key: cord-1038028-fdkdj4l5
authors: VJ, Gokani; A, Fouarge; J, Dunne; N, Jallali; FP, Henry; SH, Wood; JE, Hunter
title: Immediate autologous free-flap breast reconstruction in the COVID-19 era can be safely performed
date: 2021-04-01
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2021.03.045
sha: 5bbd1a5857cc97bacc172aede0eda08fb9e3703e
doc_id: 1038028
cord_uid: fdkdj4l5

nan

The COVID-19 pandemic has changed the way in which elective services are delivered across healthcare. For several months breast reconstruction services were halted. We published guidance on restarting immediate abdominal based reconstructive surgery following mastectomy in the breast cancer setting 1 . This included details of patient selection, COVID-19 testing, and recommended in-patient and out-patient follow-up protocols. Here we present our initial data from this service reconfiguration compared to the outcomes to the corresponding time-frame in 2019.

During the period of the first peak of COVID-19 within the UK we performed no autologous breast reconstruction from 23 rd March at the Imperial College Healthcare NHS Trust Plastic Surgery Unit until our restart on 9 th June 2020. From this time until October 8 th 2020 we performed 29 immediate free-flap reconstructions on 25 patients. The first six were performed in the private sector owing to lack of capacity within the NHS.

As planned, all women referred by the breast surgeons were discussed at a formal oncoplastic breast MDT (run via a virtual platform) to ensure consensus regarding safe patient selection. Those women who fulfilled criteria for consideration of immediate breast reconstruction were seen at a face-to-face appointment pre-operatively, when an abdominal wall perforator mapping CT scan was performed, along with pre-operative blood tests (including vitamin D levels). Vitamin D was supplemented with 10, 000IU daily for 2 weeks pre-operatively, if found to be below 70nmol/L. Patients who were of Black and Minority Ethnic origin were counselled regarding increased risk of COVID-19 related death 2 , but not denied surgery based on ethnicity.

The second pre-operative appointment was typically virtual; information was also available via a virtual breast reconstruction seminar. No patient was denied reconstruction on the basis of a CT scan. All patients were admitted on the morning of surgery, and asked to take private-hire or personal transport into hospital. Patients were asked to self-isolate for 14 days pre-operatively, and undergo a PCR COVID-19 antigen test 3 days prior to surgery.

Family and friends were not allowed to visit the hospital. Patients were treated within a riskmanaged pathway, and were separated from patients with potential or confirmed COVID-

No patients developed COVID-19 pre-operatively, during their hospital admission, or in the post-operative period. There were no flap losses, and there was one return to theatre within 30 days of surgery, for washout of infected breast seroma. The same pre-operative COVID-19 testing and isolation protocol was employed for this, and she did not develop COVID-19. During the pandemic, evidence suggested that age over 65 and BMI over 35 increased the risk of severe COVID-related illness 1 . In terms of co-morbidities, our COVID-19 pathway meant that we could no longer offer the surgery to patients with diabetes, those over the age of 70, those with a BMI greater than 35.0, and those with chronic cardiac, respiratory or renal disease. Prior to the pandemic, these alone would not have been contra-indications.

All patients were discussed at the oncoplastic MDT, where a consensus was achieved as to the suitability of each patient for surgery.

Throughout the pandemic, we continued to follow the published pathway, but also reviewed it regularly, in line with available evidence. We reconsidered offering surgery to patients with diabetes, however, research published following the first peak of COVID-19 suggested that it remained unsafe to do so 3, 4 . Although the intention was to restart delayed breast reconstruction, a second surge in cases has meant that the staff availability could not be guaranteed, and this has therefore not been recommenced as of January 3 rd 2020.

In summary, our data show that there are mechanisms to provide safe care for these women. Although they do not allow comment on the delayed breast reconstruction pathways, the results support the fact that immediate breast reconstruction in selected women should not be neglected due to the COVID-19 pandemic. This surgery should only be precluded if staff availability is limited, or the surgery is unsafe. 

The feasibility and safety of immediate breast reconstruction in the COVID-19 era

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