Scientific Paper Session : Breast Tuesday January 27 , 2015 7 : 00 am - 8 : 45

BACKGROUND: Immediate, implant-only breast reconstruction is traditionally discouraged inpatients who receive radiation therapy for reasons of the significant morbidity associated withthis approach. It is not clear however, whether this widely-recognized mantra of breastreconstruction is actually currently observed in practice. The aim of this study is thus to evaluatereconstruction trends and practices in breast cancer patients who have undergone mastectomyand radiation therapy. METHODS: Female patients with unilateral breast cancer who required radiation therapy inaddition to mastectomy were extracted from the Surveillance, Epidemiology, and End Results(SEER) database from 2000 through 2010. Patients who underwent immediate reconstructionwere identified and analyzed. Reconstructive techniques from the database were implant only,combined implant-tissue reconstruction and tissue only reconstruction. Bivariate andmultivariate logistic regression analyses were performed to study the odds of implant orcombined implant-tissue reconstruction over tissue only reconstruction based on specificdemographic and oncologic characteristics. RESULTS: A total of 40,658 female patients were included for analysis. Reconstruction wasperformed in 6975 patients (17%) who required radiation. Post mastectomy radiation therapywas performed in 98.2% of the patients. The reconstruction rate among patients requiringradiation increased from 13.6% to 25.1% during the study period. The percentage ofreconstructed patients who had implant only reconstruction increased from 22% to 42% (r=0.96,p<0.001) with a concomitant decrease in tissue only reconstruction from 42% to 26% (r=-0.90,p<0.001); combined implant-tissue reconstructions remained stable at 12% (Figure 1).Multivariate logistic regression analysis of all reconstructed patients requiring radiation showedthat African American patients were less likely than white patients to undergo implant onlyreconstruction (OR 0.48, 95% CI 0.39-0.60, p<0.0001). We also found that a diagnosis madebetween 2006-2010 was associated with higher odds of implant-only reconstruction (2010 vs2000, OR 2.83, 95% CI 2.08-3.86, p<0.0001). CONCLUSIONS: The frequency of immediate reconstruction continues to increase in the settingof radiation therapy. Our study shows that a larger proportion of patients who require radiationare undergoing immediate implant-based reconstruction, contrary to traditionalrecommendations. In additions to factors such as cost and the overall increase in use ofimmediate implant reconstruction, these findings likely reflect a changing attitude towardsimplant reconstruction in the setting of radiation therapy. Figure 1: Reconstruction Rates by Method in Radiated Patients from 2000-2010 8:06 AM 8:12 AMDiscussion 8:12 AM 8:16 AMIndocyanine Green Laser Angiography Improves Deep Inferior Epigastric Perforator Flap Outcomes Following Abdominal LiposuctionMayo Clinic in Arizona, Phoenix, AZ, USAWilliam Casey, MD1; Katharine A Connolly1; Alisha Nanda, BS2; Alanna M. Rebecca, MD3;Galen Perdikis, MD4; Anthony Smith3; (1)Mayo Clinic in Arizona, (2)University of ArizonaCollege of Medicine Phoenix Campus, (3)Mayo Clinic Arizona, (4)Mayo Clinic in FloridaBackground The reliability of deep inferior epigastric perforator (DIEP) flap reconstructionfollowing abdominal liposuction is controversial. Our early cases were technically successful,however we experienced high partial flap loss and fat necrosis rates when the flaps were assessedintraoperatively using clinical examination. We sought to compare DIEP flap outcomes in thesetting of prior liposuction following the utilization of intraoperative indocyanine green (ICG)angiography as opposed to when flaps were assessed on clinical grounds alone. Methods A retrospective review of a consecutive series of DIEP flaps following liposuction at asingle institution was performed, comparing those evaluated on clinical grounds alone and thosein which ICG angiography was used intraoperatively. The outcomes measured includedanastomotic complications, total flap loss, partial flap loss, fat necrosis, and postoperativeabdominal wounds. Results Thirteen DIEP flaps following prior liposuction were performed for breastreconstruction on eleven patients from July 2003 through January 2014. All patients hadpreoperative imaging with duplex ultrasound (one patient, bilateral reconstruction) or CTangiography (ten patients, eleven flaps) to analyze perforator suitability prior to surgicalexploration. Seven flaps were evaluated intraoperatively on clinical grounds alone. Six flapswere assessed and modified based on intraoperative ICG angiography. All