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Introduction: Vasopressors are traditionally avoided in microsurgery due to concerns about their effect on free flap survival. We examine the impact of intraoperative vasopressors on microsurgical outcomes in a large series of DIEP flap breast reconstructions., Methods: A retrospective chart review was performed of patients who underwent DIEP breast reconstruction between January 2010 and May 2020. Intraoperative and postoperative microsurgical outcomes were compared in patients who received vasopressors and those who did not., Results: The study included 1102 women who underwent 1729 DIEP. 878 patients (79.7%) received intraoperative phenylephrine, ephedrine, or a combination of both. There was no significant difference in overall complications, intraoperative microvascular events, takebacks for microvascular complications, or partial or total flap loss between groups. Outcomes were not affected by vasopressor type, dose, or timing of administration. The vasopressor group received significantly lower intraoperative fluid volumes. Multivariate logistic regression found a significant association between overall complications and excessive fluids (OR 2.03, 99% CI 0.98-5.18, p = 0.03) but not vasopressor use (OR 0.79, 99% CI 0.64-3.16, p = 0.7) CONCLUSION: This study demonstrates that vasopressors do not adversely affect clinical outcomes after DIEP breast reconstruction. Withholding vasopressors results in excessive intravenous fluid administration and increased postoperative complications., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To elicit a patient-prioritized agenda and preferences for upper extremity lymphedema (LE) research., Methods: Focus group sessions (FGs) were conducted with English-speaking, adult women (18 years and older) with breast cancer-related LE (BCRL) seeking conservative or surgical care at two tertiary cancer centers in Ontario, Canada. An interview guide was used; women were asked to describe health-related quality of life (HRQL) outcomes that mattered the most to them, followed by their preferences for research study design and for providing patient-reported outcomes measure (PROM) data. Inductive content analysis was used to identify themes and subthemes., Results: A total of 16 women participated in 4 FG sessions (55 ± 9.5 years) and described the impact of LE on their appearance, physical, psychosocial, and sexual well-being. Women emphasized that psychosocial well-being was often not discussed in clinical care and that they were poorly informed of LE risk and care options. Most women said that they would not be willing to be randomized to surgical versus conservative management of LE. They also expressed a preference to complete PROM data electronically. All women emphasized the value of having an open text option alongside PROMs to expand on their concerns., Conclusion: Patient centeredness is key to generating meaningful data and ensuring ongoing engagement in clinical research. In LE, comprehensive PROMs that measure a range of HRQL concerns, especially psychosocial well-being, should be considered. Women with BCRL are reluctant to be randomized to conservative care when a surgical option is available, resulting in implications for planning trial sample size and recruitment., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Immediate breast reconstruction has many advantages but is associated with higher complication rates than delayed reconstruction. Complications can delay the delivery of adjuvant cancer treatments. This study aimed to develop and validate a risk stratification model for the prediction of perioperative complications in immediate microvascular breast reconstruction., Methods: The association between patient and treatment variables and perioperative complications was evaluated in a retrospective cohort of 351 women undergoing immediate breast reconstruction using free deep inferior epigastric artery perforator flaps. Multivariable logistic regression was used to determine the strength of association and weighted scores were assigned. Using cumulative risk scores, patients were stratified into low, intermediate, and high-risk groups. The model was then validated in a prospective cohort of 100 consecutive patients., Results: Obesity, smoking, prior radiation, and comorbidities were important predictors and incorporated into the risk model. Complications occurred in 23.5% of low-risk (95% confidence interval [CI] = 17.7-29.2), 38.4% of intermediate-risk (95% CI = 29.2-47.5) and 53.9% of high-risk (95% CI = 33.3-74.4) patients. Validation confirmed a linear relationship between the risk stratification categories and complications in a model with good predictive power (c-statistic = 0.7, 95% CI = 0.6-0.8)., Conclusion: A simple risk score, based on known preoperative variables, provides accurate risk stratification for patients considering immediate microvascular breast reconstruction., (© 2019 Wiley Periodicals, Inc.)

The analysis of a single surgeon's 5 year attempt at performing autologous tissue breast cancer reconstruction, with one general anesthetic. A single-stage breast cancer reconstruction is successful if after the original reconstruction, no correction for complications, revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction. This is a review of a single surgeon's breast reconstruction practice. Three hundred fifty-six breast cancer reconstruction patients had surgery in a period of 5 years. One hundred forty-one of 356 (39.6%) were consecutive attempts at single-stage autologous tissue reconstruction: 106 of 141 (75.1%) were free abdominal flaps (transverse rectus abdominis myocutaneous, muscle-sparing flaps [MS], or deep inferior epigastric artery perforator flaps), 29 of 141 (20.6%) pedicled transverse rectus abdominis myocutaneous flaps, and 6 of 141 (4.3%) latissimus dorsi flaps; 37 of 141 (26.2%) were immediate reconstructions, 100 of 141 (70.9%) delayed reconstructions, and 4 of 141 (2.8%) mixed reconstructions. One hundred seven of the 141 patients (75.9%) had their autologous tissue reconstruction successfully performed in one general anesthetic. Reconstructions requiring more than one general anesthetic were due to 18 of 141 (12.8%) postoperative and donor-site complications, 16 of 141 (11.3%) revisions of breast mound or contralateral breast procedures. A total of 34 of 141 (24.1%) reconstructions required a second general anesthetic for successful completion, only 16 of 141 (11.3%) of autologous tissue breast cancer reconstructions required revisions for symmetry. Therefore, single-stage breast cancer reconstruction is feasible and should be attempted to decrease the morbidity of breast cancer survivors.