J. A. Ricci1, P. Kamali1, B. Becherer1, D. Curiel1, W. Wu1, B. T. Lee1 1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA
Introduction: Umbilical stalk necrosis represents a rare, yet important complication after abdominal based microsurgical breast reconstruction, which is both under-recognized and under-studied in the literature. Once identified, umbilical reconstruction can be an extremely challenging problem. Previously unreported in the literature, this study aims to categorize this problem and identify associated risk factors, in an effort to prevent its occurrence.
Methods: All consecutive microsurgical free flaps for breast reconstruction at a single institution from February 2004 to February 2016 were reviewed. Non-abdominal based flaps were excluded. Patients were then divided in to cohorts depending on the development of umbilical necrosis postoperatively. Demographics, surgical characteristics and other complications were compared between the groups.
Results: A total of 1335 flaps met the inclusion criteria, with 1286 flaps performed in patients who did not develop umbilical necrosis (96.3%) and 49 instances of umbilical necrosis identified (3.5%). Patients who developed necrosis tended to be older (49.4 yrs vs. 52.9 yrs; p <0.01), have higher BMI (31.3 vs. 27.8; p <0.01), have higher rates of hypertension (40.8% vs. 14.1%; p <0.01) and were more likely to be smokers (26.5% vs. 11.4%; p <0.01). Umbilical necrosis was associated with increased flap weight (829.8 g vs. 656.2 g; p <0.01), decreased time allotted to perforator dissection (150 min vs. 169 min; p =0.02) and increased number of perforators dissected per flap (2.5 vs. 2.2; p =0.03). There was no association with flap type (DIEP, SIEA or free TRAM), history of diabetes, previous abdominal surgery, use of preoperative imaging to identify perforators. Umbilical necrosis was not associated with most complications, but was associated with a concomitant donor site seroma (14.2% vs. 5.1%, p =0.01). A total of six patients underwent eventual reconstruction of the umbilicus.
Conclusion: Umbilical stalk necrosis represents a rare, though serious complication for patients following abdominal based microsurgical breast reconstruction and to date, no series in the literature has focused on this complication. Overall, umbilical necrosis was found to occur at a rate of 3.5% and was found to be associated with several preoperative comorbidities. Additionally, it was associated with several intraoperative characteristics, including larger flap harvest, decreased time spent on perforator dissection and increased number of perforators harvested per flap. This information should help influence surgeon’s intraoperative decision making to prevent the development of this undesirable complication.