16.06 Implementation of Acute Care Surgery Model Increases Use of Outpatient Appendectomy

Posted on January 31, 2019

R. Mallick1, A. Asban2, T. Wang2, H. Chen2, L. Tanner2, V. Strickland2  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction: The model of a designated acute care surgery (ACS) program for care of the emergency general surgery patient has arisen in academic centers across the globe, with proponents advocating improved outcomes and more expeditious care for common surgical problems.  We adopted this paradigm at our own institution and in this study sought to review our own outcomes and perioperative metrics prior to and following implementation of an ACS service.

Methods: Patients undergoing either laparoscopic appendectomy or open appendectomy for the indication of acute appendicitis were identified by relevant Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and 10 coding and retrospectively reviewed from January 2013- February 2018. From January 2013 – December 2015 patients were treated by a Surgeon-on-call (SOC) model, and from January 2016-February 2018, an Acute Care Surgery (ACS) model was utilized. We reviewed demographic variables including age, race, gender, and insurance type, as well as outcomes including time from admission to the operating room, length of stay, use of outpatient management, and readmission. Student’s t-test was utilized for comparison of means, and chi-square test for multiple variables.

Results: A total of 424 patients were identified, 252 in the SOC group, and 172 in the ACS group. The mean age of the cohort was 38.6 ± 15.8 years, and 49.5% were female.  There was no difference in gender, race, insurance type, or use of laparoscopic or open surgery between groups. Patients in the ACS group was slightly older (p =0.016).  With respect to time from admission to the operating room, there was no difference between the SOC or ACS model (11.6 ± 14.6 hrs vs. 11.7 ± 15.7 hrs, p = 0.919), nor was there a difference in postoperative length of stay (1.4 ± 1.5 days vs. 1.6 ± 3.5 days, p = 0.870) or readmission rates (6.7% vs. 7.0%, p = 0.926).  With respect to outpatient management, the ACS group demonstrated a higher percentage in comparison to the SOC group (67.4% compared to 55.1%, p = 0.04).

Conclusion: Initiation of an ACS service at our hospital did not grossly modify time to surgery, length of stay, or readmission for patients undergoing appendectomy. However, it did appear to correlate with a higher rate of outpatient management.
 

16.05 Adherence to Post-Operative Opioid Guidelines by Trainees, Advanced Practitioners, and Attendings

Posted on January 31, 2019

B. Nguyen1, S. Stokes1, J. Bleicher1, R. Glasgow1,2, B. S. Brooke1, L. C. Huang1,2  1University Of Utah,General Surgery,Salt Lake City, UT, USA 2Huntsman Cancer Institute At The University Of Utah,General Surgery,Salt Lake City, UT, USA

Introduction:
The quantity and duration of opioid use after surgery has increased over the past several decades. Recent published guidelines specify an optimal amount of opioid medication to be prescribed following a given operation to minimize excess prescribing by surgeons. We sought to determine historical adherence to these current guidelines.

Methods:
We performed a retrospective, observational study analyzing discharge opioid prescriptions following common inpatient and outpatient general surgery procedures at a tertiary academic medical center from 2014 to 2018. All adult patients who underwent cholecystectomy, inguinal hernia repair, appendectomy, mastectomy, umbilical hernia repair, and ventral hernia repair were included. Patient and provider-level demographics were recorded. Morphine milligram equivalents (MME) were calculated from discharge prescriptions. These prescriptions were then classified as appropriate or inappropriate based on the maximum recommended amount as determined by Michigan-OPEN, Dartmouth-Hitchcock, and Hopkins Surgical Opioid Guidelines. The opioid guideline adherence was then analyzed using hierarchical, multivariable logistic regression, adjusting for patient and provider-level covariates.

Results:
There were 4,500 patients included in the study. Opioid prescriptions were written by 775 (17%) junior residents (PGY1-2); 1,488 (33%) senior residents (PGY3-5); 864 (19%) advanced practice clinicians (e.g., nurse practitioners and physician assistants); and 1,373 (31%) attending surgeons. The median MME prescribed for laparoscopic cholecystectomy was 30 (IQR [20-45]). The median MME prescribed for open inguinal hernia repair was 30 (IQR [20-45]). The overall rate of guideline adherence was 12.6%. Advanced practice clinicians (APC) were most likely to follow guidelines (22%), followed by senior residents (12%), junior residents (11%), and attending providers (8%). After adjustment for patient characteristics with multivariable logistic regression, junior residents (OR 2.88, 95% CI 1.99-4.16), senior residents (3.01, 95% CI 2.22-4.08), and advanced practitioners (OR 5.87, 95% CI 4.23-8.15) had higher odds of following guidelines as compared to attending providers.  Prescriptions in excess of current inpatient and outpatient guidelines led to the distribution of the equivalent of 79,947 five mg hydrocodone tablets over a four-year time period.

Conclusion:
Historical adherence to current opioid prescribing guidelines is low, particularly by attendings surgeons. In order to adapt to the recommendations, further research is needed to determine the most effective method to change prescribing practices.
 

16.04 Faster Colectomy Times Associated with Greater Team Familiarity: Mixed Model Analysis of 645 Cases

Posted on January 31, 2019

R. Mallonee1, S. Parker3, A. Tegge2, S. Safford1  1Virginia Tech Carilion School of Medicine,Surgery,Roanoke, VA, USA 2Virginia Tech,Statistics,Blacksburg, VA, USA 3Carilion Clinic,Human Factors,Roanoke, VA, USA

Introduction:

Longer operative durations have been linked to higher complication rates, longer hospital stays, and increased infection risk. System-based approaches have identified systems-factors external to the patient/surgeon that influence duration. One factor of interest is team familiarity. In multiple settings, greater familiarity between attending/ assisting surgeon has been associated with decreased operative times. However, little research has considered familiarity across the entire team, including team members such as anesthetist, circulator, or surgical technician. Further work is needed to appreciate the importance of familiarity in determining operative time.

