Background Same-day discharge after mastectomy is a recently described treatment approach. Limited data exist investigating whether same-day discharge can be successfully implemented in patients undergoing mastectomy with immediate implant-based breast reconstruction (IBR). Methods Patients having mastectomy with IBR from 2013 to 2019 were reviewed. Enhanced recovery with same-day discharge was implemented in 2017. Patient characteristics, oncologic treatments, surgical techniques, and 90-day postoperative complications and reoperations were analyzed comparing enhanced recovery patients with historical controls. Results A total of 363 patients underwent nipple-sparing (214, 59%) or skin-sparing (149, 41%) mastectomy with 1-stage (270, 74%) or tissue expander (93, 26%) IBR. Enhanced recovery was used for 151 patients, with 79 of these patients (52%) discharged same-day. Overall, enhanced recovery patients experienced a significantly lower rate of 90-day complications (21% vs 41%, P < 0.001), including hematoma (3% vs 11%, P = 0.002), mastectomy flap necrosis (7% vs 15%, P = 0.02), seroma (1% vs 9%, P < 0.001), and wound breakdown (3% vs 9%, P = 0.05). Postoperative complication rates did not significantly differ among enhanced recovery patients discharged same day. Postoperative admissions significantly decreased after enhanced recovery implementation (100% to 48%, P < 0.001), and admitted enhanced recovery patients experienced a lower length of stay (1.2 vs 1.8, P < 0.001). Enhanced recovery patients experienced a lower incidence of ≥1 unplanned reoperation (22% vs 33%, P = 0.01); overall average unplanned and total reoperations did not significantly differ between groups. Conclusions In conjunction with enhanced recovery practices, same-day discharge after mastectomy with IBR is a safe and feasible treatment approach.
Background Novel secondary flap options are paramount for patients who are not candidates for common reconstructive methods. The purpose of this study is to identify the prevalence of single arterial pedicle supplying both the gracilis muscle and medial thigh tissue carried in a profunda artery perforator (PAP) flap. Such a pedicle could allow the creation of a chimeric gracilis and PAP flap with a single-arterial anastomosis. Methods We conducted a retrospective review of 157 lower extremity computed tomography (CT) angiograms to assess the vasculature of the thigh soft tissues. Imaging evaluation was supervised by a board-certified musculoskeletal radiologist. Results Prevalence of a single-arterial pedicle to a gracilis and PAP flap in each patient was 59% (31% within the right leg and 28% in the left leg). Furthermore, 16% of patients had a common arterial pedicle in both lower extremities. Conclusion Existence of a single-arterial pedicle to both the gracilis muscle and PAP flap tissues is frequently present in most patients in at least one lower extremity. This chimeric flap configuration could serve as a reconstructive avenue for patients, particularly those who have exhausted other more common flap options. Screening angiography is warranted in patients looking for this anatomic variation to establish its presence.
To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction. Design: Case series. Setting: Academic setting. Patients: Pelvic reconstruction surgery patients. Interventions: The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. Measurements and Main Results: A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57−79 years) and median follow-up time of 9.2 months (range = 5−12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset. Conclusion: Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.
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