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Umbilical Necrosis Rates After Abdominal Based Microsurgical Breast Reconstruction
Joseph A. Ricci, MD, Adam M. Tobias, MD, Samuel J. Lin, MD, MBA, Bernard T. Lee, MD, MBA, MPH.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

BACKGROUND: Microsurgical breast reconstruction with abdominal based flaps is increasingly popular among microsurgeons. While the complications of these procedures most commonly discussed include flap thrombosis and venous congestion, umbilical stalk necrosis represents a rarer, yet equally important complication after abdominal based microsurgical breast reconstruction, which is both under-recognized and under-studied in the literature. Once found to have occurred, reconstruction of the umbilicus can be an extremely challenging problem. Previously unreported in the literature, this study aims to categorize this problem and identify associated risk factors, in an effort to prevent its occurrence.
METHODS: All consecutive microsurgical free flaps for breast reconstruction at a single institution from February 2004 to February 2016 were reviewed. Non-abdominal based flaps, such as the Superior Gluteal Artery Perforator Flap (SGAP) were excluded. Patients were then divided in to cohorts depending on the development of umbilical necrosis postoperatively. Demographics, surgical characteristics and other complications were compared between the groups.
RESULTS: A total of 1335 flaps were identified to meet the inclusion criteria, with 1286 flaps performed in patients who did not develop umbilical necrosis (96.3%) and 49 instances of umbilical necrosis identified (3.5%). Overall, patients who developed umbilical necrosis tended to be older (49.4 yrs vs. 52.9 yrs; p <0.01), have a higher BMI (31.3 vs. 27.8; p <0.01), have higher rates of baseline hypertension (40.8% vs. 14.1%; p <0.01) and were more likely to be smokers (26.5% vs. 11.4%; p <0.01). Umbilical necrosis was also associated with increased flap weight (829.8 g vs. 656.2 g; p <0.01), decreased time allotted to perforator dissection (150 min vs. 169 min; p =0.02) and increased number of perforators dissected per flap (2.5 vs. 2.2; p =0.03). There was no association with flap type (DIEP, SIEA or free TRAM), history of diabetes, previous abdominal surgery, use of preoperative imaging to identify perforators. While umbilical necrosis was not associated with a majority of complications, like donor hernia or hematoma, it was in fact associated with the presence of a concomitant donor site seroma (14.2% vs. 5.1%, p =0.01). A total of six patients underwent eventual reconstruction of the umbilicus.
CONCLUSIONS: Umbilical stalk necrosis represents a rare, though serious complication for patients following abdominal based microsurgical breast reconstruction and to date, no series in the literature has focused on this complication. Overall, umbilical necrosis was found to occur at a rate of 3.5% and was found to be associated with several preoperative comorbidities. Additionally, it was associated with several intraoperative characteristics, including larger flap harvest, decreased time spent on perforator dissection and increased number of perforators harvested per flap. This information should help influence surgeon’s intraoperative decision making to prevent the development of this undesirable complication.

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