Methods:

Retrospective analysis of 98 colectomies performed by 15 surgeons at Roanoke Memorial Hospital and New River Valley Medical Center from 2011-2016. Cases were selected from larger sample of 645 colectomies based on -1SD from mean operative time.  Linear mixed-effects models (LMEM) were used to identify interactions between systems factors and duration. Factors included patient factors (age, BMI, gender, race, procedure type, ASA score, and wound class) and external factors (night surgery, facility, day-of-week, month, and cumulative dyadic familiarity scores). Physician ID acted as random effect to accommodate surgeon-specific differences in speed. Cumulative dyadic familiarity scores were calculated via summed number of cases worked together in each dyad of physician, anesthetist, circulator, and surgical tech. 

Results:

For initial sample of 645 cases, mean operative duration was 141.9 min and mean familiarity score was 335.1 (range: 1-2650). For initial sample of 645 cases, operative duration was not correlated with cumulative familiarity (p=0.82 via Kendall rank correlation). For identified faster cases(-1SD below the mean), mean operative time was 74.1min and mean familiarity score was 361.7 (range: 1-2567). Faster cases was associated with cumulative dyad familiarity (-0.011min/point of familiarity, p=0.037) and female gender of the patient (-9.17min, p=0.04) and year the operation was performed as significant predictors of operative time. 

Conclusion:

System factors, including familiarity and patient gender and year of the operation influence operative time. Familiarity between key members of the surgical team has a statistically significant impact on colectomy operative time, but the clinical meaningfulness of this indicator alone requires further study. Further research is necessary to understand whether this finding is consistent across additional types of operations and health systems.
 

16.03 Inpatient Pain-related Interventions and Analgesic Utilization After Surgery

Posted on January 31, 2019

R. Amin2, K. K. Somers1, M. S. Knezevich2, M. A. Lingongo2, M. J. Arca1, D. M. Gourlay1  1Medical College Of Wisconsin,Children’s Hospital Of Wisconsin And Division Of Pediatric Surgery, Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Pediatric Surgery, Department Of Surgery,Milwaukee, WI, USA

Introduction: Due to implications of the opioid crisis on the pediatric population, it is imperative to better define inpatient pain management practices.  We hypothesize that non-narcotic analgesics remain underutilized.

Methods: We performed an IRB-approved retrospective observational study of patients with acute appendicitis who underwent laparoscopic appendectomy from 1/1/13-12/31/15 at a Level I Children’s Surgery Center. Analgesic medication administration and timing of pain-related interventions was collected. Pouissan and logistic regression was used to analyze interventions and medication usage respectively, where p<0.05 is statistically significant.

Results: There were 608 patients, 59% were male, with median age of 12 years (range 1-20).   The mean aggregate pain score (3.3 ±2.5) was unchanged over time (p=0.137).  There was an increase in ibuprofen (OR 1.36, p=0.003), acetaminophen (OR 4.93, p<0.001), and single-agent narcotic (OR 13.25, p<0.001) administration. There was a decrease in intravenous narcotics (OR 0.72, p=0.009), and combination narcotics (OR 0.11, p<0.001). The overall use of inpatient narcotics decreased (OR 0.65, p<0.001) (Figure 1). The number of pain scores measured (p<0.001), narcotic administration (p<0.001), and non-pharmacologic interventions (p<0.001) were lower overnight. Overall, there was underutilization of non-narcotic medications, with no significant difference between shifts (p=0.391). 

Conclusion: There has been a significant decrease in narcotic usage.  Non-narcotic usage has improved, but remains underutilized.  There is significant variability in the frequency of pain score assessment, medication administration, and non-pharmacologic interventions.  A scheduled regimen of non-narcotic therapy while reserving narcotic medications for breakthrough pain control may help optimize pharmacologic pain control in this population.

16.02 Serum Albumin Strongly Predicts Mortality and Sepsis Following Laparoscopic Cholecystectomy

Posted on January 31, 2019

S. E. Rudasill1, Y. Sanaiha1, J. W. Antonios1, H. Khoury1, A. L. Mardock1, H. Xing1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:

Hypoalbuminemia (serum albumin <3.5 g/dL) is associated with increased morbidity and mortality following invasive procedures. Whether this predictive value persists for less invasive laparoscopic surgery has not yet been characterized. This study examined the association of preoperative serum albumin with outcomes for laparoscopic cholecystectomy.

Methods:

This was a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2005-2016. All adult patients undergoing laparoscopic cholecystectomy who had a preoperative serum albumin level within two days of surgery were included. Patients were stratified by gender and albumin levels into: <3.0 g/dL (severe malnutrition), 3.0 to <3.5 (moderate malnutrition), 3.5 to <4.0 (mild malnutrition), and ≥4.0 g/dL (normal nutrition). The primary outcome was 30-day mortality. The Kruskal-Wallis and chi-squared tests were used for univariate analysis. Multivariable logistic regressions, adjusted for baseline differences, assessed the predictive value of preoperative serum albumin on mortality, septic shock, infection, readmission, and hospital length of stay (LOS).

Results:

Of 131,855 patients undergoing laparoscopic cholecystectomy, 14.0% had severe, 22.8% moderate, and 29.7% mild malnutrition, with 33.5% classified as normal nutrition. Patients with severe malnutrition were older (59.6 vs. 45.0 years, p<0.001) and more likely to have a history of diabetes (22.1 vs. 8.5%, p<0.001) and hypertension (53.1 vs. 26.7%, p<0.001) relative to those with normal nutrition. After adjustment for patient and operative characteristics, severe (OR=3.17 [2.17-4.64], p<0.001) and moderate (OR=1.82 [1.24-2.69], p=0.002) malnutrition were associated with increased mortality relative to the normally nourished cohort. Severe malnutrition was independently associated with ventilator use >48 hours (OR=3.51 [2.28-5.40], p<0.001), infection (OR=1.35 [1.14-1.59], p<0.001), and 30-day readmission (OR=1.17 [1.05-1.31], p=0.004). There was a stepwise increase in hospital LOS by serum albumin class, with an average increase of 0.9 days for moderate and 2.3 days for severe malnutrition. Female gender was independently associated with the development of septic shock in malnourished patients (Figure 1).

Conclusion:

Malnutrition, as measured by serum albumin levels, is prevalent among patients treated via laparoscopic cholecystectomy. Reduced albumin levels are strongly associated with mortality, postoperative septic shock, and increased LOS. Hypoalbuminemic patients, and particularly those with severe hypoalbuminemia <3.0 g/dL, may benefit from preoperative optimization prior to laparoscopic cholecystectomy.
 

