Download PDF
J Reconstr Microsurg 2024; 40(08): 589-600
DOI: 10.1055/a-2253-6099
Original Article

Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis

Joshua Xu 
1   Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Xi Ming Zhu
2   Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
,
Kimberly C. Ng
3   Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
,
Muayyad M. Alhefzi
4   Department of Surgery, King Khalid University, Abha, Saudi Arabia
,
Ronen Avram
2   Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
,
Christopher J. Coroneos
2   Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
5   Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS).

Methods A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes.

Results Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD −0.65, 95% confidence interval [CI] −1.01 to −0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] −1.02, 95% CI −1.37 to −0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD −0.39, 95% CI −0.71 to −0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different.

Conclusion CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Keywords

co-surgeon - autologous breast reconstruction - microsurgery - surgical outcomes

Supplementary Material



Publication History

Received: 28 August 2023

Accepted: 21 January 2024

Accepted Manuscript online:
24 January 2024

Article published online:
21 February 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Zhong T, Hu J, Bagher S. et al. A comparison of psychological response, body image, sexuality, and quality of life between immediate and delayed autologous tissue breast reconstruction: a prospective long-term outcome study. Plast Reconstr Surg 2016; 138 (04) 772-780
    CrossrefPubMedGoogle Scholar
  • 2 Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg 2018; 153 (10) 891-899
    CrossrefPubMedGoogle Scholar
  • 3 Hu ES, Pusic AL, Waljee JF. et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg 2009; 124 (01) 1-8
    CrossrefPubMedGoogle Scholar
  • 4 Nelson JA, Allen Jr RJ, Polanco T. et al. Long-term patient-reported outcomes following postmastectomy breast reconstruction: an 8-year examination of 3268 patients. Ann Surg 2019; 270 (03) 473-483
    CrossrefPubMedGoogle Scholar
  • 5 Yueh JH, Slavin SA, Adesiyun T. et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010; 125 (06) 1585-1595
    CrossrefPubMedGoogle Scholar
  • 6 Toyserkani NM, Jørgensen MG, Tabatabaeifar S, Damsgaard T, Sørensen JA. Autologous versus implant-based breast reconstruction: a systematic review and meta-analysis of Breast-Q patient-reported outcomes. J Plast Reconstr Aesthet Surg 2020; 73 (02) 278-285
    CrossrefPubMedGoogle Scholar
  • 7 Pirro O, Mestak O, Vindigni V. et al. Comparison of patient-reported outcomes after implant versus autologous tissue breast reconstruction using the BREAST-Q. Plast Reconstr Surg Glob Open 2017; 5 (01) e1217
    CrossrefPubMedGoogle Scholar
  • 8 Char S, Bloom JA, Erlichman Z, Jonczyk MM, Chatterjee A. A comprehensive literature review of patient-reported outcome measures (PROMs) among common breast reconstruction options: what types of breast reconstruction score well?. Breast J 2021; 27 (04) 322-329
    CrossrefPubMedGoogle Scholar
  • 9 Lemaine V, Schilz SR, Van Houten HK, Zhu L, Habermann EB, Boughey JC. Autologous breast reconstruction versus implant-based reconstruction: how do long-term costs and health care use compare?. Plast Reconstr Surg 2020; 145 (02) 303-311
    CrossrefPubMedGoogle Scholar
  • 10 Albornoz CR, Bach PB, Mehrara BJ. et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131 (01) 15-23
    CrossrefPubMedGoogle Scholar
  • 11 Kulkarni AR, Sears ED, Atisha DM, Alderman AK. Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons. Plast Reconstr Surg 2013; 132 (03) 534-541
    CrossrefPubMedGoogle Scholar
  • 12 Gurtner GC, Robertson CS, Chung SCS, Li AKC. Two-team synchronous oesophagectomy. Br J Surg 1994; 81 (11) 1620-1622
    CrossrefPubMedGoogle Scholar
  • 13 Skinner A, Maoate K, Beasley S. Retroperitoneal laparoscopic nephrectomy: the effect of the learning curve, and concentrating expertise, on operating times. J Laparoendosc Adv Surg Tech 2010; 20 (04) 383-385
    CrossrefPubMedGoogle Scholar
  • 14 Palavecino M, Kishi Y, Chun YS. et al. Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1,557 consecutive liver resections. Surgery 2010; 147 (01) 40-48
    CrossrefPubMedGoogle Scholar
  • 15 Hayes JW, Feeley I, Davey M, Borain K, Green C. Comparison of a dual-surgeon versus single-surgeon approach for scoliosis surgery: a systematic review and meta-analysis. Eur Spine J 2021; 30 (03) 740-748
    CrossrefPubMedGoogle Scholar
  • 16 Scheer JK, Sethi RK, Hey LA. et al; and the SRS Adult Spinal Deformity Committee. Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery. Spine 2017; 42 (12) 932-942
    CrossrefPubMedGoogle Scholar
  • 17 Macdonald J, Thomson S, Eames N, McLorinan G, Verzin E, Darwish N. Two consultant spinal operating: operator perceived benefits. Ulster Med J 2017; 86 (01) 48-49
    PubMedGoogle Scholar
  • 18 Asaad M, Xu Y, Chu CK, Shih YT, Mericli AF. The impact of co-surgeons on complication rates and healthcare cost in patients undergoing microsurgical breast reconstruction: analysis of 8680 patients. Breast Cancer Res Treat 2020; 184 (02) 345-356
    CrossrefPubMedGoogle Scholar
