patients who underwent mastectomy with immediate or delayed breast reconstruction with abdominal free flaps at a single institution between 2006 and 2016 were identified. Medical records were reviewed to identify patients with a pre-existing CT scan of the abdomen/pelvis. CT images were reviewed by the senior surgeon for identification of a dominant perforator. Scans were ranked on a 1-3 rating to indicate the utility of scans for pre-operative planning. A cost analysis was performed to assess the potential financial savings associated with use of a pre-existing scan for perforator identification.

Results

We identified 301 female patients who underwent mastectomy and abdominal free flap reconstruction. Of these, 44.9% (n=135) had a pre-existing CT scan available. A dominant perforator was identified on 125 (92.6%) of these scans. Using a scale of 1-3 to estimate scan utility, 78.4% were given a 3, indicating high utility for pre-operative planning. A higher proportion of dominant perforators were identified using pre-existing PET/CT scans compared to CT scans performed with IV contrast and non-contrast CTs (PET/CT: 97.7% vs. CT with IV contrast: 92.1% vs. Non-Contrast CT: 33.3%). While average scan utility scores were similar between PET/CTs and CTs with IV contrast, the average utility score for non-contrast CTs was lower (PET/CT: 2.7 ± 0.6; CT with IV contrast: 2.7 ± 0.6 vs. Non-Contrast CT: 1.3 ± 0.5). Bilateral dominant perforators were clearly identified in patients who had both a remote CT scan in addition to a pre-operative CTA. In patients with pre-existing scans, perforator mapping using remote PET/CT or CT abdomen/pelvis scans instead of CTA yielded a projected reduction in radiation exposure of 13.2 mGy and a projected cost savings of $4,157 per patient. Given that 14,499 breast free flap reconstructions are performed annually, assuming that 100% of patients would have pre-operative imaging performed, utilization of pre-existing scans would yield an annual US healthcare savings of up to $27,065,116.

Conclusion

Our study suggests that when available, pre-existing CT scans with IV contrast represent a viable and cost-effective alternative to CTA for pre-operative perforator mapping in abdominal-based free flap breast reconstruction.

2:01 PM - 2:06 PM RM 24. Long-Term Outcomes Using the Diagonal Upper Gracilis (DUG) Flap for Breast Reconstruction Memorial Sloan Kettering Cancer Center, New York Presenter: Erez Dayan, MD Joseph H Dayan, MD(1), Erez Dayan, MD(2), Joseph J Disa, MD(3), Babak J. Mehrara, MD(3), Robert J Allen, Jr., MD(1) and Smith L. Mark, M.D.(4) (1)Memorial Sloan Kettering Cancer Center, New York, NY, (2)Plastic Surgery, Harvard Medical School, Boston, MA, (3)Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, (4)Northwell Health, New Hyde Park, NY

Background

Thigh-based flaps such as the TUG or PAP are commonly designed in a transverse orientation near the gluteal crease. Tension on the closure limits the flap width and can also impair wound healing. The diagonal upper gracilis (DUG) flap is a modification where the axis of the skin paddle follows LangerÕs lines and the angiosome of the gracilis pedicle. This orientation allows for greater flap width and minimizes tension on closure with presumably favorable wound healing. The purpose of this study was to assess outcomes during this 6 year experience with the DUG flap.

Methods

A retrospective study was performed on a prospectively-maintained database of consecutive patients undergoing DUG flap breast reconstruction. Flap width and complications were evaluated. Surgical technique: All patients receive pre-operative enoxaparin. The anterior incision marked along the posterior border of the adductor longus muscle from the groin to 10 cm inferiorly, then posteriorly, parallel to LangerÕs lines. A pinch test defines the posterior incision. The pedicle is then mobilized, gracilis divided, and subfascial elevation of the flap is completed. All patients ambulate post-op day 1 without restriction.

Results

58 flaps in 40 patients were performed between April 2011 and May 2017. Follow-up range was from 1 to 74 months with an average of 34.5. 32 patients had mastectomy reconstruction and 8 patients had partial mastectomy reconstruction. There were no flap failures in this series, but one takeback for subtle color change that was negative and resolved spontaneously. Flap width ranged from 8 to 13 cm with a mean with of 10.3 cm. There were 5 complications in 40 patients (12.5%), 4 of these were donor site related (10%). 2 patients had a small local abscess at the donor site requiring I&D and 2 patients had cellulitis, one with concomitant seroma. There were no wound dehiscences. One patient had a bilateral DVT and 20% partial flap necrosis.

Conclusion

The DUG flap may be a useful option to consider in thigh-based reconstruction. A relatively wide flap can be harvested with minimal donor site healing issues. The harvest is rapid, stays posterior to major lymphatic collectors, and has reliable perfusion.

2:09 PM - 2:14 PM RM 25. Mobile Smart-Phone Thermal Imaging Accurately Predicts Perforator Location and Microvascular Flow Insufficiencies Swedish Medical Center, Seattle Presenter: Cody J Phillips, DO Cody J Phillips, DO(1), Vance Y Sohn, MD(1), Keith Paige, MD(2) and Kevin Beshlian, MD(2) (1)Madigan Army Medical Center, JBLM, WA, (2)The Polyclinic, Seattle, WA

Background: Mobile smart-phone thermal imaging (MTI) devices provide a low-cost, non-invasive, real time temperature measuring tool that makes it an appealing adjunct during free flap surgery to assess blood flow and tissue viability. We sought to assess the usefulness of MTI in the planning and monitoring of deep inferior epigastric artery perforator (DIEAP) free flaps. We hypothesized that thermal signatures can be used as surrogates for blood flow and are able to identify perforators preoperatively as well as microvascular flow insufficiencies.