16.01 Are you ready? Assessing Readiness to Implement Enhanced Recovery After Surgery

Posted on January 31, 2019

L. J. Kreutzer1, M. F. McGee1,2,3, S. Oberoi3, K. Y. Bilimoria1,2,3, J. K. Johnson1,2  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 3Northwestern Memorial Hospital,Chicago, IL, USA

Introduction: Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention to improve patient outcomes, yet hospitals often underestimate the complexity of implementation. To be most effective, the intervention needs to be context-specific and often requires adaptations so that it is appropriate to the setting and available resources. Organizational and unit-level readiness for change, including the extent to which organizational members are prepared to implement a new intervention, is often overlooked. Our objective was to develop and test a tool to assess hospital readiness to implement ERAS for patients undergoing colorectal procedures.

 

Methods: We developed a Readiness to Implement Core Components of Enhanced Recovery (RECOVER) Tool based on a literature review and our prior experience implementing ERAS. The RECOVER Tool is dual purpose, designed to (1) provide a practical planning tool for the implementation team and (2) collect baseline data of hospital willingness and perceived ability to change practice. The RECOVER Tool includes 4 sections. Section 1 captures information about the hospital’s implementation task force. Section 2 inventories the components of ERAS and identifies implementation willingness. Sections 3 and 4 use a 5-point Likert scale of agreement to assess areas where the task force perceives a need for guidance in implementation and where individual units may need assistance in implementation and in changing behavior. Five hospitals within one health system were asked to complete the RECOVER Tool. Sections 1 and 2 were emailed to representatives from each hospital for completion. Members of the task force from each hospital received sections 3 and 4 through REDCap.

 

Results: The response rate for sections 1 and 2 was 100%. Of the task force members who received a link to complete sections 3 and 4 through REDCap, 60.3% (44 out of 73) completed the survey. The hospital-specific survey response rates ranged from 46.2% to 66.7%.

All hospitals indicated willingness to implement ERAS. Four of the five hospitals struggled with: 1) setting specific goals for implementing ERAS; 2) assigning or clarifying task force roles; 3) gaining buy-in from leadership, 4) engaging IT; and 5) engaging analytics/statistical support.

At the department-level, perceptions of readiness were strong overall across departments; however, one hospital department identified a need to strengthen the ability to adapt quickly when making changes to the way the department works.

 

Conclusion: Assessing readiness to implement a complex intervention, such as ERAS, provides an opportunity to gain insight into perceived barriers to implementation. Furthermore, tools can be tailored to strengthen targeted areas to support hospitals’ implementation process by giving insight into key implementation outcomes: acceptability, feasibility, and appropriateness.

15.20 The Limited Role of Ultrasound in the Assessment of Solid Pediatric Breast Lesions

Posted on January 31, 2019

C. J. Granger2, E. L. Ryon3, A. R. Hogan1, H. L. Neville1, C. M. Thorson1, E. A. Perez1, J. E. Sola1, A. Brady1  1University Of Miami,Division Of Pediatric And Adolescent Surgery/Department Of Surgery/Miller School Of Meidcine,Miami, FL, USA 2University of Miami,Leonard M. Miller School Of Medicine,Miami, FL, USA 3University of Miami,Division Of Surgical Oncology/Department Of Surgery/Miller School Of Medicine,Miami, FL, USA

Introduction: Ultrasound (US) imaging is an adjunct to clinical exam (CE) in the assessment of pediatric breast lesions.  We sought to investigate the accuracy of CE and US in determining maximum diameter (Ø) of breast lesions versus final pathology (P).

 

Methods: A single institutional retrospective analysis of patients < 25 years of age who underwent breast mass resection (CPT 19120, 19301) from Feb 2011 to Sept 2015 was performed.  Data was collected and analyzed using SPSS.  

 

Results: 67 patients underwent breast resection with a mean age of 16 ± 2 years.  The mean PØ (MPØ) for all lesions was 4.2 ± 2.7 cm.  Lesions encountered were fibroadenoma (88%, MPØ 3.8  ± 1.8 cm), juvenile fibroadenoma (7.5%, MPØ 8.1 ± 6.8 cm), low-grade phyllodes sarcoma (3%, MPØ 7.5 ± 3.5 cm), and fibrous hamartoma of infancy (1%, the only male patient).  51% of lesions were right sided, 37% were left sided, and 12% were bilateral.  34% of patients had no surgical indication documented.   Documented indications included: 28=increasing size, 11=mastodynia, 8=large size, 1=malignant US findings, and 1=recommended by primary physician. 13% of patients developed recurrent and/or new lesions.  The complications from surgery included: 3=mastodynia, 2=seromas, 3=local skin reactions, and 1=numbness.  Of the two patients with low-grade phyllodes sarcoma, one was lost to follow-up and the other underwent re-excision for a positive margin.

50 patients had documented CE measurements while 48 patients underwent US imaging.  Of these, 28 patients had both CE and US measurements and were included in the sub-group analysis.  Both groups were normally distributed by Shapiro-Wilk’s test (p=0.107 for CEØ; p=0.373 for USØ). Paired t-test comparing PØ to CEØ found the groups to be the same with an underestimation on CE of 0.4 ± 1.2 cm, p=0.87. When comparing PØ to USØ there was a statistically significant underestimation on US of 0.6 ± 1.2 cm, p=0.01.  The difference between CEØ and USØ was not statistically significant (0.2 ± 0.8 cm, p=0.227).  

 

Conclusion: In this single institutional retrospective study, CE estimates were equivalent to final P, while US significantly underestimated the size of breast lesions. The underestimation in each case was between 0.4 cm for CE and 0.6 cm for US which is likely not clinically significant and possibly biased by time to surgery.  Nevertheless, given the accuracy of CE, the utility of US in measurement of pediatric breast lesions is limited and should be individualized. 