  • 19 Bauermeister AJ, Zuriarrain A, Newman M, Earle SA, Medina III MA. Impact of continuous two-team approach in autologous breast reconstruction. J Reconstr Microsurg 2017; 33 (04) 298-304
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Gösseringer N, Mani M, Cali-Cassi L, Papadopoulou A, Rodriguez-Lorenzo A. Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: experience in a Swedish medical center. Microsurgery 2017; 37 (05) 416-420
    CrossrefPubMedGoogle Scholar
  • 21 Haddock NT, Kayfan S, Pezeshk RA, Teotia SS. Co-surgeons in breast reconstructive microsurgery: What do they bring to the table?. Microsurgery 2018; 38 (01) 14-20
    CrossrefPubMedGoogle Scholar
  • 22 Mericli AF, Chu CK, Sisk GC. et al. Microvascular breast reconstruction in the era of value-based care: use of a cosurgeon is associated with reduced costs, improved outcomes, and added value. Plast Reconstr Surg 2022; 149 (02) 338-348
    CrossrefPubMedGoogle Scholar
  • 23 Razdan SN, Panchal HJ, Hespe GE. et al. The impact of the cosurgeon model on bilateral autologous breast reconstruction. J Reconstr Microsurg 2017; 33 (09) 624-62
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Weichman KE, Lam G, Wilson SC. et al. The impact of two operating surgeons on microsurgical breast reconstruction. Plast Reconstr Surg 2017; 139 (02) 277-284
    CrossrefPubMedGoogle Scholar
  • 25 Canizares O, Mayo J, Soto E, Allen RJ, Sadeghi A. Optimizing efficiency in deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2015; 75 (02) 186-192
    CrossrefPubMedGoogle Scholar
  • 26 Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014; 14 (01) 135
    CrossrefPubMedGoogle Scholar
  • 27 Walter SD, Yao X. Effect sizes can be calculated for studies reporting ranges for outcome variables in systematic reviews. J Clin Epidemiol 2007; 60 (08) 849-852
    CrossrefPubMedGoogle Scholar
  • 28 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Routledge, New York: Taylor & Francis Group; 1988
    Google Scholar
  • 29 Clemens MW, DeCoster RC, Fairchild B, Bessonov AA, Santanelli di Pompeo F. Finding consensus after two decades of breast implant-associated anaplastic large cell lymphoma. Semin Plast Surg 2019; 33 (04) 270-278
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Coroneos CJ, Selber JC, Offodile II AC, Butler CE, Clemens MWUS. US FDA breast implant postapproval studies: long-term outcomes in 99,993 patients. Ann Surg 2019; 269 (01) 30-36
    CrossrefPubMedGoogle Scholar
  • 31 Haddock NT, Teotia SS. Efficient DIEP flap: bilateral breast reconstruction in less than four hours. Plast Reconstr Surg Glob Open 2021; 9 (09) e3801
    CrossrefPubMedGoogle Scholar
  • 32 Hardy KL, Davis KE, Constantine RS. et al. The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases. Aesthet Surg J 2014; 34 (04) 614-622
    CrossrefPubMedGoogle Scholar
  • 33 Kotha VS, Abadeer AI, Amdur RL, Song DH, Fan KL. A critical examination of length of stay in autologous breast reconstruction: a national surgical quality improvement program analysis. Plast Reconstr Surg 2021; 147 (01) 24-33
    CrossrefPubMedGoogle Scholar
  • 34 O'Neill AC, Mughal M, Saggaf MM, Wisniewski A, Zhong T, Hofer SOP. A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications. J Plast Reconstr Aesthet Surg 2020; 73 (01) 19-26
    CrossrefPubMedGoogle Scholar
  • 35 Offodile II AC, Gu C, Boukovalas S. et al. Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2019; 173 (01) 65-77
    CrossrefPubMedGoogle Scholar
  • 36 Frey JD, Salibian AA, Karp NS, Choi M. Examining length of hospital stay after microsurgical breast reconstruction: evaluation in a case-control study. Plast Reconstr Surg Glob Open 2017; 5 (12) e1588
    CrossrefPubMedGoogle Scholar
  • 37 Oh C, Moriarty J, Borah BJ. et al. Cost analysis of enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2018; 71 (06) 819-826
    CrossrefPubMedGoogle Scholar
  • 38 Kaoutzanis C, Ganesh Kumar N, O'Neill D. et al. Enhanced recovery pathway in microvascular autologous tissue-based breast reconstruction: Should it become the standard of care?. Plast Reconstr Surg 2018; 141 (04) 841-851
    CrossrefPubMedGoogle Scholar
  • 39 Mericli AF, McHugh T, Kruse B, DeSnyder SM, Rebello E, Offodile II AC. Time-driven activity-based costing to model cost utility of enhanced recovery after surgery pathways in microvascular breast reconstruction. J Am Coll Surg 2020; 230 (05) 784-794.e3
    CrossrefPubMedGoogle Scholar
  • 40 DelMauro MA, Chen K, Keller A. Reducing length of stay after microsurgical breast reconstruction with a standardized postoperative protocol. J Reconstr Microsurg 2019; 35 (08) 557-567
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Torabi SJ, Chouairi F, Dinis J, Alperovich M. Head and neck reconstructive surgery: characterization of the one-team and two-team approaches. J Oral Maxillofac Surg 2020; 78 (02) 295-304
    CrossrefPubMedGoogle Scholar
  • 42 Teotia SS, Dickey RM, Liu Y, Jayaraman AP, Haddock NT. Intraoperative microvascular complications in autologous breast reconstruction: the effects of resident training on microsurgical outcomes. J Reconstr Microsurg 2021; 37 (04) 309-314
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Haddock NT, Teotia SS. Deconstructing the reconstruction: evaluation of process and efficiency in deep inferior epigastric perforator flaps. Plast Reconstr Surg 2020; 145 (04) 717e-724e
    CrossrefPubMedGoogle Scholar