Background:. Current methods for assessing outcomes after bilateral breast reduction (BBR) include traditional metrics (length of stay, morbidity, and mortality), and more recently, patient-reported outcome measures. These can be limited by subjectivity and poor granularity. Postoperative physical activity collected from patients’ smartphones has since been validated as an objective measure of recovery. This study aims to investigate recovery after BBR using this novel outcome measure. Methods:. A single-center, retrospective cohort analysis was conducted of patients who had undergone BBR surgery at Imperial College NHS Healthcare Trust from August 2021 to February 2024. A smartphone application was used to retrospectively gather physical activity data from patients covering 1 month preoperatively to 6 months postoperatively. Data were analyzed to provide the time taken to return to 90% of preoperative activity levels, as well as daily activity patterns. Results:. Fifty-six patients undergoing breast reduction were recruited. Postoperative recovery data were used to plot novel recovery curves, whereby the average return to baseline activity was 33.5 days. The only patient or surgical factor found to be a predictor of recovery was the weight of tissue removed, correlating negatively with activity levels in the first 2 weeks (P = 0.027). Daily activity patterns revealed clear changes in behavior over time, providing novel insight into return to work. Conclusions:. Activity data from patients’ smartphones enhance our ability to investigate postoperative recovery with unique detail. Integration of these data alongside traditional measures could help to better inform patients and clinicians regarding recovery, outcomes, and funding decisions in this cohort.

Analysis of patients’ smartphone activity data has recently been validated as a novel recovery-metric after breast surgery. The aim of this study was to compare recovery from secondary breast procedures (symmetrisation, re-reduction and scar revision after breast reduction and cancer excision/reconstruction) with patients who underwent primary bilateral breast reduction (BBR) surgery. A single-centre retrospective cohort-analysis was conducted from patients who had undergone breast reduction surgery at Imperial College NHS Healthcare Trust from August 2021 to February 2024. A simple, user-friendly mobile application was used to gather activity data from patients’ smartphones perioperatively. Novel post-operative recovery curves were plotted for each cohort. 56 patients provided data to the study. 38 patients who had undergone primary BBR for symptomatic macromastia and 12 who had undergone secondary procedures. 6 datasets were unusable due to missing data. Recovery from primary BBR was estimated to take 33.5 days, compared with 13.5 days for secondary procedures. Increased weight of tissue removed was found to correlate significantly with reduced activity over the first two weeks post-operatively (p=0.027). This study contributes to a currently small pool of data measuring recovery from breast surgery using smartphone activity data. Patients may be cautious about undergoing further procedures if they anticipate their recovery to take a similar amount of time to their primary procedure. The results of this study may be helpful to clinicians and patients for reassurance that recovery should be significantly faster after a secondary procedure compared with a primary one.

Aims: To understand variation in the cost of autologous breast reconstruction in the UK, including identifying key areas of cost variability, differences between and within units and the impact of enhanced recovery protocols (ERAS).Methods: A micro-costing study was designed based on the responses to a national survey of clinical preferences completed by the majority of plastic surgeons and anaesthetists involved in the UK. Detailed costs were estimated from macro elements such as ward and theatre running costs, down to that of surgical meshes, anaesthetic drugs and flap monitoring devices.Results: The largest variation in cost arose from postoperative location and length of stay, preoperative imaging and flap monitoring strategies. Plastic surgeon costs varied from 1282 pound to 3141 pound, whereas anaesthetic costs were between 32 pound and 151 pound (not including salary). Estimated cost variation within units was up to 893 pound per case. Units with ERAS had significantly lower total costs than those without (p < 0.05).Conclusion: This study reveals significant cost variation in breast reconstruction in the UK based on clinician preferences. Many areas of practice driving this variation lack strong evidence of any clinical advantage. The total cost of a deep inferior epigastric perforator in the majority, if not all units, likely surpasses the national tariff for reimbursement, particularly when considering additional resource demand for immediate and bilateral breast reconstruction, as well as future symmetrisation procedures. Whilst units should look to streamline costs through ERAS, there should also be a realistic tariff that promotes excellent care.(c) 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd.