15.19 Methotrexate Use In Patients With Granulomatous Mastitis

Posted on January 31, 2019

B. Caballero2, J. Sugandi1,2, R. K. Viscusi1,2  1Banner- University of Arizona,Department Of Surgery,Tucson, AZ, USA 2University Of Arizona,College Of Medicine,Tucson, AZ, USA

Introduction:  Granulomatous mastitis (GM) is a rare, benign, chronic inflammatory disease of the breast that usually affects women of child bearing age. The most common clinical symptoms are a palpable breast mass associated with overlying erythema, induration, pain or drainage. Imaging is non-specific and histopathology is needed for confirmative diagnosis. The etiology is unclear, but an autoimmune reaction is favored and it has been linked to prior contraceptive use, a history of pregnancy and breastfeeding. Given the limited knowledge of etiology, initial treatment of this benign, yet locally aggressive disease remains controversial. Observation alone, antibiotics, surgical excision, steroids alone, and immunosuppressive agents have all been described in the literature. There is no consensus on treatment but knowing GM is generally a self-limited disease and surgery can be associated with poor cosmetic outcomes, a non-invasive alternative such as methotrexate (MTX) is a viable option. 

Methods:  A retrospective chart review of patients with histologically confirmed GM between January 2013 and December 2017 was analyzed to identify response to MTX treatment. Eight adult female patients, age range 29-57, were diagnosed with GM via excisional or core breast biopsy. Methotrexate treatment was planned for all 8 patients with confirmed GM. Liver function tests and a full blood count were evaluated during treatment course. Treatment protocol included MTX administered at 2.5-10 mg orally together with folic acid in one dose, once a week. 

 

Results: On physical exam, a palpable breast mass was detected on 8 patients. All patients underwent ultrasound examination and after diagnosis of GM was confirmed, MTX + folic acid treatment was initiated. Treatment was administered for 3-15 months. One patient discontinued MTX due to plans to conceive. None of the patients developed complications from MTX and no recurrence was observed during follow up periods. Patients noted relief of symptoms including, erythema, breast tenderness and nipple discharge following 30-60 days of MTX treatment. 

Conclusion: Evidence in most literature has shown most patients with GM have a troublesome course of recurrence. There is no consensus on treatment but non-invasive alternatives such as steroids and methotrexate are good options. More cases using methotrexate alone or in combination with corticosteroids are needed to confirm those results. Ultimately, treatment depends on the size of the lesions and symptom severity. Prompt diagnosis and treatment with methotrexate can often treat the disease or provide symptomatic improvement without subjecting patients to multiple trials of medications that could pose risks of adverse effects. 
 

15.18 Effects of Dry Calyx of Hibiscus Sabdariffa Linn. on Serum Lipid Profile in Hyperlipidemic Subjects

Posted on January 31, 2019

M. Thway1, M. J. Hsann1, L. M. May1, N. H. Win1  1University of Medicine 1,Pharmacology,Yangon, LANMADAW, Myanmar

Introduction: Hyperlipidemia is a group of disorders characterized by an excess of serum total cholesterol, excess LDL-C or excess triglycerides. Hyperlipidemia is a major modifiable risk factor for coronary heart disease and it is important to correct all causes of disease condition.Hibiscus sabdariffa Linn. known as Chin-baung-ni is a plant which belongs to the Malvaceae family and is widely cultivated in tropical and subtropical areas. Taking together these evidences of hypolipidemic efficacies of Hibiscus sabdariffa Linn., it was also worth to know lipid lowering and the sustained lipid lowering action of Hibiscus sabdariffa Linn. Moreover, it was so interesting to focus the effects of Hibiscus which grow in Myanmar climatic and ecological changes. Therefore this study was conducted to evaluate the effects of Hibiscus sabdariffa Linn. on serum lipid profile  in hyperlipidemic subjects.

Methods: In this study, fourty-four hyperlipidemic human volunteers of both genders, who were between 20 – 60 years age group were chosen as subjects and they were randomly allocated into 3 g intake group and 10 g intake group. All subjects were requested to take one package of Hibiscus powder per day for 30 days. The package of Hibiscus powder was prepared in 250 mL of boiled water with sugar (5 g), steeped for 15 minute and it was drunk daily before lunch. Initial baseline levels were recorded and at 30 day of the study, 10 hour fasting blood samples were taken and analyzed for serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and then these biochemical parameters were analyzed again after two week washout period to know the sustainable lipid lowering effect.  Enzymatic colorimetric test with Lipid Clearing Factor CHOD-PAP-method and Lipid Clearing Factor GPO-PAP method were used for determination of serum TC and TG levels respectively. HDL-C was determined by HUMAN Cholesterol liquicolour test Kit. Estimation of LDL cholesterol level was calculated by using method of Fridewald et al. (1972). 

Results:

After 30 days consumption, it was found that no significant serum lipid level changes in 3 g daily intake group (P = > 0.05).  However, 10 g daily intake group showed significant reduction in mean serum TC, TG, LDL-C levels by 16.13%, 19.33% and 22.33% respectively. Then, 12.3% elevation of mean serum HDL-C from baseline levels (P = 0.00) was seen. Concerned about sustainable effect in 10 g daily intake group, serum lipid profile levels returned nearly to the initial baseline levels after two week washout period. Therefore, 30 days consumption of Hibiscus is not sustainable after 2 week cessation of the intake.

 

Conclusion:Therefore, according to the obtained data, the higher dose of Hibiscus, daily 10 g intake gave significant lipid lowering effect, however the lower dose, daily 3 g intake have no significant lipid lowering effect

 

15.17 A Comparison of Postoperative Aesthetic and Functional Outcomes in Meshed vs Unmeshed Hand Burns

Posted on January 31, 2019

A. Idicula1, M. Effendi1, A. Nair1, J. Griswold1  1Texas Tech University,Surgery,Lubbock, TX, USA

Introduction:   Split Thickness Skin Grafting (STSG) is considered one of the principal techniques in the treatment of hand burns in the setting of larger, more complex burn injuries.  While traditional STSG does have a few advantages over 1:1 meshed STSG, such as better cosmesis, less surface scaring, and better long term appearance and function they do have many disadvantages. These disadvantages include a longer operating time, increased time demands for deblebbing , limited donor site availability, and longer post-operative healing times.

The use of meshed STSGs allows blood and edematous fluid to drain, leading to reduced healing time as well as reduced incidence of seroma and hematoma formation5,6. Additionally, meshed grafts may also be stretched to provide added area of coverage, which is essential in full body burns where donor site availability is limited. However, excessive tension on the meshed graft may result in additional skin contracturing, leading to a decreased range of motion along with a scale-like appearance11.  Long-term postoperative reviews have shown that tension free meshed grafts have a superior aesthetic result when compared to stretched meshed grafts6. This study plans to retrospectively compare the functional and cosmetic outcomes of hand burn patients who were treated with 1:1 Meshed STSG to those who were treated with traditional STSG grafts.

