key: cord-0860860-7pwceu2m
authors: Ho, Weiguang; Köhler, Guido; Haywood, Richard; Rosich-Medina, Anais; Masud, Dhalia
title: Microsurgical Autologous Breast Reconstruction in the Midst of a Pandemic – A Single-unit COVID-19 experience
date: 2021-10-07
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2021.09.007
sha: 9e97c62d9017de79c56d971e9c65e697cc92767c
doc_id: 860860
cord_uid: 7pwceu2m

INTRODUCTION: COVID-19 has disrupted the provision of breast reconstructive services throughout the UK. Autologous free flap breast reconstruction was restarted in our unit on 3/6/2020. We aim to compare the unit's performance of microsurgical autologous breast reconstruction in the “post-COVID” period compared with the exact time period in the preceding year. METHODS: We retrospective reviewed prospectively collected data in the “pre-COVID” (3/6/2019-31/12/2019) and “post-COVID” period (3/6/2020-31/12/2020). Patient demographics included age, BMI, co-morbidities, ASA grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, reconstruction timing, number of pedicles, contralateral symmetrisisation and other procedures. Dependent variables were ischaemic time, operative time, mastectomy weight, flap weight, length of stay, return to theatre and complication rates. The number of trainers and trainees present in theatre were recorded and analysed. RESULTS: Fewer DIEP flaps were performed in the “post-COVID” period (45 vs 29). There was no significant difference in mastectomy resection weight, but flap weight was significantly increased. There was no significant difference in ischaemic time. The postoperative length of stay was significantly reduced. There was no significant difference in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. No cases of venous thromboembolism or flap failures were recorded. The mean number of trainers and trainees, and the trainee-to-trainer ratio was not found to be significantly different between. CONCLUSION: Although fewer cases were performed, autologous breast reconstruction was safely delivered throughout the COVID-19 pandemic in the first wave without affecting training.

The novel Coronavirus disease 2019 (COVID-19) has thrown a spanner in the works in the continuity of provision of breast reconstructive services throughout the United Kingdom (UK). This was on the background of early literature from Wuhan, China (1) (2) (3) (4) and New York, United States of America (USA) (5) (6) (7) , suggesting that cancer patients may be at increased risk of contracting COVID-19. Further early data also suggested a cancer patient may experience a more severe disease course with greater risk of intensive care admissions, mechanical ventilation and death if they contracted COVID-19 (3) (4) (5) . Additionally, international data from the COVIDSurg Collaborative found the 30-day mortality in elective surgery patients diagnosed perioperatively with COVID-19 may be as high as 19.1% (8) .

Consequently, the Clinical Guide to Surgical Prioritisation during the Coronavirus Pandemic jointly published by the Federation of Surgical Specialty Associations states that breast reconstruction is priority level 4 surgery, implying that it can be delayed for over three months (9) .

After reviewing the available evidence, Jallali et al concluded that there is a paucity of high-quality prospective data and therefore insufficient evidence to deny patients the benefits of immediate reconstruction (10) .

After widespread consultation with stakeholders both locally and nationally, regional guidelines for selecting patients and postoperative management of patients undergoing microsurgical breast reconstruction were produced. Consequently, as of 3 June 2020 autologous free flap breast reconstruction was restarted in the Norfolk and Norwich University Hospital (11) . Since then, we had also published our experience with managing a patient diagnosed with COVID-19 in the postoperative period, including dressings, drains and management of seroma of the right breast. In this case, steps were taken to minimise risk to patient and staff (12) .

The aim of this study is to compare the unit"s performance of microsurgical autologous breast reconstruction in the "post-COVID" period compared with the exact time period in the preceding year in order to objectively assess the impact of COVID-19 on microsurgical autologous breast reconstruction.

A retrospective review of prospectively collected data in two separate cohorts. Cohort 1 or the "pre-COVID" cohort was defined as patients who underwent free DIEP flap procedures between 3 June 2019 to 31 December 2019. Cohort 2 or the "post-COVID" cohort was defined as patients who underwent free DIEP flap procedures in the same time period in the year 2020. Patient demographics that were studied were age, body mass index (BMI), co-morbidities, American Society of Anaesthesiologists (ASA) grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, immediate or delayed reconstruction, unipedicled or bipedicled flaps, contralateral symmetrisisation surgery and other additional procedures.

Intraoperative dependent variables investigated are ischaemic time, operative time, mastectomy weight and flap weight. Postoperative dependent variables included length of stay, return to theatre and complication rates.

In order to assess training, the number of trainers, defined as Plastic Surgery Consultants, and trainees, defined as Plastic Surgery Fellows or Registrars, present in theatre for the case were also recorded for analysis.

