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Background:  The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients., Methods:  This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications., Results:  Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age ( p  = 0.026), body mass index ( p  = 0.003), mean flap weight ( p  = 0.006), and surgery time ( p  = 0.035) were predictors of donor site complications. On multivariate regression analysis, age ( p  = 0.025), body mass index ( p  = 0.010), and surgery duration ( p  = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications ( p  > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87., Conclusion:  This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  Mastectomy skin flap necrosis often necessitates prolonged wound care, surgical re-excision, and it increases the risk for infection. This study aims to compare rates of skin flap necrosis between autologous and device-based reconstructions and identify risk factors., Methods:  The authors retrospectively identified patients who underwent immediate breast reconstruction using either the deep inferior epigastric perforator (DIEP) flap ( n  = 373 breasts, 41%) or tissue expanders ( n  = 529 breasts, 59%) by two surgeons at a single institution between 2011 and 2021. The rate of skin flap necrosis between autologous and device-based reconstructions was compared and multivariate regression analysis was performed to identify risk factors., Results:  There was no significant difference in rates of skin flap necrosis between the two cohorts (26.8 vs. 15.5%, p  = 0.052). Across all patients, hypertension and body mass index >30 were significant predictors of necrosis ( p  = 0.024 and p <0.001, respectively). Within our DIEP cohort, mastectomy specimen weight was a significant risk factor for necrosis ( p  = 0.001). The DIEP flap weight itself did not confer a higher risk for necrosis ( p  = 0.8)., Conclusion:  Immediate autologous reconstruction does not place patients at higher risk of skin necrosis. Hypertension and obesity (body mass index >30) were independent risk factors for necrosis in all patients. Mastectomy specimen weight was a significant predictor of necrosis in DIEP flap patients while the DIEP flap weight itself did not increase the risk for necrosis., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  Many patients who undergo free flap breast reconstruction develop postoperative hemodynamic changes, most noticeably, tachycardia. As there is currently no consensus on whether this tachycardia leads to clinically significant morbidity, it can trigger physician alarm and lead to extensive work-up. In this study, we aim to evaluate the predictors, evaluation, and outcomes associated with postoperative tachycardia in deep inferior epigastric perforator (DIEP) flap patients., Methods:  A retrospective review of DIEP flap patients between 2011 and 2020 was performed. Variables examined included demographics, preoperative laboratories and heart rate (HR), and intraoperative factors. Work-up of postoperative tachycardia and adverse postoperative events was noted. Tachycardia was defined as persistent HR of 100 beats/min or more for at least 12 consecutive hours following surgery. Tachycardic patients were compared with non-tachycardic patients using regression analysis., Results:  In total, 249 patients (439 flaps) were included in this study. Sixty-one patients (24.9%) developed tachycardia postoperatively. Regression analysis revealed that preoperative HR ( p  = 0.002) and flap weight ( p  = 0.037) predicted the development of tachycardia. While tachycardic patients were significantly more likely to undergo additional imaging and specialty consultations ( p <0.05), they were not at higher risk for most postoperative complications, with the exception of delayed abdominal donor-site healing., Conclusion:  A significant number of DIEP flap patients can be expected to develop persistent tachycardia postoperatively. Isolated tachycardia should be considered a relatively benign finding that does not warrant extensive work-up or prolonged inpatient monitoring. Having the ability to predict tachycardia using preoperative HR and flap weight arms plastic surgeons with the confidence to limit costly work-up., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  Based on the 2005 Caprini Risk Assessment Model for venous thromboembolism, the American Society of Plastic Surgeons prevention guidelines would result in prolonged chemoprophylaxis (1 week or more) for the majority of patients undergoing deep inferior epigastric perforator flap breast reconstruction. We aim to assess the necessity of prolonged prophylaxis by describing our institutional experience in thromboembolism prevention and evaluating the incidence of symptomatic VTE in our patient cohort., Methods:  Women who underwent DIEP flap reconstruction from August 2011 to March 2020 at a tertiary care center were included. Charts were retrospectively reviewed for patient characteristics, VTE prophylaxis regimens, and development of deep vein thrombosis and pulmonary embolism within 60 days of surgery. Caprini scores were calculated for all patients., Results:  Out of the 249 patients included in the study, 245 patients received chemoprophylaxis only during hospitalization, while four patients additionally received anticoagulant for at least 2 weeks after discharge for prophylactic or therapeutic indications. The cohort's average Caprini score was 6.0, with 72.7% of scores between 3 and 6 and 26.5% at 7 or higher. One patient (0.4%), who scored a 7 and received prophylaxis only while hospitalized, developed deep vein thrombosis. There were no cases of pulmonary embolism. There was no significant difference in VTE rate between patients who received chemoprophylaxis consistent with ASPS guidelines and those who did not ( p  = 1.000)., Conclusion:  Despite our limited chemoprophylaxis use in DIEP flap patients, our VTE incidence is low. This current work suggests that the blanket application of prolonged prophylaxis is not warranted, and it further serves as impetus to re-evaluate the 2005 Caprini RAM in this patient population., Competing Interests: None declared., (Thieme. All rights reserved.)