Methods:

Total of 46 Patient screened for inclusion criteria de-indentified. The chart review and data collection of  occupation therapy and physical therapy review of range of motion collected in regards to postoperative hand function. IRB approved Aesthetic survey performed show photographs of hand burns ranging from 3 months postoperative to 1 year postoperative.  

Results:
Comparison of  aesthetic and functional post-surgical outcomes for hand burn patients receiving 1:1 Meshed STSG to those who were treated with STSG.have similar functional outcomes to those receiving STSG, and if the 1:1 Meshed modification of the STSG reduces the formation of recognizable scar patterns. The 1:1 Meshed STSG modification will provide a functional advantage over traditional STSG by avoiding scarring and contracture and improve range of motion.

Conclusion:

This study will faciitate additional breadth of knowledge in treating hand burns utlizling 1:1 meshed STSG. Our study can serve as a pilot towards establishing standard of care for hand-burn patients receiving skin grafts.  

15.15 The Predictive Value of Baseline Creatinine in Abdominal Wall Reconstruction

Posted on January 31, 2019

C. Davis1, C. Boyd1, J. Wilson1, J. I. De La Torre1  1University Of Alabama at Birmingham,Plastic Surgery,Birmingham, Alabama, USA

Introduction:  Abdominal wall reconstruction (AWR) is an invasive surgical procedure that can result in lengthy hospital stay for patients with certain comorbidities. Postoperative kidney injury is a well described complication in other surgeries.  This study investigates baseline preoperative creatinine and its correlation to hospital length of stay (LOS) as well as acute kidney injury (AKI) after AWR.

Methods:  A retrospective analysis of patients who underwent AWR from a single surgeon at University of Alabama at Birmingham over January 2017-July 2018. Statistical analysis of patients’ charts was compared for baseline creatinine, AKI, LOS, and postoperative complications.  All patient who underwent component separation with acellular dermal reinforcement for ventral hernias during the study period were included.  Patients who did not require the use of biologic acellular dermal matrix were excluded.  Statistical analysis included t-tests and regression analysis.

Results: 52 patients underwent AWR during the respective time frame. Average age of patients was 56, and the majority of patients were female (73.1%).  Of these patients, 11 had a baseline creatinine of ≥1.  Individuals with baseline creatinine ≥1 had a longer length of stay (6.55 days) compared to patients with a baseline Cr < 1 (5.1 days) (p=0.25).   Including all 52 patients into the analysis, baseline creatinine was not significantly correlated to LOS.  Postoperative AKI was associated with a significantly longer LOS compared to patients who did not have a postoperative AKI (9.08 vs 4.14 days, p=0.03012).

Conclusion: Although baseline creatinine alone was not predictive of length of stay, baseline creatinine levels ≥1 correlated to longer length of stay in this patient group. Furthermore, AKI was also predictive of longer hospital courses. These factors can help forecast hospital courses in patients at risk based on their comorbidities and allow physicians to prevent and treat possible complications to reduce LOS and optimize patient health.

15.14 Abdominal Wall Reconstruction in Orthotopic Liver Transplant Patients

Posted on January 31, 2019

S. Kurapati1,2, B. D. Denney1, J. I. De La Torre1,2  1University of Alabama at Birmingham,Plastic Surgery,Birmingham, AL, USA 2Birmingham V.A. Medical Center,Plastic Surgery,Birmingham, AL, USA

Introduction:   Component separation has been established as an effective technique for complex abdominal wall reconstruction. However, incisional hernias following orthotopic liver transplantation (OLT) presents a particular challenge.  This patient population which is immune suppressed often has pre-existing incisions that present a challenge for reconstruction.

Methods:  The records of 183 patients who underwent complex abdominal wall reconstruction since 2010 were reviewed and used as our control.  Within this group, patients were identified by CPT codes for a history of both component separation and  liver transplantation. Data reviewed included patient demographics and comorbidities, concomitant procedures, and characteristics of the reconstruction such as surgical incision. Primary data endpoints were complications following surgery, including recurrence. 

Results: The study group consisted of 9 patients, 8 who were OLT recipients and a single patient who was a partial liver donor. In the study group, there were no hernia recurrences. Primary myofacial continuiuty was achieved in 100% of the patients. A chevron incision was used in 66% of cases and biologic material was used in 78%. Overall morbidity was 11%, with one patient identified with deep venous thrombosis.  There were no significant wound healing problems.  For comparison, in the control group, the recurrence rate was 7% and primary approximation of the fascial defect was achieved in 92% of the patients. Significant complications occurred in 17%.

Conclusion: Modified abdominal wall reconstruction with component separation with or without onlay biologic mesh is a reliable approach to address hernia defects in patients who have had incisions associated with liver transplants, including those on ongoing immunosuppression.  With appropriate care, this patient group has no increase in adverse outcomes compared to those patients who do not have the pre-existing surgical scars and immunosuppression.
 

15.13 Meta-Analysis of Superficial Temporal Artery Anatomy

Posted on January 31, 2019

C. D. Liao1, S. Svoboda1, M. Applebaum1,2, J. Thompson1,2  1Virginia Tech Carilion School of Medicine,Roanoke, VA, USA 2Carilion Clinic,Department Of Plastic And Reconstructive Surgery,Roanoke, VA, USA

Introduction:  

In head and neck reconstruction, the superficial temporal artery (STA) and vein are often the first-choice recipient vessels for tissue flaps. Thorough understanding of STA anatomy and variability is crucial for avoiding surgical complications.

To date, no study has determined the influence of patient characteristics such as ethnicity, age, and sex on anatomical variations in the STA, underscoring a need to record these data in future studies. Additionally, study designs of reports documenting STA anatomy vary considerably. Therefore, more robust and comprehensive studies are necessary to accurately capture STA anatomy, enable more skillful dissections, and minimize complications.

A comprehensive review of the current literature offers an appropriate starting point. This study aims to provide surgeons with accurate and reliable measurements of STA architecture to promote safe dissection.

