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Plastic Surgery Research Council

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Intraoperative Microvascular Complications In Autologous Breast Reconstructions: The Effects Of Resident Training On Microsurgical Outcomes
Avinash P. Jayaraman, B.A.1, Ryan M. Dickey, M.D.1, Yash Kadakia, B.A.1, Julie L. Cooper, B.S.1, Ricardo Garza, B.S.1, Sami U. Khan, M.D.2, Sumeet S. Teotia, M.D.1, Nicholas T. Haddock, M.D.1.
1UT Southwestern, Dallas, TX, USA, 2Stony Brook University, Stony Brook, NY, USA.

PURPOSE: Academic medical centers with large volumes of autologous breast reconstruction afford residents an invaluable, hand-on educational experience in microsurgical techniques. We present our experience with flaps (DIEP, PAP, LAP, stacked) where a supervised resident or microsurgical fellow completed the microvascular anastomoses.
METHODS: Retrospective chart review was performed on n=417 flaps (N=190 patients) which had microvascular anastomoses performed by a physician who is a PGY-4 (n=70), PGY-5 (n=58), PGY-6 (n=74), PGY-7 (microsurgery fellow, n=47), or AP (attending physician, n=168). Comorbidities including age, BMI, hypertension, diabetes, autoimmunity, DVT/PE, and prior surgeries were tracked. Intraoperative anastomoses complications, revisions of original anastomoses, flap losses, operative times, flap ischemia times, and unplanned returns to the OR were analyzed with ANOVA. When analyzing comorbidities, operative times, and unplanned returns, patients were grouped by the lowest PGY who was involved with microsurgical anastomosis.
RESULTS: Age and all comorbidities were equivalent between groups. Total operative time was equivalent between groups: PGY-4 (400min), PGY-5 (367min), PGY-6 (403min), PGY-7 (415min), and AP (439min), p=.45. Flap ischemia time was equivalent between groups: PGY-4 (49.2min), PGY-5 (47.4min), PGY-6 (47.8min), PGY-7 (43.2min), and AP (47.9min), p=.73. Rate of unplanned return to OR was equivalent between groups: PGY-4 (4.6%), PGY-5 (14%), PGY-6 (15%), PGY-7 (11%), and AP (17%), p-.273. Percentage of flaps with at least one intraoperative anastomosis complication was equivalent between groups: PGY-4 (8.6%), PGY-5 (12%), PGY-6 (9.5%), PGY-7 (4.3%), and AP (16%) p=.93. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p=.04. Rates of flap loss were equivalent between groups: PGY-4 (0%), PGY-5 (0%), PGY-6 (1.4%), PGY-7 (0%), and AP(<1%) p=.73. Overall flap loss between all groups was 2/417 (<1%).
CONCLUSION: With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. There were small differences in the rates of revisions of anastomoses between groups, though ultimately these did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

Table 1. Age and Comorbidities.
PGY-4 (N=65 pts)PGY-5 (N=37 pts)PGY-6 (N=33 pts)PGY-7 (N=9 pts)AP (N=46 pts)p-value
Age (yrs)51.852.250.752.051.7.97
BMI (kg/m2)30.429.830.729.228.7.50
Hypertension16/65 (25%)4/37 (11%)10/33 (30%)3/9 (33%)12/46 (26%).31
Diabetes7/65 (11%)6/37 (16%)1/33 (3.0%)2/9 (22%)4/46 (8.7%).32
Current or Past Smokers20/65 (31%)9/37 (24%)6/33 (18%)4/9 (44%)6/46 (13%).12
Autoimmune3/65 (4.6%)0/37 (0%)3/33 (9.1%)0/9 (0%)6/46 (13%).12
Prior DVT/PE6/65 (6.2%)1/37 (2.7%2/33 (6.1%)0/9 (0%)2/46 (4.4%).88
Prior Abdominal Surgery46/65 (71%)24/37 (65%)22/33 (67%)7/9 (78%)30/46 (65%).91
Prior Breast Reconstruction7/65 (11%)8/37 (22%)8/33 (18%)3/9 (33%)9/46 (20%).38

Table 2. Procedure Time, Length of Stay, Unplanned Returns to OR.
PGY-4 (N=65 pts)PGY-5 (N=37 pts)PGY-6 (N=33 pts)PGY-7 (N=9 pts)AP (N=46 pts)p-value
Procedure Time (mins)400367403415439.45
Lengthof Post-Op Stay (nights)
Return to OR during Hospital Stay3/65 (4.6%)5/37 (14%5/33 (15%)1/9 (11%)8/46 (17%).27

Table 3. Ischemia Times & Microvascular Complications.
PGY-4 (n=70 flaps)PGY-5 (n=58 flaps)PGY-6 (n=74 flaps)PGY-7 (47 flaps)AP (168 flaps)p-value
Flap Ischemia Time (mins)49.247.447.843.247.9.73
At least one microvascularcomplication6/70 (8.6%)7/58 (12%)7/74 (9.5%)2/47 (4.3%)26/168 (16%).18
At least one revision of anastomosis11/70 (16%)7/58 (12%)5/74 (7%)1/47 (2.1%)27/168 (16%).04*
Flap Loss0/70 (0%)0/58 (0%)1/74 (1.4%)0/47 (0%)1/168 (<1%).73

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