Background Communication, particularly transmission of information between the surgical and nursing teams, has been identified as one of the most crucial determinants of patient outcomes. Nonetheless, transfer of information among and between the physician and nursing teams in the immediate postoperative period is often informal, verbal, and inconsistent. Methods An iterative process of multidisciplinary information gathering was undertaken to create a novel postoperative communication system (the "Pop-form"). Once developed, nurses were surveyed on multiple measures regarding the perceived likelihood that it would improve their ability to provide directed patient care. Data were quantified using a Likert scale (0-10), and statistically analyzed. Results The Pop-form records and transfers operative details, specific anatomic monitoring parameters, and senior physician contact information. Sixty-eight nurses completed surveys. The perceived usefulness of different components of the Pop-form system was as follows: 8.9 for the description of the procedure; 9.3 for the operative diagram; 9.4 for the monitoring details and parameters; and 9.4 for the direct contact information for the appropriate surgical team member. All respondents were in favor of widespread adoption of the Pop-form. Conclusion This uniform, visual communication system requires less than 1 minute to compose, yet formalizes and standardizes inter-team communication, and therefore shows promise for improving outcomes following microvascular free tissue transfer. We believe that this simple, innovative communication tool has the potential to be more broadly applied to many other health care settings., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Partial hypopharyngeal defects are most commonly reconstructed with the pectoralis major myocutaneous flap (PMMF) or free fasciocutaneous (FFC) flap. The purpose of this study is to determine the ideal method for reconstruction of partial hypopharyngeal defects by reviewing our institutional experience and the literature., Methods: A retrospective review of partial hypopharyngeal reconstructions since 2009 was performed. A National Library of Medicine search of studies on partial hypopharyngeal reconstruction since 1988 was performed. Data on complications, diet, and speech were extracted and pooled., Results: A total of 18 patients were studied-9 had PMMF reconstruction and 9 had FFC reconstruction. Operative time (8.75 vs. 13.0 hours, p = 0.0003) was shorter in the PMMF group. Pharyngocutaneous fistula developed in one PMMF patient (11.1%) and two FFC patients (22.2%). Late strictures occurred in three PMMF patients. Six patients in each group (66.7%) progressed to a regular diet. Three patients in each group produced tracheoesophageal speech after TEP. Literature review identified 36 relevant studies, with 301 patients reconstructed with PMMF and 605 patients with FFC. Pooled-data analysis revealed that PMMF had higher reported rates of fistula (24.7 vs. 8.9%, p < 0.0001) and requirement for second surgery (11.3 vs. 5.5%, p = 0.04). There was no difference in stricture rates or progression to regular diet. Fewer PMMF patients produced tracheoesophageal speech (17.5 vs. 52.1%, p < 0.0001)., Conclusions: PMMF and FFC flaps are valid approaches to reconstructing partial hypopharyngeal defects, though rates in the literature of fistula, need for revisional surgery, and tracheoesophageal speech after laryngectomy are more favorable after free flap reconstruction., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)