Methods: In this proof of concept prospective evaluation, 16 patients underwent 27 DIEAP free flaps for breast reconstruction. Surgeons were blinded to MTI images. MTI images were obtained preoperatively, throughout the procedure, prior to leaving the operative suite, and at any time of concern for flap viability. Preoperative MTI mapping of perforators was correlated to operative perforator selection. Three groups were established for comparison: normal DIEAP flaps (NDF), flaps with arterial insufficiency (AI) and flaps with venous congestion (VC). Images were reviewed for temperature differences.

Results: All flaps were successful and there were no unplanned returns to the operating room. Preoperative perforator mapping performed with MTI correlated with operative perforator selection in 23 of 27 (85.2%) of flaps (Figure1). There was a significant increase in temperatures from max ischemia (24.5±2.1 ⁰C) to one minute after anastomosis (27.2±1.6⁰C, p < 0.001). NDF continued to warm until the final MTI taken when leaving the OR. There were no significant temperature differences between groups prior to transfer to the chest and at 1, 5, 10, 15 minutes after completion of microsurgical anastomosis (Figure2). Once flap viability was questioned by clinical and Doppler examination, VC and AI temperatures were found to be significantly colder when compared to the NDF group (28.3±1.9⁰C vs. 32.2±1.8⁰C, p=0.003) in the VC group and (27.2±0.7⁰C vs. 32.2±1.8⁰C, p=0.001) in the AI group (Figure3). After surgical correction, VC and AI rewarmed and temperatures were no different when compared to NDF. General characteristics were compared and no statistically significant differences were observed for age, co-morbidities, ASA classification, or flap ischemia times.

Conclusion: Mobile smart-phone thermal imaging recognizes microanastomotic failure and represents a dramatic advance in the evaluation of free flap perfusion and viability compared to current assessment methods. It accurately identifies perforators suitable for DIEAP free flaps and is useful in preoperative planning.

2:14 PM - 2:19 PM RM 26. Revisiting the Relationship Between Hospital Volume and Outcomes in Abdominal-Based Free Flap Breast Reconstruction Beth Israel Deaconess Medical Center, Boston Presenter: Anmol Chattha, BA Anmol Chattha, BA(1), Austin D. Chen, BS(1), Bernard T. Lee, MD, MBA, MPH, FACS(2), Samuel J. Lin, MD, MBA, FACS(2) and Justin B Cohen, MD(3) (1)Beth Israel Deaconess Medical Center / Harvard Medical School, Boston, MA, (2)Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center / Harvard Medical School, Boston, MA, (3)Beth Israel Deaconess Medical Center, Boston, MA

Background

Increased operative volume has been associated with benefits in both patient and economic outcomes for a variety of surgical procedures. In autologous abdominal-based breast reconstruction, however, there are few studies assessing the association between procedure volume and patient outcomes. The objectives of this study are to re-evaluate the associations between abdominal based free flap breast reconstruction and patient outcomes, including both clinical and economic outcomes.

Methods

The 2013-2014 Healthcare Cost and Utilization Project National Inpatient Sample was queried for all female patients with a diagnosis of breast cancer who underwent mastectomy and immediate abdominal-based breast reconstruction (Deep Inferior Epigastric Perforator or Transverse Rectus Abdominus Muscle free flaps). Outcomes included occurrence of major or surgical site in-hospital complications, cost and length of stay (LOS). High-volume hospitals (HV) were defined as the 90th percentile of annual case volume or higher (>18 cases/year). Multivariate regressions and generalized linear modelling with gamma log-link function were performed to access the outcomes associated with high-volume hospitals.

Results

Overall, 7145 patients at 473 hospitals were retrieved; of these, 42.4 percent of patients were treated at high-volume hospitals. There were significant differences in unadjusted major complications (2.1 percent vs 4.3 percent; p<0.001), and unadjusted surgical-site complications (3.5 percent vs 6.1 percent; p<0.001) between HV and non-HV. After adjustments for clinical and hospital characteristics, patients treated at HV hospitals were less likely to experience a major complication (OR, 0.488; 95 percent CI, 0.353 to 0.675; p<0.001) or surgical site complication (OR, 0.678; 95 percent CI, 0.519 to 0.887; p=0.005). There was no difference in inpatient costs between HV and non-HV hospitals ($26,822 vs $26,295; marginal cost: $528; p=0.102); however, HV hospitals had a shorter LOS (4.31 vs 4.40 days; marginal LOS: -0.10; p=0.005)

Conclusion

Hospitals that perform a larger number of immediate abdominal based breast reconstructions after mastectomy appear to have a lower rate of major complications in the present study than lower-volume hospitals, with a shorter length of stay. However, these same high-volume centers demonstrate no decrease in cost. Further research is needed to understand how these high-volume centers can reduce costs.