Methods:

We screened 1,105 studies by title/abstract. We consolidated data from 16 primary reports, all of which were examined for study design, patient characteristics, and relevant anatomical data.

Results:

The 16 studies represent patient populations in 11 different countries and yielded a total of 961 STAs for analysis. About half of the studies were cadaveric; the other half were angiographic. The male-to-female ratio is 57:43 among the studies that specified these details (N = 343 subjects). On average, only about 6 out of 16 of the studies documented important patient descriptors such as health status, sex, ethnicity, and age.

About 98% of STAs were reported to have two branches. About 74% of STAs bifurcated above the zygomatic arch; furthermore, we discovered considerable variation in the level of bifurcation among the 16 studies. Forest plots demonstrated that the average diameters of the STA, frontal branch, and parietal branch differ significantly from the pooled average in all categories, indicating cross-study inconsistencies. The pooled average diameters of the STA, frontal branch, and parietal branch were 2.03 ± 0.09 mm, 1.53 ± 0.06 mm, and 1.48 ± 0.06 mm, respectively. Distance of the STA anterior to the pinna was also inconsistent among the 3 studies that reported this information; the pooled average was 1.46 ± 0.12 cm. Comparing radiologic and cadaveric studies demonstrated significant differences in reported parietal and frontal artery diameters, but no differences in STA diameter, level of bifurcation, and number of branches.

Conclusion:

This meta-analysis provides a necessary first step in revisiting anatomical architecture and variability of the STA, which can promote positive outcomes for patients requiring flaps for head and neck reconstruction. Future work will entail collection of anatomical data with consistent documentation of patient characteristics.
 

15.12 Breast Lidocaine Priming for Improved Mastectomy Survival: The Lazarus Effect

Posted on January 31, 2019

A. M. Botty Van Den Bruele1, M. Crandall1, D. Chesire1, J. Murray1  1University of Florida- Jacksonville,Department Of Surgery,Jacksonville, FL, USA

Introduction:  Insufficient perfusion in breast skin is a leading cause of early complications following mastectomy reconstructive procedures. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis. Image guided mastectomy with indocyanine green (ICG) fluorescent angiography has emerged as form of intraoperative imaging that helps provide assessment of tissue perfusion. Perfusion indices have been developed for ICG imaging to indicate when the operative surgeon should remove ischemic tissue. Less than 20% perfusion has been shown to correlate with necrosis. While tumescent priming of the breast with lidocaine-epinephrine solution facilitates dissection and decreases blood loss, associated dermal vasoconstriction may affect ICG perfusion indices. Our goal was to study the effect of pre-mastectomy breast lidocaine priming on intraoperative perfusion indices and aesthetic outcomes. 

Methods:  We performed a retrospective review of perfusion indices and aesthetic outcomes for 49 mastectomies performed on 31 consecutive patients (some unilateral vs bilateral). Patient data recorded included age, race, BMI, smoking status, HTN, DM, and history of radiation therapy. All mastectomies were performed with lidocaine-epinephrine tumescence and received paravertebral block; ICG measurements <20% and mastectomy weight were recorded. Outcomes of interest were dermal necrosis/epidermolysis and hematoma or seroma formation. 

Results: Of the 49 mastectomies performed, 44 were reviewed and included in our analysis due to incomplete data in 5 of the mastectomies. Thirty-four breasts exhibited areas of <20% perfusion by ICG fluorescent analysis. Of these, only 5 demonstrated minor necrosis in postoperative follow-up, none of which warranted operative intervention. Multivariate analysis was performed and independent t-test employed. Increased BMI was noted to be a risk factor for minor necrosis, although not statistically significant (p=0.051). Only smoking history was noted to have a positive correlation with minor necrosis (p£ 0.001), whereas ICG perfusion was not significantly associated with necrosis in our sample (p=0.146).

Conclusion: Several previous studies have found ICG angiography to be highly accurate at predicting mastectomy skin flap viability after breast reconstruction. Therefore, the 34 patients who were noted to have decreased perfusion with ICG imaging in our study should have gone on to have extensive necrosis. Fortunately, however, all of those breasts went on to uneventful healing without additional intervention. Given our results, future research should focus on whether it is a difference in demographic factors or operative technique that may explain the discordance.

 

15.11 Comparing Plastic Surgery and ENT Outcomes and Cartilage Graft Preferences in Pediatric Rhinoplasty

Posted on January 31, 2019

A. F. Doval1, A. Ourian1, V. Chegireddy1, M. Lypka2, J. Friedman1, A. Echo1  1Houston Methodist Hospital,Plastic And Reconstructive Surgery,Houston, TEXAS, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Plastic And Reconstructive Surgery,Kansas City, MO, USA

Introduction:  Rhinoplasty in children has raised concerns about its impact in nasoseptal growth as well as its safeness in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. Here, we analyze post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists on a national level.

Methods:  Data was collected through the Pediatric National Surgical Improvement Program (NSQIP) from 2012 to 2016. Current Procedure Terminology (CPT) and International Classification of Disease 9th Revision (ICD-9) codes were used for data extraction. A comparison between plastic surgeons and otolaryngologists was made in terms of 30-day post-operative complications followed by a sub-group analysis based on cartilage preferences for rhinoplasty in each specialty.

Results: The data demonstrated that plastic surgeons performed 944 (71.3%) and otolaryngologists performed 380 (28.7%) of rhinoplasty cases. There were significant differences in terms of demographic characteristics between the two specialties including ages, race, ethnicity, and history of congenital malformations (all p < 0.0001). The most common post-operative complications were superficial wound infections (0.3% and 0.8%) and related reoperations for infection drainage and surgical control of hemorrhage (0.6% and 0.3%). No outcome differences between plastic surgeons and otolaryngologists were noted. Subgroup analysis revealed that plastic surgeons prefer to use rib and ear cartilage, while otolaryngologists prefer septal cartilage.

Conclusion: This national level study confirms that rhinoplasty in the pediatric population is a safe procedure. Plastic surgeons and otolaryngologists have comparable 30-day complication rates but the preferences of cartilage usage varies between specialties.

