2 Starting a Perforator Flap Breast Program

10.1055/b-0036-141874

2 Starting a Perforator Flap Breast Program

Christina R. Vargas and Bernard T. Lee

Microsurgical options for breast reconstruction have gained popularity over the past 15 years as a result of better patient access to postmastectomy reconstruction, less abdominal morbidity, excellent long-term aesthetic results, and thus high patient satisfaction.1–3 According to the American Society of Plastic Surgeons, deep inferior epigastric perforator (DIEP) flaps were the most commonly performed autologous reconstructive breast procedure in 2012, with over 6,500 cases in that year alone.4 However, recent surveys of plastic and reconstructive surgeons indicate that fewer than one in five currently perform microsurgery as part of their breast reconstructive practice.

Several studies have suggested that disparities in decision making about reconstruction are heavily influenced by the availability of procedures, provider bias, and hospital factors rather than aesthetic, functional, or anatomic aspects of surgery.5,6 Microsurgical reconstructive procedures are inherently more complicated than implantbased or pedicled methods, and they require more specialized training, extended operative time, and longer patient hospitalization. Thus, many breast cancer treatment centers have not yet developed perforator flap programs, and large geographic regions of the United States lack even low-volume institutions.7 Not surprisingly, providers who do perform perforator breast flap reconstruction were more likely to be affiliated with a multidisciplinary cancer center, involved with resident training, and part of a larger group practice.8

The American College of Surgeons established the National Accreditation Program for Breast Centers, which has provided guidelines for comprehensive breast cancer care that emphasize access to plastic surgeons and perforator flap reconstruction.9 Patients who are diagnosed and undergo oncological treatment at nonmicrosurgical centers are forced to travel to referral centers if they wish to seek perforator reconstruction, resulting in fragmentation of their overall cancer care.10,11

The development of a dedicated perforator flap program meets the demands of routinely performing these complicated procedures. Gaining microsurgical experience by performing a large number of procedures is important, because plastic surgeons who perform more microsurgical reconstructions have been shown to encounter fewer obstacles related to the logistic and financial aspects of the procedures as compared with surgeons who performed few or no perforator reconstructions.8 Patient outcomes after reconstruction are known to correlate with institutional autologous and microsurgical operative volume.7 Improvement in outcome measures after the implementation of designated subspecialty programs has also been reported in other surgical and oncological fields.12,13 Establishment of a specialized program for perforator reconstruction can contribute significantly to existing breast cancer care centers and bring new referrals from other local and regional institutions.10 Finally, creating comprehensive breast care programs in underrepresented areas increases patient access to these highly sought-after and highly successful reconstructive options. Key phases in the design and implementation of a perforator flap program include a preliminary assessment, faculty recruitment, program development, and expansion and growth ( Table 2.1 ).

Preprogram Assessment

Creation of a perforator flap program is a multifaceted process, and it requires both departmental and institutional commitment. Evaluation of current breast cancer care and postmastectomy reconstruction services is important in making the decision to proceed with subspecialty program development. Active communication among leaders in the departments of surgery, plastic and reconstructive surgery, breast surgery, and hospital administration is vital for program success. Assessment of current local and regional referral patterns for breast reconstruction should be performed to identify opportunities to offer advanced breast cancer care options and to increase reconstructive volume. Requirements for recognition by the National Accreditation Program for Breast Centers (NAPBC) should be reviewed, and any areas for improvement noted.9 Current infrastructure should be evaluated for its ability to provide excellent, well-coordinated cancer care. Input should be sought from institutional specialists in breast surgery, medical oncology, radiation oncology, pathology, and breast radiology. It is also vitally important that physicians in these other disciplines understand the value of implementing a microsurgical breast surgeon.

**Table 2.1** Key Components of Perforator Flap Program Design and Development
Preprogram assessment	• Evaluation of current systems
	• Institutional support
	• Breast care infrastructure
	• Microsurgery infrastructure
Recruitment	• Surgeon recruitment
	• Adoption of team-based approach
	• Multidisciplinary collaboration
Program development	• Standardization of perforator flap management
	• Intraoperative standardization
	• Learning curve
	• Staff education
	• Negotiation of financial reimbursement
Expansion and growth	• Community and referring provider outreach

	• Addition of staff
	• Fellowship training program
	• Outcomes assessment
	• Quality improvement

As successful microsurgery requires a well-trained multidisciplinary team and education of operating room (OR) staff, anesthesia teams, residents, and recovery room and floor nurses. Clinic staff should be provided and routinely reinforced. Access to appropriate facilities and equipment must be secured, including OR block time, staffed recovery rooms with flap monitoring capabilities, microsurgical instruments, and operating microscopes. Surgeons must confirm that they will be able to allocate sufficient time to performing these long operative cases and to integrate microsurgery effectively into their clinical practice schedules.

Recruitment

Gathering a team of skilled microsurgeons is integral to perforator program success. In anticipation of a teambased approach to complex microsurgery, recruitment of surgeons interested in collaboration is important. Inclusion of multiple surgeons in the program results in shorter operating time with potential for breaks during long perforator flap cases, and provides for rotating, expert postoperative coverage should complications arise. Input from other members of the multidisciplinary breast care team, such as breast surgeons and oncologists, may also be helpful during the recruitment process.

Program Development

Standardization of Perforator Flap Management

Standardization of reconstructive microsurgical care results in efficient use of staffing and resources, provides opportunities for quality improvement, increases patient safety, and decreases costs of care.10 Early in program development, consider designing or adapting perioperative clinical pathways and postoperative order sets for perforator reconstruction. Anticipating the clinical course of microsurgical patients can facilitate identification of specific areas for collaboration with other specialty units and services. The most appropriate level of care for postoperative monitoring and initial recovery may vary by institution, and could include either a prolonged recovery room or a brief intensive care unit stay. Incorporation of anesthesia or pain medicine consultation may be valuable, depending on the surgeon’s preferred method of postoperative analgesia. On a larger scale, collaboration with breast oncology services within the institution enables streamlining the referral process and eliminates unnecessary delays in obtaining reconstructive consultation. Coordination of preanesthesia evaluation may also be considered.

Microsurgery staff may wish to standardize the approach to flap monitoring, as there is considerable variability in these techniques within the field. Other adjunctive measures, such as the use of surgical drains, anticoagulation or antiplatelet therapy, projected postoperative progression, management of complications, and expected time to discharge should be discussed with nursing administration. Coordination of standard instructions and follow-up procedures can help to eliminate confusion on the part of patients, nurses, house staff, and midlevel providers at the time of discharge.

A standard, well-organized approach to the reconstruction process can help patients and staff to anticipate the next steps in care. Surgeons may wish to develop their own methods for preoperative patient education, which can be tailored to each institution’s needs. Consistent support staff education and training also translates directly to better preand postoperative clinical management and flap monitoring, and reduces costs.14 A recent investigation of the use of simulation for nurse training in microsurgery patient care found high levels of staff satisfaction and good retention of knowledge and skills.15 Reinforcement of key components of the pathway with OR staff, recovery room staff, and hospital floor nurses should be conducted at least every few months. Facilitation of ongoing feedback from these team members can help to identify areas for improvement in the perioperative process.

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