2:19 PM - 2:24 PM RM 27. Complications in Post-Mastectomy Breast Reconstruction: Two Year Outcomes of the Mastectomy Reconstruction Outcomes Consortium (MROC) Study University of Michigan, Ann Arbor Presenter: Katelyn G. Bennett, MD Katelyn G. Bennett, MD(1), Jennifer B. Hamill, MPH(1), Hyungjin M Kim, ScD(1), Ji Qi, MS(1), Andrea L Pusic, MD, MHS(2) and Edwin G. Wilkins, MD, MS(3) (1)University of Michigan, Ann Arbor, MI, (2)Memorial Sloan Kettering Cancer Center, New York, NY, (3)Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI

Background

In planning post-mastectomy reconstruction, it is critical for patients and providers to have accurate, comprehensive information on the relative risks of the available options. However, previous studies evaluating complication rates have been limited by their single center/surgeon designs, short-term follow-up, and lack of controls for potential confounding variables. We sought to assess long-term complication rates among common techniques for mastectomy reconstruction in a large, multicenter patient population.

Methods

Patients for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were recruited from 11 centers in the U.S. and Canada between 2011 and 2015. All women undergoing first-time reconstruction after mastectomy with at least two years of follow-up were included. Procedures evaluated included direct-to-implant (DTI), expander-implant (E/I), latissimus dorsi/implant (LD), pedicled TRAM (pTRAM), free TRAM (fTRAM), DIEP, and SIEA techniques. Outcomes assessed included development of any complications, re-operative complications, and wound infections during the two-year postoperative period. Mixed-effects logistic regressions controlled for between-center variability and for demographic/clinical variables, including age, BMI, timing of reconstruction, laterality, mastectomy indication, lymph node management, diabetes, smoking, chemotherapy, and radiation.

Results

A total of 2,343 patients met inclusion criteria. Most patients underwent E/I reconstruction (1,525), with the remainder receiving DTI (112), pTRAM (85), fTRAM (95), DIEP (390), LD (71), or SIEA (65) procedures. Overall, complications were noted in 32.9%, with re-operative complications in 19.3%. Wound infections occurred in 9.8% of all procedures. Two years postoperatively, all autologous reconstruction types had significantly higher odds of developing any complication, compared with E/I techniques (OR: pTRAM 1.93, p=0.02; fTRAM 2.07, p=0.005; DIEP 1.97, p<.001; LD 1.85, p=0.043; SIEA 4.64, p<.001). With the exception of LD reconstructions, all flap procedures were associated with higher odds of re-operative complications (OR: pTRAM 2.46, p=0.005; fTRAM 2.99, p<.001; DIEP 2.74, p<.001; SIEA 2.58, p=0.013), compared with E/I techniques. Of the autologous reconstructions, only DIEP flaps were at significantly lower risk for infections, compared with E/I procedures (OR 0.45, p=0.006). However, DTI and E/I procedures had higher failure rates than autologous methods (E/I and DTI 7.1%, pTRAM 1.2%, fTRAM 2.1%, DIEP 1.3%, LD 2.8%, SIEA 0%; p<.001).

Conclusion

In this large multicenter analysis, significant differences were noted across reconstructive procedure types for overall (any) and re-operative complications. When discussing reconstructive options with patients, these potential risks must be weighed against possible benefits.

2:27 PM - 2:32 PM RM 28. Knowledge about Breast Cancer and Decisions Made for Contralateral Prophylactic Mastectomy- A Comparison of Surgeons and Women in the General Population University Of Michigan Medical School, Ann Arbor Presenter: Rachel Hooper, MD Rachel Hooper, MD(1), Jessica Hsu, MD, PhD(1), Tony Duncan, BS(1), Kelly Kidwell, PhD(2), Adeyiza O. Momoh, MD(3), Jessica Bensenhaver, MD(4) and Lisa A Newman, MD, PhD, PhD(5) (1)University of Michigan, Ann Arbor, MI, (2)Univeristy of Michigan, Ann Arbor, MI, (3)Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, (4)Henry Ford Health System, Detroit, MI, (5)Henry Ford Medical Center, Detroit, MI

Background: In women with a diagnosis of unilateral early stage breast cancer, contralateral prophylactic mastectomy (CPM) is often pursued with the goal of improving overall survival. Decisions to undergo CPM in “lower risk” women are often attributed to a “lack of knowledge". To examine the role of knowledge, this study evaluates the choices made for surgical treatment and factors driving these decisions made by lay women (referred to as women) and surgeons for themselves or a loved one when faced with a diagnosis of early stage unilateral breast cancer.

Methods: We targeted 3 different groups: 1) women ages 25-65, 2) American Society of Plastic Surgeons-board certified plastic surgeons and 3) American Society Breast Surgeons-board certified breast surgeons from 9 states. Women respondents (non-surgeons) were recruited using Amazon Turk crowdsourcing. Surgeons received the surveys electronically via email. Demographic and CPM specific information were obtained and analyzed.