 

15.10 Implications of incidental abdominal CT angiography findings on free flap breast reconstruction

Posted on January 31, 2019

L. M. Ngaage1,2, D. Ghorra3, G. Oni3, B. C. Koo4, J. Ang2, S. L. Benyon3, M. S. Irwin3, C. M. Malata3,5,6  1Imperial College Trust,Foundation School,London, ENGLAND, United Kingdom 2University of Cambridge,School Of Clinical Medicine,Cambridge, ENGLAND, United Kingdom 3Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 4Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Radiology,Cambridge, ENGLAND, United Kingdom 5Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Cambridge Breast Unit,Cambridge, ENGLAND, United Kingdom 6Anglia Ruskin University,School Of Medicine,Chelmsford & Cambridge, ENGLAND, United Kingdom

Introduction:
Preoperative CT angiography (CTA) of the abdominal wall vessels is routinely used when planning free flap breast reconstruction (FFBR) because it provides a surgical roadmap, which facilitates flap harvest. However, there are few reports on the effect of incidental findings on the operative plan.

Methods:
A retrospective study of all FFBRs performed at a tertiary referral centre for breast reconstruction over a six-year period (November 2011 to June 2017) was conducted. One consultant radiologist (BCK) reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.

Results:
200 patients received preoperative CTAs. 14% of patients (n=28) had incidental findings. Of the incidental findings, 18% were vascular anomalies; 36% tumour-related and 46% were “other”. In four patients, findings were severe enough to prevent surgery. They comprised of mesenteric artery aneurysm, absent DIEVs due to previous surgery, bilateral occluded DIEAs, and significant bone metastasis. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled TRAM flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of a free flap breast reconstruction. Nearly a quarter of those with incidental findings went on to have further imaging before their operation. 

Conclusion:
CTA in breast reconstruction can have a wider impact than facilitating surgical planning and reducing operative times.  Incidental findings can influence the surgical plan, and in some instances, avoid doomed to fail and unsafe surgery. It is important that these scans are reported by an experienced interventional radiologist. 
 

15.09 Prepectoral Breast Reconstruction with BraxonR Acellular Dermal Matrix (ADM): Indications & Pitfalls

Posted on January 31, 2019

E. Theodorakopoulou1, D. T. Ghorra1,2, S. Samaras1, P. Forouhi3, C. M. Malata1,3,4  1Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 2University of Alexandria Medical School,Department Of Plastic & Reconstructive Surgery,Alexandria, ALEXANDRIA, Egypt 3Cambridge Breast Unit,Department Of Surgery,Cambridge, ENGLAND, United Kingdom 4Anglia Ruskin Univerisity School of Medicine,Surgery,Cambridge & Chelmsford, ENGLAND, United Kingdom

Introduction:
Epipectoral implant placement is a new technic designed to simplify and minimize the drawbacks of immediate implant-based breast reconstruction. As with most new procedures the indications have yet to be clearly defined. A single plastic surgeon's initial experience with prosthetic reconstruction using BraxonR total acellular dermal matrix coverage of the implant/expander in the prepectoral plane at the time of mastectomy is presented.

Methods:
Patients undergoing Braxon (porcine ADM) immediate breast reconstruction by a single surgeon (2017-2018) were reviewed with respect to demographics, specific indication, implant type & volume, mastectomy type and early outcomes. They were identified from a prospective Implant Register and data collected from Epic.

Results:
Eleven consecutive patients (mean age 38 years) underwent Braxon-ADM reconstruction of 17 breasts with fixed volume implants i.e., direct-to-implant (7) and permanent expanders (4). The surgical indications (number of breasts) were risk-reduction (9), therapeutic (6) and noncancer (2). The reconstructions were bilateral in six patients. Based on the breast size and shape, mastectomies were performed via a variety of incisions: Wise pattern skin-reducing technics (6 with half of them including dermal slings), inframammary incisions (4), hemi-Y periareolar incisions (4) and traditional elliptical periareolar incisions (3). Twelve breasts had nipple-sparing mastectomies. Uneventful healing was achieved in 9 breasts, implant loss 4 breasts, large seromas (5 breasts – 2 of the implant losses), infection (4 breasts, included in the implant losses), unplanned readmissions (3 patients), severe capsular contracture following unplanned radiotherapy (1 breast), transient localised tenderness at the superior fixation points (3 breasts), exercise-induced "partial dislodging" (1 breast) and visible rippling (4 breasts). Unlike subpectoral breast recosntructions there were no cases of breast animation deformity caused by hyperactive pectoralis major muscle contraction with resulting distortion of the breasts.

The putative prredisposing factors (by patients) to implant loss and significant seromas/ wound dehiscence were smoking (1), skin-reducing mastectomy (2), early (<5 days) removal of drains (1), tight wound closure (1), postoperative radiotherapy (1) and axillary clearance (1).

Conclusion:
Prepectoral implant placement constitutes a practical novel addition to the repertoire of postmastectomy breast reconstruction technics. It is particularly useful in bilateral reconstructions such as for risk-reducing mastectomies. Patient selection is, however, very important to avoid complications and optimise outcomes. It is also more exacting in terms of implant selection for unilateral breast reconstruction. Further large-scale studies are needed to determine the place of prepectoral reconstruction and whether it is an improvement on current implant-based reconstructive methods.
 

15.08 Geometric analysis and retrospective study of fascial tensile reduction in severe keloid surgery.

Posted on January 31, 2019

T. Tsuge1, M. Aoki1, S. Akaishi1, T. Dohi1, H. Yamamoto1, R. Ogawa1  1Nippon Medical School,Plastic, Reconstructive And Aesthetic Surgery,Tokyo, TOKYO, Japan

Introduction: The current treatment for severe keloids is surgery followed by postoperative radiation. The possibility of recurrence after surgery is high without strict follow-up treatment. Some specific suture methods are thought to be effective for preventing recurrence. Stretching tension is an important factor associated with keloid generation and progression. We believe that suture methods that prevent tension occurring in the dermis are effective. We have attempted a fascial tensile reduction (FTR) method in severe keloid surgery over the long term. Tension after the resection of keloids is strong in the anterior chest, and we have tried the combination of deep fascia tensile reduction (DFTR) and superficial fascia tensile reduction (SFTR). We analyzed the effects of SFTR and the combination of DFTR and SFTR (DFTR+SFTR).

