L. M. Ngaage1, B. Di Pace2,4, R. Hamed5, G. Oni2, L. Fopp2, B. Koo3, C. M. Malata2,6,7 1University Of Cambridge,School Of Clinical Medicine,Cambridge, , United Kingdom 2Addenbrooke’s Hospital,Plastic And Reconstructive Surgery,Cambridge, , United Kingdom 3Addenbrooke’s Hospital,Radiology,Cambridge, , United Kingdom 4Università Degli Studi Della Campania Luigi Vanvitelli,,Plastic Surgery Unit,Naples, , Italy 5University Of Alexandria,Medical School,Alexandria, , Egypt 6Addenbrooke’s Hospital,Cambridge Breast Unit,Cambridge, , United Kingdom 7Anglia Ruskin University,Faculty Of Medical Sciences,Cambridge & Chelmsford, , United Kingdom
Introduction: Notable amongst recent advances in free flap breast reconstruction, have been the introduction flap imaging technologies (computed tomography angiography (CTA) of the donor vessels) and the use of anastomotic couplers for venous anastomoses. There have been many reports of reduced operative times with the use of CTA or venous couplers (VC). However, none of these reports have compared the effect of these two advances relative to each other. We therefore decided to review the effect of VCs alongside CTA on the operative times of free flap breast reconstruction (FFBR).
Methods: Following the introduction of venous couplers in June 2010 and the introduction of CTA in November 2011, a retrospective cohort study was conducted of all abdominal FFBRs performed by a single plastic surgeon (CMM) with respect to CTA and venous coupler use between August 2008 and February 2014. Bipedicled free flaps were excluded (n=26). 40 patients with venous couplers (July 2010 – May 2013) were compared to the 40 patients immediately before the introduction of couplers (August 2008 – June 2010) and 40 patients after the addition of CTA to venous coupler use (November 2011 – February 2014). All CTA patients received venous couplers so it was not possible to compare CTA to venous couplers. Operative time was defined as from knife-to-skin to insertion of the last stitch. Data analysis was completed with SPSS IBM Software.
Results: A total of 120 patients were identified; 40 without intervention (WI), 40 venous couplers only (VC), and 40 with CTA and venous coupler use (CT/VC). The introduction of VC did not significantly reduce the operative time compared to WI (572 vs 586 minutes, p=0.5306). However, patients with both interventions had significantly shorter operative times vs WI (472 vs 586 minutes, p<0.00001). Interestingly, the CT/VC group had a significantly reduced operative time to the VC group (472 vs 572 minutes, p=0.0002), implying that the main factor was the introduction of CTA. Similarly, the use of both modalities reduced the ischaemia time from 100 minutes to 80 minutes (CT/VC vs WI, p<0.00001). CT/VC reduced ischaemia time compared to VC alone (80 vs 89 minutes, p=0.0307). There was also significance between the ischaemia times of WI and VC (100 vs 89 minutes, p=0.0106).
Conclusion: The combined effect of CTA and VC significantly reduced operative and ischaemia times for FFBR; this is predominantly due to use of CTA, although VCs might have a role. The superior effect of CTA on operative time compared to VC is because it facilitates surgery without a surgical learning curve and helps in surgical planning by providing a useful roadmap of the perforator vessels.