Results: There were 212 women, 198 reconstructive surgeons, and 142 breast surgeons included in the analysis. The response rate for all surgeons was 9.3%. 67.5% of the women were under 40 years old, whereas 80% of breast surgeons and 70% of reconstructive surgeons were over 40. 90% of women had a college education or beyond. Women had the wrong response to breast cancer knowledge questions 34-78% of the time. A greater proportion of women in the general population favored CPM (79%) relative to reconstructive and breast surgeons (51% and 26% respectively), p<0.0001. 80% of women identified the following factors as extremely important in their decision: 1) lower chance of breast cancer in the other breast, 2) not having cancer spread and 3) improved survival. Breast surgeons who chose CPM were younger (p=0.044) and female (p=0.012); though not significant, reconstructive surgeons in favor of CPM were also predominantly female (61.7%) vs. males (45.2%), p=0.06.

Conclusion: Breast and reconstructive surgeons are more knowledgeable about breast cancer and survival rates after unilateral mastectomy and CPM. This knowledge gap may explain the lower rates with which surgeons choose CPM for themselves or loved ones relative to women in the general population. Continued patient education on the surgical options for breast cancer treatment and survival remains crucial. However, even with education, a greater proportion of young and female surgeons favored CPM—suggesting that improved knowledge may not completely resolve this challenge.

Table 1: Major influences on CPM decision among women respondents.

2:37 PM - 2:42 PM RM 30. Potential Risk Factors for Worsening Abdominal Well-Being after Abdominal Flap Breast Reconstruction: There’s No Such Thing As a Free Tummy Tuck Johns Hopkins University, Baltimore Presenter: Charalampos Siotos, MD Meredith Meyer, MD(1), Ricardo J Bello, MD, MPH(1), Charalampos Siotos, MD(2), Mohamad E. Sebai, MBBS(3), Rachel M Payne, MD(1), Michele A Manahan, MD(4), Justin M Sacks, MD, MBA, FACS(5), Carisa M. Cooney, MPH(4) and Gedge D Rosson, MD(4) (1)Johns Hopkins University, Baltimore, MD, (2)Johns Hopkins University School of Medicine, Baltimore, MD, (3)Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, (4)Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, (5)Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD

Background: Data analysis from a prior cohort in our institution’s breast reconstruction registry demonstrated that perceived lower satisfaction of the abdomen preoperatively is a strong predictor of undergoing a DIEP flap. Therefore, this study aimed to evaluate physical well-being of the abdomen after flap-based breast reconstruction, as well as potential predictors for decreased well-being postoperatively.

Methods: We performed a retrospective analysis on a prospectively-maintained institutional breast reconstruction registry. We extracted data on patient characteristics, surgical treatment, and clinical and quality-of-life outcomes for patients undergoing abdominally-based autologous flap breast reconstruction from 2010-2015. Our primary outcome was the Physical Well-being of the Abdomen (PWA) domain from the Breast-Q, measured as a preoperative baseline and at 6- and 12-month follow-ups after final reconstruction. We compared patients who experienced a clinically-important worsening of PWA from baseline to 12-month follow-up (defined as a decrease of>7 points) with those who did not and examined potential predictors of decreased PWA using Chi-squared test, t-test, and Wilcoxon rank-sum test. We fitted a multivariable logistic regression model to estimate which data points may be potential risk factors for worsened PWA.

Results: Of 142 women studied, 35(24.6%) patients underwent immediate reconstruction, 71(50%) staged reconstruction, and 36(25.3%) delayed reconstruction. Mean age was 50 years(SD:9); mean BMI was 28.4 Kg/m2(SD:5.5). These patients represented 222 reconstructions, including DIEP flaps(91.0%), free msTRAM(3.6%), free TRAM(3.6%), and pedicled TRAM(1.8%) reconstructions. PWA significantly decreased from baseline (median: 83 points; inter-quartile range [IQR]:83-100) to 6-month (median:79;IQR:70-89;p<0.001) and 12-month follow-up (median79;IQR:70-100;p<0.001;figure 1). The distribution of PWA improved between the 6-month and 12-month follow-ups (p=0.019). The multivariate logistic regression (table 1) showed an association between a higher baseline PWA (OR=1.07;CI[1.03–1.11];p<0.001) and race (p<0.009) with higher odds of decreased PWA at the 12-month follow-up. Similarly, African-American and “Other” races exhibited an independent association with a roughly four-fold and eight-fold increase in the odds of decreased PWA, respectively. A higher baseline RAND-36 general health score, bilateral reconstruction versus unilateral, and a lower BMI demonstrate a trend for clinically important worsening of PWA.

Conclusion: Our analysis demonstrates that patients with greater preoperative abdominal well-being tend to have worsened well-being of the abdomen after flap-based breast reconstruction. Patients with lower BMI and higher quality-of-life scores may experience similar outcomes. Our finding that African-American patients and those classified under “Other” races are

independently associated with significant worsening of PWA may be due to confounding factors that should be explored in larger, prospective studies.