Methods: Geometric analysis was performed by Obtaining Anatomic Shapes in 3D using DISCUS drawing software and ADINA analytical software. All keloids were treated by surgery and postoperative radiation therapy. The data set consisted of 386 patients who were treated surgically from 2011 through 2016 in the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School in Tokyo. Among the patients, 77 with anterior chest severe keloids who underwent fascial tensile reduction and were followed for over 18 months after surgery were used as the subjects of this study. The patient characteristics, surgical outcomes, and recurrence rates at the point of 18 months after surgery were analyzed.

Results:The maximum mechanical force to the dermis was 4700 Pa when only a dermal suture was used, whereas that to the dermis was decreased to the maximum of 573 Pa with additional SFTR.  DFTR+SFTR decreased the force to the superficial fascia compared with SFTR. The percentage of total keloid excision was significantly higher in the group of DFTR+SFTR (60.0%) than in the group of SFTR (34.6%). The length of hospital stay in the DFTR+SFTR group was significantly longer than in the SFTR group. At the point of 18 months after surgery, no recurrence was recognized in 44.0% and 51.9% of the patients in the DFTR+SFTR group and the SFTR group, respectively. Signs of recurrence or residual keloids were observed in 54.0% and 44.4% of the patients in the DFTR+SFTR group and the SFTR group, respectively. Only 1 case in the DFTR+SFTR group (2.0%) and 1 case in SFTR group (3.7%) were judged to be obvious recurrence. Statistical analysis detected no significant difference between the 2 groups (p=0.670).

Conclusion:DFTR + SFTR should be selected in cases of total resection with relatively large keloids. DFTR appears to facilitate SFTR, and is considered to be useful when reduction by SFTR is technically difficult. It was found that the additional DFTR did not lower the recurrence rate.

 

15.07 Enhanced Recovery after Surgery in Breast Reconstruction: A Meta-Analysis of the Literature

Posted on January 31, 2019

A. C. Offodile1, C. Gu2, S. Boukovalas1, C. J. Coroneos3, A. Chatterjee4, R. D. Largo1, C. Butler1  1University Of Texas MD Anderson Cancer Center,Department Of Plastic Surgery,Houston, TX, USA 2McGovern Medical School at UTHealth,McGovern Medical School,Houston, TX, USA 3McMaster University,Division Of Plastic Surgery,Hamilton, ONTARIO, Canada 4Tufts Medical Center,Division Of Plastic Surgery,Boston, MA, USA

Introduction:  Enhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in
breast reconstruction.

 

Methods:  Electronic database search identified reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis.

Results: A total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use (Mean difference (MD) = – 183.96, 95%CI -340.27 – -27.64, p=0.02) and LOS (MD = -1.58, 95%CI -1.99 – -1.18], p<0.00001) versus traditional care. There is no difference in complications (major complications, readmission, hematoma, and infection).

Conclusion: ERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.

 

15.06 Bipedicled DIEP & SIEA Lower Abdominal Perforator Free Flaps For Unilateral Breast Reconstruction

Posted on January 31, 2019

I. See1,3, D. T. Ghorra2,3, L. MacLennan3, N. G. Rabey3, C. M. Malata3,4,5  1University Of Auckland,Auckland, AUCKLAND, New Zealand 2University of Alexandria,Alexandria, ALEXANDRIA, Egypt 3Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic And Reconstructive Surgery,Cambridge, CAMBRIDGE, United Kingdom 4Addenbrooke’s University Hospital,Cambridge Breast Unit,Cambridge, CAMBRIDGE, United Kingdom 5Anglia Ruskin University School of Medicine,Cambridge & Chelmsford, CAMBRIDGE & CHELMSFORD, United Kingdom

Introduction: Double-pedicled lower abdominal free flaps are an effective technique for postmastectomy autologous reconstruction of patients who are slim, nulliparous, large-breasted relative to their abdominal pannus or have midline abdominal scars. These are particularly useful when adjuvant radiotherapy is planned or implant-based reconstruction is declined. Studies suggest they carry no increased morbidity over unipedicled flaps. Both extraflap (independent) and intraflap (dependent) microvascular anastomoses have been employed but utilizing rib-sacrifice technique of internal mammary recipient vessel exposure. We report a consecutive series of 40 patients (80 flaps) undertaken with both configurations without recourse to rib sacrifice. An algorithm incorporating CT angiography of the lower abdominal wall is presented.

Methods: Patients undergoing bipedicled flap unilateral breast reconstruction by a single surgeon (2010-2018) were reviewed with respect to flap type, anastomotic configuration, intercostal space(s) used for the microsurgery and the flap outcomes.

Results: 40 consecutive double-pedicled free flaps (20% of the all breast free flaps) utilizing both intra-flap (n=11) and extra-flap (n=29) techniques with no partial or total flap losses and only one postoperative re-exploration for flap salvage were undertaken in 40 patients with a median age of 46 years (range 27-66). 32 reconstructions were immediate, 3 delayed, and 5 salvage (tertiary). The series comprised 67 deep inferior epigastric artery perforator (DIEP) and 13 superficial inferior epigastric artery (SIEA) flaps. All 80 anastomoses but three (which used the thoracodorsal system) were performed to the internal mammary vessels using the total rib-preserving method. The combinations used were DIEA/DIEA (29), DIEA/SIEA (9) and SIEA-SIEA (2). The median surgery duration was 697 (range 468-790) with a first flap ischemia time of 104 minutes. The 2nd space was used in 22 patients and both 2nd and 3rd in 18 patients. The vein of the 2nd flap was anastomosed anterogradely to the bifurcated IMV vein in 10 cases, retrograde limb in 25, intraflap continuity in 10 and to the thoracodorsal vein in two. The arterial anastomosis of the 2nd pedicle was performed to the retrograde IM artery in 24 cases. Five breasts were liposuctioned for reshaping and three showed minor fat necrosis, which did not require excision.

Conclusion: Bipedicled free abdominal perforator flaps are a reliable option for unilateral breast reconstruction. In view of their technical complexity and prolonged surgical duration, our algorithm facilitates microsurgical flap design in terms of flap pedicle, recipient vessels, and anastomotic permutations to enable successful execution of these operations. CT angiography helps to predict those patients who will benefit from intraflap anastomoses (Moon & Taylor type II vascular anatomy) and thus do not need apriori exposure of the 3rd intercostal space.

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