PURPOSEThis work aimed to investigate the validity of Wearable Activity Monitors (WAMs) as an objective tool to measure the return towards normal functional mobility following abdominal wall surgery. This was achieved by quantifying and comparing pre- and postoperative physical activity (PA).METHODSA multi-centre, prospective, observational cohort study was designed. Patients undergoing abdominal wall surgery were assessed for eligibility and consented for study participation. Participants were asked to wear a WAM on the wrist of their dominant hand (AX3, Axivity) at least 48hours pre-operatively, for up to 2 weeks post-op, and then again after 6 months postop for 48hours.RESULTSA cohort of 20 patients were recruited in this validation study with a mean age of 47.3 ± 13.0 years. Post operation, the percentage median PA (±IQR) dropped to 32.6% (20.1), while on day 14, PA had reached 64.6% (22.7) of the preoperative value providing construct validity. Activity levels at > 6 months postop increased by 16.4% on average when compared to baseline preoperative physical activity, p=0.046.CONCLUSIONThis study demonstrates that WAMs are valid markers of postoperative recovery following abdominal wall surgery. This was achieved by quantifying the reduction in PA post-operation, which has not been previously shown. In addition, this study suggests that abdominal wall surgery improves patient quality of life via increased functional mobility at 6 months postop. In the future, this technology could be used to identify the patient and surgical factors that are predictors of outcome following abdominal wall surgery.

Introduction: Autologous free-flap breast reconstruction accounts for 30% of reconstruction following mastectomy. However there is no consensus regarding immediate post-operative monitoring protocols. We report the time periods and salvage rates for free-flaps which were returned-to-theatre at a high-volume practice. Materials and Methods: The prospectively collected electronic records for patients undergoing breast free-flap reconstruction between January 2015 and August 2019 were reviewed retrospectively. All free-flaps were reviewed by nurses using the standardised hospital protocol until discharge. Primary end-points evaluated include free-flaps which were returned-to-theatre for full free-flap loss, complication type and free-flap salvage. Results: We identified 679 autologous breast free-flap reconstructions. Fifteen (2.2%) were returned-to-theatre for surgery-related complications during inpatient stay. Eight (1.2%) developed microvascular complications; seven (1.0%) were successfully salvaged and we encountered one free-flap loss (0.1%) due to an arterial complication developing 72-hours postoperatively. Six of the eight microvascular complications (75%) occurred within the first 24 hours from surgery. Surgical time in the takeback population was statistically significantly longer than in the non-takeback population (539 minutes vs. 406 minutes, p=0.00585). Conclusion: Majority of microvascular complications occurred within the first 24-hours in our cohort and these were successfully identified and salvaged at our high-volume practice. We believe all free-flaps should be closely monitored in the first 24-hours. Beyond this period, protocols should be suited to each institution based on their patient demographic, facilities available for free-flap monitoring and case-volume.

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base. Methods Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached. Results The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis. Conclusion To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

Background Radiotherapy before mastectomy and autologous free-flap breast reconstruction can avoid adverse radiation effects on healthy donor tissues and delays to adjuvant radiotherapy. However, evidence for this treatment sequence is sparse. We aimed to explore the feasibility of preoperative radiotherapy followed by skin-sparing mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction in patients with breast cancer requiring mastectomy. Methods We conducted a prospective, non-randomised, feasibility study at two National Health Service trusts in the UK. Eligible patients were women aged older than 18 years with a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy radiotherapy, who were suitable for DIEP flap reconstruction. Preoperative radiotherapy started 3-4 weeks after neoadjuvant chemotherapy and was delivered to the breast, plus regional nodes as required, at 40 Gy in 15 fractions (over 3 weeks) or 42.72 Gy in 16 fractions (over 3.2 weeks). Adverse skin radiation toxicity was assessed preoperatively using the Radiation Therapy Oncology Group toxicity grading system. Skin-sparing mastectomy and DIEP flap reconstruction were planned for 2-6 weeks after completion of preoperative radiotherapy. The primary endpoint was the proportion of open breast wounds greater than 1 cm width requiring a dressing at 4 weeks after surgery, assessed in all participants. This study is registered with ClinicalTrials.gov, NCT02771938, and is closed to recruitment. Findings Between Jan 25, 2016, and Dec 11, 2017, 33 patients were enrolled. At 4 weeks after surgery, four (12.1%, 95% CI 3.4-28.2) of 33 patients had an open breast wound greater than 1 cm. One (3%) patient had confluent moist desquamation (grade 3). There were no serious treatment-related adverse events and no treatment-related deaths. Interpretation Preoperative radiotherapy followed by skin-sparing mastectomy and immediate DIEP flap reconstruction is feasible and technically safe, with rates of breast open wounds similar to those reported with post-mastectomy radiotherapy. A randomised trial comparing preoperative radiotherapy with post-mastectomy radiotherapy is required to precisely determine and compare surgical, oncological, and breast reconstruction outcomes, including quality of life. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd.

