Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes

Abstract

Background Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. Methods Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. Results Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. 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 = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). Conclusion With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences 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.

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction

“…This finding also confirms Teotia and colleagues findings that resident progression does not affect operative duration. 23 Therefore, improvements in operative time can be attributed to the efficiency of the primary microsurgeon in both technique and decision making.…”

Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps

“…7 However, no differences in operative time, complication rate, or flap losses based on resident training level were determined. 7 Our finding that presence of a junior resident, regardless of total resident experience years present, increases risk of anastomotic failure suggests that even with several experienced hands in the room, teaching early-stage trainees during a case may necessitate greater attention during key steps of the anastomosis, a highly complex endeavor. 10 Within the same postgraduate year, academic quarter did not affect rates of anastomotic failure.…”

“…Teotia et al found that up to 16% of autologous free flaps at an academic medical center required at least one intraoperative microvascular revision for venous congestion, arterial thrombosis, kinked vessels, leakage, or vessel collapse. 7 Despite potential anastomotic complications, a paucity of studies have examined factors associated with intraoperative anastomotic complications during DIEP flaps.…”

Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction

“…However, our experience and reported literature shows that there are no impacts on operative time or intraoperative complications based on trainee level. 33 As such, it may be included in microvascular surgery to gain real-life operative experience and repetition while having no negative financial impact on the patients or institution utilizing an ERAS protocol.…”