All statistical analyses were performed using Microsoft Excel (Microsoft, USA). Means for all continuous and categorical data were reported with standard deviations (SD). Parametric continuous variables were compared statistically using the two-tailed non-paired t-test. Categorical variables were statistically analysed using the Pearson"s chi-squared test. Statistical significance was defined as p-value of less than 0.05.

In total, 46 patients were in "pre-COVID" (Cohort 1) and 29 patients were "post-COVID" (Cohort 2). Mean ages for cohorts 1 and 2 were 50.7 years (SD 10.2 years) and 51.7 years (SD 10.8 years) respectively. Mean BMIs were 25.8 (SD 3.1) and 27.3 (SD 3.6) respectively. Mean ASA grades were 1.8 (SD 0.5) and 1.7 (SD 0.5) respectively. All the aforementioned independent factors were not statistically different (Table 1) . About two-thirds of both cohorts were non-smokers, while the rest were ex-smokers (Cohort 1: n=28 non-smokers and 14 ex-smokers vs Cohort 2: n=19 non-smokers and 10 ex-smokers, p = 0.896). This was not significantly different (Table 1) .

33 immediate and 12 delayed procedures were performed in the "pre-COVID" period, while 23 immediate and 6 delayed procedures were performed in the "post-COVID" period. Cohort 1 comprised of 23 unilateral and 13 bilateral reconstructions, while cohort 2 had 23 and six, respectively. In immediate reconstruction cases, mastectomy types were not significantly different between cohorts [Cohort 1: 28 skin-sparing mastectomies (SSM) and 1 nipple-sparing mastectomy (NSM) vs Cohort 2: 22 SSM and 1 NSM, p = 0.813].

Where nodal surgery was required for staging or therapeutic purposes, sentinel lymph node biopsies (SLNB) accounted for a significantly larger proportion compared with axillary node clearances (ANC) (Cohort 1: 6 SLNB and 6 ANC vs Cohort 2: 13 SLNB and 3 ANC, p = 0.012).

The proportion of bipedicled to unipedicled cases were statistically similar (Cohort 1: 41 unipedicled and 5 bipedicled vs Cohort 2: 26 unipedicled and 3 bipedicled, p = 0.928). In unilateral cases, the proportion of cases requiring contralateral symmetrisising surgery was also not significantly different [Cohort 1: n = 9

(27.2%) vs Cohort 2: n = 8 (34.7%), p = 0.927].

Mean drains for the recipient site (breast and/or axilla) were not significantly different between cohorts (Cohort 1 = 1 drain vs Cohort 2 = 1 drain, p = 0.00), however, the mean number of drains for the donor site (abdomen) was significantly reduced (Cohort 1 = 1 drain vs Cohort 2 = 0 drains, p = <0.0001).

There was no significant difference found in mastectomy resection weights, but flap weights were significantly increased from Cohort 1 to Cohort 2. Ischaemic time between cohorts were statistically similar.

The operative time for unilateral breast reconstruction cases were significantly reduced in Cohort 2, but there was no significant change for bilateral breast reconstruction cases.

All statistical findings are summarised in Table 2 .

Due to the newly introduced criteria, the postoperative length of stay has been significantly reduced [Cohort 1: 5.1 days (SD 1.4) vs Cohort 2: 3.0 (SD 1.2), p < 0.0001]. In Cohort 2, three patients (10.3%) were recatheterised postoperatively. Of these, two patients required recatheterisation to facilitate fluid monitoring for a general anaesthetic on return to theatre, and one patient had urinary retention. The latter patient had a successful trial without catheter two days later.

There were no significant changes in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. In both cohorts, no cases of venous thromboembolism or flap failures were recorded. The statistical findings are reported in Table 3 .

The mean number of trainers (Cohort 1 = 1.5 vs Cohort 2 = 1.8, p = 0.075), the mean number of trainees (Cohort 1 = 2.0 vs Cohort 2 = 1.7, p = 0.129) and the trainee-to-trainer ratio was not found to be significantly different between cohorts [Cohort 1 = 1.6 (SD 0.9) vs Cohort 2 = 1.3 (SD 1.0), p = 0.549] ( Table 4 ). Figure 1 shows temporal trends of mean trainee-to-trainer ratios. Although initially low, there is an increasing trend toward "pre-COVID" trainee-to-trainer ratios.

This study found that there was no significant difference in the complication rate during the "pre-COVID" and "post-COVID" cohorts, indicating that the safety of delivery of care throughout the patient journey is assured through the measures that were taken to minimise COVID-19 risk to patients. The data suggests that the current changes in practice are feasible for in our unit when microsurgical autologous breast reconstruction resumes after the next COVID-19 wave.