Background: Radiotherapy (RT) prior to mastectomy and autologous reconstruction spares healthy donor tissues the adverse effect of radiation, avoiding delay to adjuvant RT due to post-operative healing. However, little is known regarding the surgical safety of RT sequence reversal in this setting. We investigated the feasibility of microvascular anastomosis and surgical safety of deep inferior epigastric perforator (DIEP) breast reconstruction after neoadjuvant radiotherapy (NRT).Methods: PRADA was a multi-centre, non-randomized, observational study in the United Kingdom. Eligible participants were aged 18 years or older, requiring mastectomy either for extensive disease or for positive margins following attempted breast conserving surgery, and requiring PMRT and deemed suitable for a DIEP flap reconstruction. NRT was commenced 2-6 weeks following completion of neoadjuvant chemotherapy (NACT) and intention for surgery within 6 weeks of completion of NRT. Data was prospectively captured on demographic and clinicopathological variables, treatment schedules and timelines, and perioperative complications. Oncological outcomes including loco-regional recurrence (LRR), overall survival (OS) and disease-free survival (DFS) were recorded. The primary outcome was the open wound rate, and the primary end point was the rate of open breast wounds requiring a dressing 4 weeks following surgery. Findings: Between 26th January 2016 and 11th December 2017, 33 patients receiving immediate DIEP breast reconstruction after NRT were enrolled. Median time from NRT completion to surgery was 19·0 days with all completing surgery within 6 weeks of NRT (range=12-39). Microvascular anastomosis was successfully achieved in all patients and there were no DIEP flap failures. In three cases immediate revision anastomosis was required at the index surgery. There were two unplanned returns to the operating room: one <24hrs to assess a congested DIEP flap; the second at 4 weeks for debridement of mastectomy skin flap necrosis and split skin graft. At 4 weeks there was an open wound rate of 12·1% (4/33). After median follow up of 23 months (range 2-41), none had LRR, four had distant metastatic relapses and there were two breast cancer related deaths, with OS 93·9% and DFS 87·8%.Interpretation: NRT prior to mastectomy with immediate DIEP flap reconstruction is technically feasible with rates of mastectomy skin flap necrosis and open wounds analogous to those observed following post-mastectomy radiotherapy. An appropriately powered randomized trial of NRT compared to conventional PMRT is needed to determine more precisely the surgical, oncological, and quality of life outcomes of breast reconstruction.Clinical Trial Registration Details: Registered with clinical trials.gov [NCT02771938].Funding Information: NIHR Imperial BCR, the CR:UK Imperial Centre and the Royal Marsden Hospital.Declaration of Interests: PTRT reports personal fees from Stryker Surgical and Cytoveris. JH reports personal fees from Stryker Surgical. All other authors declare no competing interests.Ethics Approval Statement: Local Regional Ethical Committee (LREC) approval was obtained for the Primary Radiotherapy And DIEP flAp (PRADA) study [15/LO/1071].

The coronavirus disease-2019 pandemic has had a significant impact on the delivery of surgical services, particularly reconstructive surgery. This article examines the current evidence to assess the feasibility of recommencing immediate breast reconstruction services during the pandemic and highlights considerations required to ensure patient safety. (C) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background:. Failure to accurately assess the perfusion of free tissue transfer (FTT) in the early postoperative period may contribute to failure, which is a source of major patient morbidity and healthcare costs. This systematic review and meta-analysis aim to evaluate and appraise current evidence for the use of near-infrared spectroscopy (NIRS) and/or implantable Doppler (ID) devices compared with conventional clinical assessment (CCA) for postoperative monitoring of FTT in reconstructive breast surgery. Methods:. A systematic literature search was performed in accordance with the preferred reporting items for systematic reviews guidelines. Studies in human subjects published within the last decade relevant to the review question were identified. Meta-analysis using random-effects models of FTT failure rate and STARD scoring was then performed on the retrieved publications. Results:. Nineteen studies met the inclusions criteria. For NIRS and ID, the mean sensitivity for the detection of FTT failure is 99.36% and 100% respectively, with average specificity of 99.36% and 97.63%, respectively. From studies with sufficient reported data, meta-analysis results demonstrated that both NIRS [OR = 0.09 (0.02–0.36); P < 0.001] and ID [OR = 0.39 (0.27–0.95); P = 0.04] were associated with significant reduction of FTT failure rates compared with CCA. Conclusions:. The use of ID and NIRS provided equivalent outcomes in detecting FTT failure and were superior to CCA. The ability to acquire continuous objective physiological data regarding tissue perfusion is a perceived advantage of these techniques. Reduced clinical staff workload and minimized hospital costs are also perceived as positive consequences of their use.