2:45 PM - 2:50 PM RM 31. Optimal Post-operative Antibiotic Prophylaxis after Breast Surgery: A Meta-Analysis Johns Hopkins, Baltimore Presenter: Charalampos Siotos, MD Charalampos Siotos, MD(1), Michael McColl, MD(2), Mohamad E. Sebai, MBBS(3), Stella M. Seal, MLS(4), Michele A Manahan, MD(1), Mehran Habibi, MD, MBA(2), Carisa M. Cooney, MPH(4) and Gedge D Rosson, MD(4) (1)Johns Hopkins University School of Medicine, Baltimore, MD, (2)Johns Hopkins University, Baltimore, MD, (3)Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, (4)Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD

Background: Current clinical guidelines dictate the use of prophylactic antibiotics after breast surgery for the prevention of surgical site infections (SSI). However, there is no agreement among physicians on whether post-operative prophylaxis after clean surgeries, like breast surgery, is necessary. Nor is there agreement on the duration of the prophylaxis. We sought to systematically evaluate the current literature regarding the optimal use and duration of post-operative antibiotic prophylaxis in plastic breast surgery.

Methods: We systematically searched the PubMed, Embase, Cochrane and Web of Science databases for relevant articles published through January, 2017. We performed meta-analysis employing Random Effects Model and the RevMan software.

Results: Our search revealed 727 articles, which were screened based on their title and abstract. Next, 56 of these were screened based on the full text. Following the screening process, 10 studies (one randomized trial, one observational prospective and eight retrospective) met our criteria. Overall, 4,354 patients were included who underwent mastectomy, breast reconstruction, breast reduction or breast augmentation. Meta-analysis of 6 studies showed that pre-operative only use of antibiotics was associated with higher risk of SSI when compared to pre-operative and post-operative antibiotic treatment together, although not at a statistically significant level (2,902 patients, OR=1.54, 95%CI [0.87-2.74], p=0.14, I2=64%, Figure 1). This higher risk of SSI was found to be significant when a cancer related sensitivity analysis was performed (OR =1.99, 95% CI [1.07-3.67], p=0.03, I2=66%, Figure 2). The results of our second meta-analysis indicated that a short duration (≤24 hours) of post-operative antibiotics was significantly associated with higher odds of SSI when compared to a prolonged duration of post-operative antibiotics (5 studies, 2,843 patients, OR=1.59, 95%CI [1.02-2.46], p=0.04, I2=28%, Figure 3).

Conclusion: According to the results of our meta-analyses, a prolonged (>24 hours) duration of prophylactic antibiotics after breast surgery may prevent surgical site infections more effectively than a short duration course of antibiotics. However, limited data are currently available. Further prospective studies are necessary to establish the optimal duration of post-operative prophylactic antibiotics, balancing the benefit of infection prevention, the risk of related complications, and cost.

Figure 1: Forest Plot for the comparison of SSI between patients who received only Pre-operative prophylaxis and patients who received pre-and post-operative prophylaxis.

Figure 2: Forest plot for the cancer related sensitivity analysis.

Figure 3: Forest Plot for the comparison of surgical site infection between patients who received short and prolonged post-operative antibiotic prophylaxis.

2:50 PM - 2:55 PM RM 32. Improving Post-Operative Monitoring of Autologous Breast Reconstruction: A Novel, Oxygen-Sensing Liquid Bandage First in-Human Trial Beth Israel Deaconess Medical Center, Boston Presenter: Alexandra Bucknor, MBBS, MRCS, MSc Alexandra Bucknor, MBBS, MRCS, MSc(1), Parisa Kamali, MD(2), Haley Marks, PhD(3), Emmanouil Rousakis, PhD(3), Nicholas Nowell, BS(3), Conor Evans, PhD(3) and Samuel J. Lin, MD, MBA, FACS(4) (1)Beth Israel Deaconess Medical Center / Harvard Medical School, Boston, MA, (2)Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands, (3)Massachusetts General Hospital, Boston, MA, (4)Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center / Harvard Medical School, Boston, MA

Background

Autologous free flaps may be used to reconstruct defects arising in a variety of contexts, including trauma and cancer. With improving microsurgical techniques flap failure rates are decreasing; however, this devastating complication may still occur in up to 5% of cases. In this study, we present results of a first in-human trial of a new, non-invasive, optical oxygen-sensing liquid bandage (OSLB) formulation in post-operative monitoring of tissue perfusion.

Methods

Four women undergoing mastectomy and deep inferior epigastric artery perforator (DIEP) flap reconstruction were prospectively enrolled from February-June 2017. In addition to standard post-operative monitoring with near-infrared spectroscopy tissue oximetry (ViOptix), the OSLB was painted on the flap skin paddle. The formulation consists of New-Skin‰ liquid bandage, incorporating an oxygen-sensing metallo-porphyrin exhibiting bright red phosphorescence and the green-fluorescing reference dye: fluorescein. Using a custom-modified camera with red and green filters, we captured phosphorescence and fluorescence, respectively, at regular time periods for 48 hours post-operatively. The relative phosphorescence intensity

was calculated.

Results

Three Caucasian and one African American woman took part. Two cases were bilateral, producing a total of six breasts. When comparing the OSLB red/green ratio with the ViOptix, an inverse correlation was observed, as expected. Notably, this persisted for an African American patient with Fitzpatrick Type V skin. No complications or flap losses occurred.

Conclusion

The success of attempted flap salvage is highly reliant on early identification of flap compromise and prompt re-exploration. Results show that OSLB phosphorescence intensity correlates well with the stO2 values provided by our current gold standard of care, the ViOptix. The OSLB proved easy to apply and remove, was well-tolerated, and enabled visualization of flap skin due to its intrinsic transparency. Moreover, we demonstrated successful use of the OSLB in a patient with Fitzpatrick type V skin. This oxygen-sensing liquid bandage offers reproducible, accurate detection of tissue oxygenation. Further research is needed to validate this technology on a larger scale.