Pre-resection SLNB constitutes the practice of some of the breast surgeons that perform the mastectomy during the immediate reconstruction cases. As theatre space has become sparse during the height of the first wave, SLNBs were not performed preoperatively as often compared with the "pre-COVID" period. This may explain the significantly different range of axillary procedures performed between cohorts.

Preceding the COVID-19 pandemic, Mennie et al found that there was an increasing trend in the use of free flaps in both immediate and delayed breast reconstruction across England (13) , with the DIEP flap being the most common flap used.

Al-Ghazal et al found that patients who had immediate reconstruction recalled less distress and had better psychosocial wellbeing than those who had delayed reconstruction (14) .

In addition, autologous breast reconstruction has also been shown to be more cost-effective than implantbased reconstruction or no reconstruction. Data from the United States of America (USA) found no significant differences in patient satisfaction or in psychosocial, sexual or physical wellbeing at two years (15). Cheng et al had shown that in autologous breast reconstruction using either a DIEP or SIEA flap, delayed breast reconstruction is as cost-effective as immediate reconstruction in the Taiwanese healthcare system (16) .

Despite recommencing microsurgical autologous breast reconstruction in the earliest soonest opportunity, our unit had a 37.0% reduction in the number of procedures performed.

This study was unable to account for the reduction in numbers of patients who underwent autologous breast reconstruction, but this is likely attributable to a combination of stricter patient selection to meet the new trust admission criteria for elective patients, patient choice and lack of theatre availability and staffing. This is consistent with the findings of a survey of 970 surgeons working within the UK published by RCSEng on 1 October 2020. At this point in time, nearly half (48%) said access to more theatres and facilities to limit theatre "downtime" was necessary for deep cleaning (17) .

The impact of COVID-19 may indirectly create a "lost tribe" of patients who could have benefited from immediate breast reconstruction, but instead have been placed in the back of the queue of an increasingly long waiting list for delayed breast reconstruction. The waiting list for such procedures will compounded the longer the pandemic draws on.

A substantial part of restarting microsurgical autologous breast reconstruction was consideration of risk to patients, as described by Jallali et al (10) . In our unit, one key effort involves minimising the length of stay and the potential risk for complications for selected patients. To facilitate this, patient selection was key to identify motivated patients, with minimal co-morbidities, who would have the best chance of going through the accelerated pathway with a minimal risk of problems.

As cohorts 1 and 2 have no significant statistical difference in patient demographics, from a physical perspective, it is apparent that the "pre-COVID" method of selecting patient was sufficient, and that in the "post-COVID" period, we were able to deliver safe care throughout the microsurgical autologous breast reconstruction pathway for patients with similar medical backgrounds as the "pre-COVID" period.

As a large proportion of workload in Plastic Surgery constitutes elective work, concerns regard how COVID-19 would directly impact training have been raised. Although data on the parts of the procedure that are actually performed by the trainee are not available for analysis, the number of trainers (Plastic Surgery Consultants) and trainees (Plastic Surgery Fellows and Registrars) available were used as a surrogate marker to assess the exposure that trainees are obtaining during the "post-COVID" period. Through this, several pertinent findings were observed: (1) The mean number of trainers, mean number of trainees and trainee-totrainer ratio has not significantly changed between cohorts throughout the study period; (2) Although the trainee-to-trainer ratio was initially low after recommencement of microsurgical autologous breast reconstruction during the "post-COVID" period, there was an increasing trend towards the average ratio as more procedures were performed. This is an objective marker showing our unit"s continued commitment and achievement in breast microsurgical training during the COVID-19 pandemic. Nationally, a survey by RCSEng found that 46% of surgeons said that surgical training has resumed having previously been suspended due to the pandemic, and a further 41% said training had never stopped. Just 8% of surgeons report that surgical training has yet to resume. Two-thirds (67%) of surgeons indicated that a lack of elective activity meant that there were fewer opportunities for training (17) . Analysis on training was not able to assess the individual parts of procedures that trainees were able to perform as part of their training. This study merely looked at the proportion of trainees present to estimate the training. We therefore cannot make strong conclusions on the quality of training received.

This study concludes that autologous breast reconstruction was as safely delivered throughout the COVID-19 pandemic in the first wave as the "pre-COVID" period.

In spite of being one of the first units in the UK to recommence autologous breast reconstruction, our throughput is still reduced compared to a similar time period last year was still.

Opportunities for training were initially reduced in view of ensuring efficiency in theatres and minimal contact with patients, however, the trend showed recovery towards that of the "pre-COVID" period.

Ethical approval: Not required 

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