Plastic Surgery Research Council
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PSRC 60th Annual Meeting

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Reducing Unplanned Reoperations for Mastectomy Skin Flap Necrosis - A Multidisciplinary Approach
Valerie Lemaine, M.D., M.P.H., Tanya L. Hoskin, M.S., Judy C. Boughey, M.D., David R. Farley, M.D., Clive S. Grant, M.D., Steven R. Jacobson, M.D., James W. Jakub, M.D., Tiffany T. Torstenson, D.O., Ryan D. Reusche, M.D., Amy C. Degnim, M.D..
Mayo Clinic, Rochester, MN, USA.

PURPOSE: Necrosis of breast skin and/or nipple areolar complex (NAC) following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and immediate breast reconstruction (IBR) can result in delayed adjuvant therapy, prosthetic infection and reconstruction failure. A multidisciplinary quality improvement (QI) project was undertaken using the DMAIC (Define, Measure, Analyze, Improve, Control) framework in an attempt to reduce mastectomy skin flap necrosis. This study’s goal was to assess the impact of the QI initiative in improving surgical outcomes, specifically by reducing unplanned reoperations for mastectomy skin flap necrosis in mastectomy patients undergoing IBR.

METHODS: Consecutive cases of SSM or NSM followed by IBR were reviewed retrospectively for mastectomy skin flap necrosis and unplanned reoperation for necrosis. Plastic and breast surgeons reviewed medical records and postoperative photographs for details of mastectomy skin flap necrosis and its management. Reoperations specifically performed for management of mastectomy skin flap necrosis were recorded. Reoperation rates were compared for time periods BEFORE initiating the QI project (Nov 2009-Oct 2010) and AFTER (Nov 2010-Dec 2011).

RESULTS: 344 patients underwent 594 breast procedures (397 SSM and 197 NSM). Of these, 296 procedures were performed BEFORE the QI project was initiated (201 SSM and 95 NSM). AFTER the QI project began, 298 procedures were performed (196 SSM and 102 NSM). Overall, reoperation rates decreased significantly from the BEFORE group (22/296 = 7.43%) to the AFTER group (10/298=3.36%, p=0.026). The rate of reoperation of SSM cases decreased in the BEFORE vs AFTER group, but this was not statistically significant (4.98% vs 3.06%, respectively; p=0.330). For NSM cases, reoperations decreased significantly from the BEFORE group (12/95=12.63%) vs AFTER group (4/102=3.92%, p=0.023).

CONCLUSIONS: This multidisciplinary QI initiative to improve outcomes after SSM and NSM with IBR resulted in substantial reductions in unplanned reoperations for mastectomy skin flap and/or NAC necrosis in NSM. Further work is ongoing to identify factors that contributed to the reduction.
Reoperation rates for mastectomy skin flap necrosis after SSM or NSM and IBR
Operation typeBEFORE QI
n
Reoperation rate
n (%)
AFTER QI
n
Reoperation rate
n (%)
p value
SSM and IBR20110 (5.0)1966 (3.1)0.330
NSM and IBR9512 (12.6)1024 (3.9)0.023
Total29622 (7.4)29810 (3.4)0.026


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