Figure 1. Top left: medial aspect of breast flap with liquid bandage painted on. Top right: liquid bandage as viewed under red filter. Below left: the oxygen-sensing, polyglutamic dendrimer with a palladium-porphyrin core embedded in the liquid bandage. Below right: phosphorescence intensity mapping.

Figure 2. Graph showing inverse temporal correlation of liquid bandage phosphorescence intensity with ViOptix reading for patient # 4 (Fitzpatrick type 5).

Post-

2:55 PM - 3:00 PM RM 33. Toxicity outcomes for immediate and delayed autologous reconstruction in patients receiving post-mastectomy radiotherapy: is it time to reconsider sequencing? The Ohio State University, Columbus Presenter: Daniel Konstantinou, B.S., M.S. Daniel Konstantinou, B.S., M.S.(1), Jessica Wobb, MD(2), Albert H Chao, MD(3), Jose G Bazan, MD(2), Rebekah Young, MD(2), Roman J. Skoracki, MD(3), Julia White, MD(2) and Maristella S Evangelista, MD(3) (1)The Ohio State University College of Medicine, Columbus, OH, (2)Department of Radiation Oncology, The Ohio State University, Columbus, OH, (3)Department of Plastic Surgery, The Ohio State University, Columbus, OH

Background: Delayed autologous reconstruction is generally recommended in patients anticipating postmastectomy radiation therapy (PMRT). It has been suggested, however, that immediate autologous reconstruction (AR) may be acceptable. In this study, we assess outcomes in patients receiving PMRT and AR.

Methods: Retrospective chart review was performed for all patients receiving AR at a single institution between April 2012 and November 2016. All patients receiving AR and PMRT with evaluable 3D planned radiotherapy and at least 3 months follow up were included. A random cohort of patients receiving AR and no PMRT were assessed as a control. Incidence of major and minor complications were assessed. Preoperative and postoperative photos were assessed. Statistical analysis was performed with ANOVA.

Results: 739 patients underwent AR, of which 50 received 3D planned PMRT and had at least 3 months follow up. 39 patients underwent delayed AR; 11 patients underwent immediate AR. 37 patients were included in the immediate AR without PMRT control group. Median age was 46 years (31 to 62) and median follow up was 9 months (3 to 53 months). Median length of stay, infection rates, fat necrosis rates, skin necrosis rates, incidence of revisions, flap failures, and 90-

No PMRT

Immediate Delayed p-value

Median length of stay

4.4 days 4.2 days 4.6 days 0.77

Infection 13.5% (N=5)

27.3% (N=3)

7.7% (N=3)

0.19

Fat necrosis 8.1% (N=3)

9.1% (N=1)

25.6% (N=10)

0.11

Skin necrosis 8.1% (N=3)

27.3% (N=3)

5.1 % (N=2)

0.20

Percentage requiring revisions

45.9% (N=17)

54.6% (N=6)

43.6% (N=17)

0.72

Unplanned reoperations

0% 0% 12.8% (N=5)

0.03

Flap failures 0% 0% 2.6% (N=1)

0.34

Total operation time

8:55 9:21 5:21 0.07

90-day readmission

2.7% (N=1)

9.1% (N=1)

10.3% (N=4)

0.53

day readmission rates were comparable between groups. Unplanned reoperation rates were in higher in delayed patients, 0% no PMRT, 0% immediate and 12.8% (N=5; p=0.03) delayed. Photo ratings were comparable between the three groups.

Conclusion: Immediate autologous reconstruction in the setting of PMRT appears to show acceptable outcomes that are comparable to delayed reconstruction. Further studies are needed to validate these early findings.

3:03 PM - 3:08 PM RM 34. Patient Reported Satisfaction and Quality of Life in Post-Mastectomy Radiated Patients: A Comparison between Delayed and Delayed Immediate Autologous Breast Reconstruction in a Predominantly Minority Patient Population Montefiore Medical Center, Bronx Presenter: George N Kamel, MD George N Kamel, MD(1), Robin Berk, BS(1), Teresa Benacquista, MD(1), Evan Garfein, MD(2) and Katie Weichman, MD(1) (1)Plastic and Reconstructive Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, (2)Plastic and Reconstructive Surgery, Montefiore Medical Center/Einstein College of Medicine, Bronx, NY

Background: Delayed immediate autologous breast reconstruction consists of immediate post mastectomy tissue expander placement, followed by radiation therapy and subsequent autologous reconstruction. The decision between delayed versus delayed immediate autologous breast reconstruction in patients anticipating post mastectomy radiotherapy is challenging and remains to be elucidated. The purpose of this investigation was to evaluate the effects of delayed versus delayed immediate autologous breast reconstruction in patients undergoing post mastectomy radiotherapy on patient reported outcomes and quality of life in predominantly minority patients.