Free tissue transfer (FTT) surgery for breast reconstruction following mastectomy has become a routine operation with high success rates. Although failure is low, it can have a devastating impact on patient recovery, prognosis, and psychological well-being. Continuous and objective monitoring of tissue oxygen saturation (StO2) has been shown to reduce failure rates through rapid detection time of postoperative vascular complications. We have developed a pervasive wearable wireless device that employs near-infrared spectroscopy (NIRS) to continuously monitor FTT via StO2 measurement. Previously tested on different models, the results of a clinical study are introduced. Our goal for the study is to demonstrate that the developed device can reliably detect StO2 variations in a clinical setting: 14 patients were recruited. Advanced data analysis was performed on the StO2 variations, the relative StO2 gradient change, and the classification of the StO2 within different clusters of blood occlusion level (from 0% to 100% at 25% step) based on previous studies made on a vascular phantom and animals. The outcomes of the clinical study concur with previous experimental results and the expected biological responses. This suggests that the device is able to correctly detect perfusion changes and provide real-time assessment on the viability of the FTT in a clinical setting.

Introduction: CPM has no proven survival advantage in sporadic BC, and when coupled with autologous reconstruction has major resource implications and morbidity. Arguably, CPM should be reserved for patients with high contralateral breast cancer risk (CBRC) [NICE threshold:>30% lifetime risk]. We aimed to evaluate the impact of BODICEA CBCR calculations versus survival predictions (PREDICT) on retrospective decision-making for CPM, within confines of service evaluation.

Deep inferior epigastric artery perforator (DIEP) flap has become the gold standard in autologous breast reconstruction. Attention is now being focused on the impact of DIEP flap harvest technique on abdominal hernia rates. The aim of this study was to evaluate DIEP abdominal wall morbidity in relation to flap harvest and fascial closure technique. A retrospective analysis of patients undergoing DIEP flap breast reconstruction between 2012 and 2016 was performed. Post-operative evaluation of the abdominal wall integrity was performed by an operating consultant. The rectus fascia was closed using one of three techniques. The study included 202 patients, in whom 234 DIEP flaps were performed. Eight patients (3.4%) developed a clinically evident abdominal bulge post-operatively and one (0.5%) had a hernia. Harvesting two or more perforators was more likely to result in post-operative abdominal hernia/bulge than taking a single perforator (p = .032). Using a perforator from the lateral row or both rows was more likely to result in a hernia/bulge than if a single medial perforator was harvested (p = .026). Comparison of the rectus fascia closure technique did not show any statistically significant difference in abdominal wall morbidity. Consideration should be given towards perforator selection when harvesting a DIEP flap. Where appropriate, a suitable single medial row perforator with a favourable suprafascial course should be chosen. This study has not shown mesh-free fascial closure to be inferior to mesh-supported closure. Careful consideration to the role of synthetic mesh within this patient cohort should be given.

Patients with sporadic breast cancer (BC) have low contralateral breast cancer risk (CLBCR; approximately 0.7% per annum) and contralateral prophylactic mastectomy (CPM) offers no survival advantage. CPM with autologous reconstruction (AR) has major morbidity and resource implications.

Results: This algorithm has been used successfully and taught locally.Total flap loss rate in 350 flaps was 0.57%, partial flap loss rate 0.28% and fat necrosis rate 2.57%. Conclusions:This simple, methodical and reliable CTA algorithm represents a way to limit the learning curve for less experienced surgeons.

Introduction: Bilateral mastectomy (BM) and addition of reconstruction is thought to increase the risk of complications when compared to unilateral mastectomy and reconstruction (UM) alone.

Introduction: For patients with sporadic breast cancer, rates of contralateral cancer are low (0.7%/annum) and there is no evidence to suggest contralateral prophylactic mastectomy (CPM) offers survival advantage. However, CPM with autologous reconstruction has major resource implications. The aim was to review the implications of bilateral reconstructive surgery in patients with unilateral breast cancer.