thirteen flaps weresuccessful with no total flap losses or anastomotic complications. Partial flap loss and fatnecrosis rates dropped from 71.4% (5 / 7 flaps) in the clinical evaluation group to 0% (0 / 6flaps) when ICG angiography was employed intraoperatively (p=0.02). In the clinical evaluationgroup, partial flap loss occurred in five of seven flaps (ranging from 20-50% of overall flapvolume) and fat necrosis developed in three of seven flaps. Due to the significant volume loss inthe flaps transferred based on clinical grounds alone, four of these seven DIEP flaps requiredsubsequent augmentation with either another autologous flap or prosthetic implant to providesufficient breast volume and contour. Every flap in the ICG angiography group had the desiredvolume and contours for reconstruction without requiring any subsequent revisions. Allabdominal wounds healed uneventfully. Conclusion ICG angiography is an excellent vascular imaging modality for intraoperative use toassess flap perfusion and aids in improving outcomes in DIEP flaps when harvested after priorabdominal liposuction. It allows optimal flap design around the chosen perforators anddemonstrates areas of sufficient perfusion to be included in the flap, thereby avoidingpostoperative complications and possibly the need for additional reconstructive procedures. 8:16 AM 8:20 AMThe Effect of Timing on Breast Reconstruction Outcomes in Diabetic WomenJohns Hopkins University School of Medicine, Baltimore, MD, USA Melanie Major, BS; Onyebuchi Ogbuagu; Pablo Baltodano Fallas; Carisa Cooney; GedgeRosson; The Johns Hopkins University School of Medicine Purpose: To determine data-driven recommendations for breast reconstruction in diabeticwomen. Current research suggests diabetes is associated with surgical complications followingautologous reconstruction, but not prosthetic reconstruction. However, little is known about theeffect of timing on breast reconstruction in the female diabetic patient population. Methods: We analyzed all diabetic females undergoing breast reconstruction from 2005-2012 inthe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were identified as immediate breast reconstructions if they had amastectomy and reconstruction with a prosthesis or autologous flap on the same day and definedas delayed breast reconstructions if they had either type of reconstruction without a mastectomyon the same day. The primary outcome of surgical morbidity was defined as 30-day post-operative superficial surgical site infection (SSI), deep incisional SSI, organ space SSI, wounddehiscence, or flap failure. Results: 1,408 diabetic women underwent breast reconstruction, including: 156 (11.1%)immediate autologous reconstruction (IAR), 802 (57.0%) immediate prosthetic reconstruction(IPR), 118 (8.4%) delayed autologous reconstruction (DAR), and 332 (23.6%) delayed prostheticreconstruction (DPR). The immediate and delayed reconstruction groups were similar in pre-surgical characteristics (Table 1). IPR was associated with reduced superficial SSI (OR = 0.320,p = 0.003), deep incisional SSI (OR = 0.320, p = 0.003), and unplanned readmission (OR =0.317, p = 0.005) compared to IAR. DPR was associated with reduced wound dehiscence (OR =0.0683, p = 0.015) compared to DAR. The relationship between timing and surgical morbiditydid not differ by reconstruction type. A multivariate logistic regression model built using pre-surgical factors and the outcome of surgical morbidity yielded the following as the onlystatistically significant contributors after controlling for all other factors: autologous flap versusprosthesis (OR = 0.350, p <0.001), immediate versus delayed reconstruction (OR = 0.467, p =0.018), BMI classifications (data omitted), hypertension (OR = 0.528, p = 0.014), and recentweight loss (OR = 48.477, p = 0.004). Conclusions: The results of this study suggest delayed breast reconstruction with prosthesis orautologous flap is associated with reduced surgical morbidity compared to both types ofimmediate reconstruction after controlling for pre-surgical factors. This study further clarifies thebreast reconstruction strategy with the lowest 30-day postoperative complications for a femalediabetic patient with multiple co-morbidities. 8:20 AM 8:24 AMThe Impact of Intraoperative Microvascular Compromise on Outcomes in Microsurgical BreastReconstructionThe Ohio State University, Columbus, OH, USAMichelle Coriddi, MD; Albert H. Chao, MD; Ohio State UniversityBackground: While factors affecting the outcome of free flap take-backs for postoperative microvascularcompromise has been previously studied, limited data exists regarding the impact ofintraoperative microvascular compromise on free flap outcomes.