Methods: After IRB approval was obtained, a retrospective review of all patients who underwent autologous based breast reconstruction at Montefiore Medical Center from January of 2009 to December of 2016 was conducted. Patients who underwent post mastectomy radiotherapy were included for analysis. Patients were divided into two cohorts: those undergoing delayed and delayed immediate autologous breast reconstruction. Patients were mailed a BREAST-Q survey. Demographic information, complications, and need for revisionary procedures were analyzed in comparison. BREAST Q satisfaction was then analyzed using Q-Score software.

Results: 56 patients met the inclusion criteria: 37.5 percent (n=21) of patients underwent delayed autologous breast reconstruction and 62.5 percent (n=35) underwent delayed immediate autologous breast reconstruction. 87.5 percent (n=49) of the patients were identified as minority. Patients in each cohort were similar in BMI, mean mastectomy specimen weight, indication for surgery and smoking status. All patients received post mastectomy radiotherapy. However, patients undergoing delayed immediate autologous breast reconstruction were more likely to have bilateral reconstruction (34.3 percent (n=12) versus 9.5 percent (n=2), p=0.04), and were more likely to have major mastectomy flap necrosis (17.0 percent (n=8) versus 0.0 percent (n=0), p= 0.02). Furthermore, 14.9 percent (n=7) of patients undergoing delayed immediate autologous breast reconstruction required removal of their tissue expanders. Of those patients undergoing delayed autologous breast reconstruction, 28.6% (n=6) responded to the BREAST-Q survey, whereas 40.0% (n=14) of patients with delayed immediate autologous breast reconstruction were responders. BREAST-Q responses showed similar satisfaction with their breasts, overall outcome, chest wall physical well-being, sexual well-being, and psychosocial well-being in both groups.

Conclusion: Delayed autologous breast reconstruction yields similar satisfaction with breasts, overall outcome, chest wall physical well-being, sexual well-being, and psychosocial well-being as compared to delayed immediate autologous based reconstruction. However, patients who undergo delayed immediate autologous breast reconstruction have higher rates of major mastectomy necrosis and subsequent removal of their tissue expanders. This information will be important in preoperative patient discussions and counseling.

3:08 PM - 3:13 PM RM 35. An Anatomical and Histological Intercostal Nerve Study to Determine Optimal Recipient Site for Sensory Reinnervation in Autologous Breast Reconstruction Presenter: Anita T Mohan, MRCS MBBS Anita T Mohan, MRCS MBBS(1), Marissa Suchyta, BA(2), Osman Akdag, MD(2), Lin Zhu, MD(3), Nirusha Lachman, PhD(3), Samir Mardini, M.D.(4) and Michel Saint-Cyr, MD(5) (1)Division of Plastic Surgery, Mayo Clinic, Rochester, MN, (2)Mayo Clinic, Rochester, MN, (3)Department of Plastic Surgery, Mayo Clinic, Rochester, MN, (4)Plastic Surgery, Mayo Clinic, Rochester, MN, (5)Baylor Scott & White Health, Temple, TX

Background Some developments in the evolution of perforator flaps in autologous breast reconstruction include attempts to reinnervate the harvested tissue. There is a paucity of data on sensory reinnervation but it has been reported that the use of innervated autologous flaps in breast reconstruction can provide stability, protection from direct trauma, recovery of erogenous sensation and higher patient satisfaction. Previous studies have evaluated the anterior abdominal wall intercostal nerve anatomy as a donor nerve to be raised with autologous abdominal based flaps.This study provides the anatomical basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction.

Methods Twelve hemi-chests were dissected from six fresh (non-frozen) cadaveric females, with a median age of 79 years (range 63-100) and BMI of 26.8.Dissections were carried out from the anterior midline proceeding laterally to identify subcutaneous portions of cutaneous branches of the anterior cutaneous intercostal nerve and then exposure of the first six ribs. Costal cartilage was sequentially removed to expose the internal mammary vessels and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) branch of the anterior cutaneous intercostal nerve (LACB). Anatomical measurements were recorded and nerve samples from both branches were reviewed histologically. Specimens were cross-sectioned and stained with H&E and Karnovsky and Roots Staining to differentiate sensory fascicles.

Results A total of 75 nerve specimens were assessed. A lateral subcutaneous branch of the anterior cutaneous branch of the intercostal nerve (LACB) was noted consistently in the 2nd to 4th rib space (96% cases), with a median length of 43mm, 37.5mm and 37mm respectively. These nerves perforated the intercostal muscles within 1cm from the sternal edge, and the length and diameter of the LACB diminished caudally, with the largest diameter nerves at the 2nd-4th intercostal spaces. Histological analysis demonstrated that the nerves in the 2nd intercostal space had a larger fascicular area compared to that in the 4th (P=0.02). Axonal count of sensory fascicles was the highest in the 2nd intercostal nerves (P=0.05). Across all rib spaces, the fascicular and axonal counts were comparable in the LACB and ACB.

Conclusion An understanding of the characteristics of the anterior cutaneous intercostal nerve branches can optimize the site of recipient site coaptation. On preparation of the internal mammary vessels, the 2nd intercostal space provides greatest sensory fascicles for coaptation with a larger diameter and the preservation of the LACB can provide additional length to assist in anastomosis.

3:13 PM - 3:18 PM RM 36. Combining abdominal flaps and implants in the breast reconstruction patient; a systematic review of complications and outcomes MedStar Georgetown University Hospital, Washington Presenter: Kenneth L Fan, MD Kenneth L Fan, MD(1), Francis D Graziano, BS(2), Michael V. DeFazio, MD(3) and Maurice Y Nahabedian, MD(4) (1)MedStar Georgetown University Hospital, Washington, DC, (2)Georgetown University School of Medicine, Washington, DC, (3)Plastic Surgery, Georgetown University Hospital, Washington, DC, (4)Georgetown University, Washington, DC

Background

Options for augmenting abdominal flaps in the setting of breast reconstruction can be performed with fat grafting or prosthetic devices. The purpose of this review is to compare personal outcomes with published data following abdominal flap reconstruction and implants.

Methods

For the systematic review, multiple databases were queried for breast reconstruction with combined abdominal flaps and implants. A single center, retrospective review was conducted for all consecutive patients who underwent breast reconstruction with an abdominal flap and implant between July 2005 and August 2015 by the senior author (MN). All implants were placed in delayed fashion. Primary outcomes assessed included patient characteristics, radiation exposure, and complications. Flap-related complications included partial or full flap loss, fat necrosis and mastectomy skin necrosis. Implant-related complications included infection, hematoma, and capsular contracture.

Results

A total of 53 patients were retrospectively reviewed. The average age was 48.6 and body mass index was 26.1. All patients received the flap and implant in a staged manner. The average time between flap reconstruction and implant placement was 356 days. Eight patients (15%) were found to have a complication; four patients had hematomas, two patients had implant infections, one patient had skin necrosis and one patient had complete flap loss. Thirty-five patients (66%) received radiation either before or after their flap placement. Systematic review yielded six articles, for a total of 158 patients. Of these 158 patients, 102 (65%) had immediate implant or tissue expander placed at the time of flap reconstruction and the other 56 patients (35%) received flap reconstruction and implant as staged operations. In the immediate group, 26 patients (26%) were found to have a flap or implant complication, where as in the staged group one patient (2%) was found to have a complication. When pooling our data, we found that complication rates were significantly lower in the staged reconstruction cohort compared to immediate flap and implant series from the systematic review (p < 0.001).

Conclusion

The results of this review support the idea that performing an abdominal free flap with implant for breast reconstruction in a delayed approach can minimize complication rates. Higher complication rates in the immediate implant placement cohort may be secondary to imprecise implant placement, open chest wound for a longer time frame, and increased risk of perforator pressure via implant.

3:18 PM - 3:23 PM RM 37. A Picture Option Grid in Breast Reconstruction: Improved Decision Making Montefiore Medical Center, Bronx Presenter: Carrie Stern, MD Carrie Stern, MD(1), Thomas Del Guercio, MD(2), Jenny Zhang, BA(2), Jeffrey Arendash, BA(2), Marie Ann Durand, PhD(3), Oren Tepper, MD(4), Evan Garfein, MD(1), Vishal Thanik, MD(5) and Katie E. Weichman, MD(4,6) (1)Plastic and Reconstructive Surgery, Montefiore Medical Center/Einstein College of Medicine, Bronx, NY, (2)Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, (3)The Dartmouth Institute, Lebanon, NH, (4)Plastic and Reconstructive Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, (5)Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, NY, (6)Plastic Surgery, Montefiore Medical Center, New York, NY

Background

The decision regarding type of breast reconstruction is multifaceted and involves shared decision-making between patients and physician. Based on the limitations associated with low socioeconomic status patients, the use of pictorial representations in decisions aids have been shown to improve understanding, compliance, and recall of health related information. We sought to develop a pictorial option grid (decision aid) to aid in decision making in patients undergoing breast reconstruction after mastectomy.

Methods

An option grid addressing frequently asked questions regarding no reconstruction, implant reconstruction, and autologous reconstruction was developed (IRB 3025-2016). Questions were developed with the help of various health care providers. Once the questions and evidence-based answers had been constructed, pictorial representations of each answer were created. Translations from English to Spanish and Mandarin Chinese were performed.

Using a Community-Based Participatory Research approach we tested the usability of the picture option grid for breast reconstruction version 1.0 using think aloud protocol and semi-structured interviews on target users. We tested prototype version 1.0 at Montefiore Medical Center and Bellevue Hospital Center, on Spanish speaking patients and English speaking patients who were greater than 18 years of age and had considered breast reconstruction in the previous 3 years. Thematic analysis of responses to semi-structured interviews was performed and based on feedback from these interviews Version 2.0 was developed.

Results

In Picture Option Grid 1.0, 12 questions and 12 evidence-based answers were developed. 29 women (15 Spanish, 14 English) were given version 1.0. Two rounds of pilot testing were performed using semi-structured interviews with women who represented the target patient population. First round included 5 Spanish-speaking and 5 English-speaking women. Version 1.0 was modified to 10 questions using feedback and additional expert opinion. Nineteen women (10 Spanish, 9 English) were included in the second pilot, and concluded when saturation of responses during the semi-structured interview was reached.

Conclusion

Preliminary data from our pilot study of women of low SES and health professionals, confirm the usability of a Picture Option Grid for breast reconstruction. Additional modifications were performed and Picture Option Grid 2.0 was created. Future studies will include a pilot randomized control trial to determine the acceptability and efficacy of a Picture Option Grid for breast reconstruction.