Complications Following Plastic Surgery in Solid Organ Transplant Recipients: A Descriptive Cohort Study

Background: In 2012, over 28,000 organ transplants were performed in the United States. Long-term survival of solid organ transplant recipients (SOTRs) has increased dramatically due to advancements in surgical technology and immunosuppressive therapies. As a result, the number of SOTRs seeking plastic and reconstructive surgery is increasing. However, the safety of plastic and reconstructive surgical procedures in SOTRs, a concerning clinical population for postoperative complications due to immunosuppression, is not well characterized.

common indication for surgical management in SOTRs is squamous cell carcinoma, which presents more frequently and at more advanced stage in SOTRs [3].
Few studies investigate outcomes of surgeries performed on SOTRs after transplantation. Case reports describe individual instances of surgery performed on SOTRs [4,5]. Case series assessing safety of plastic surgery in SOTRs, including free flap reconstruction [6], found no definitive contraindication to performing these procedures in carefully selected SOTRs [6,7]. In a 2009 nationwide survey, 25% of responding plastic surgeons reported they performed plastic surgery procedures in SOTRs with an extremely low complication prevalence based on self-report [8]. Despite these previous reports, outcomes data on plastic surgery in SOTRs is still limited. The objective of this study was to examine complication prevalence in plastic surgery procedures by reviewing longitudinal data for all plastic surgery cases in SOTRs performed at Yale-New Haven Hospital in between 2004-2011.

Objectives
Our objective was to estimate the complication prevalence of plastic surgery procedures in SOTRs at Yale-New Haven Hospital.

Methods
We used a descriptive cohort design. We identified participants as all adult SOTRs who underwent plastic and reconstructive surgery at Yale-New Haven Hospital from 2004 to 2011. We longitudinally followed their clinical course through 2014 to identify postoperative complications. Transplant, immunosuppression, and plastic surgery history were extracted and verified by authors RL and EZ via institutional review board-approved retrospective chart review. Follow-up data was available for all participants. Complications were identified by examining provider notes in the electronic medical record and noting any problems reported on provider assessment and whether any interventions were required. Expected complications included pain, bleeding, infection, and poor wound healing. Study bias was reduced by reporting all known cases at our institution over eight years. Possible sources of bias include loss to follow up and surgeon-specific patient selection among SOTRs desiring or requiring plastic and reconstructive surgery.
The number of cases performed at our institution during the study period determined the sample size. Complication frequency was calculated using simple proportions. Association analysis was performed using chi square tests, and surgery history characteristics were compared using two-sided t-tests. Loss to follow up was not observed in this sample due to frequent medical visits required of SOTRs.

Results
65 adult SOTRs who underwent 92 distinct plastic and reconstructive procedures were identified. The sample was 55.4% male, with an average age of 51 years (SD 11 years), and a mean of 8 years (SD 7 years) between transplantation and subsequent plastic surgery procedure (Table 1). There were 45 kidney recipients, 10 kidney and pancreas recipients, 6 liver recipients, 3 heart recipients and 1 pancreas recipient. The 92 procedures represented both elective (35) and non-elective (57) operations representing a wide range of plastic and reconstructive surgery cases ( Table 2).
During the acute perioperative period, patients continued their existing immunosuppressive regimens without alterations. No stress dose steroids were given to any patients and no instances of adrenocortical insufficiency occurred.
During the 140 person-years of follow-up (mean 2 years, SD 2 years), the overall observed complication prevalence was 23.9% (n=22). The majority (n=15) were wound healing complications in the setting of contaminated wounds that improved with further surgical debridement and meticulous wound care. Other complications observed included bleeding (n=2), pain requiring hospital admission (n=2), respiratory difficulty prolonging hospital stay (n=2) and acute renal graft failure resulting in one patient's death (n=1).
Among elective procedures (n=35), the complication prevalence was 6%. Among the cosmetic procedures (n=25), the complication prevalence was 4%, representing one instance of postoperative pain following a panniculectomy.
There was no statistical difference between uncomplicated and complicated cases in terms of age (51 years vs. 53 years, A chi-square test for association was conducted between immunosuppressant medication type (mycophenolate, cyclosporine, sirolimus, tacrolimus, azathioprine, and prednisone) and complication occurrence. There were no statistically significant associations between any particular immunosuppressant medication and complication occurrence.
It was noted that while complications in hand, breast and trunk surgery reflected case prevalence, a higher rate of complications were noted in lower extremity cases and a lower rate of complications were noted in head and neck procedures (Table 3). There was a statistically significant difference on two-sided t-test of procedure time between the complicated and uncomplicated cases. The complicated cases had an average duration of 168 minutes while the uncomplicated cases had an average duration of 70 minutes (p=0.03) (Tables 1 and 2).

Discussion
Complication prevalence for plastic surgery procedures in SOTRs was 23.9%, the majority being wound healing complications. As noted in previous papers, early, aggressive debridement and broad spectrum antibiotics are advocated in these patients to lower the risk of wound healing complications [9]. SOTRs are at higher risk of poor wound healing and infection due to immunosuppression and other comorbid factors, and previous reports displayed complication prevalence of 28-52%, also predominated by wound healing/infection [10].
Complications more frequently occurred in urgent/emergent cases compared to elective cases (35% vs. 6%, respectively). This association may result from various factors including existing contaminated wound and nonoptimal medical condition at time of surgery. Lower extremity cases were also more associated with complications, while head and neck cases were less likely to result in complications, possibly a reflection of blood supply in patients who were often affected by diabetes mellitus and vascular conditions such as hypertension. Additionally, longer procedures were significantly more likely to have complications. Lengthier procedures may represent increased morbidity of the surgical indication, increased surgical difficulty, and increased physiologic stressors on the patient.
SOTRs undergoing cosmetic surgery experienced particularly low complication prevalence, with only one complication (postoperative pain) in 25 patients. This low complication prevalence suggests that cosmetic surgery can safely be performed in SOTRs with other comorbidities. Through direct interaction, these patients expressed great satisfaction with their final outcomes and quality of life improvements. We believe that low complication prevalence shows that careful patient selection in this population can lead to successful outcomes for SOTRs seeking elective and cosmetic surgery.
Transplant recipients have an increased risk of cutaneous malignancy secondary to their lifelong immunosuppressive status [3]. Therefore, their need for plastic and reconstructive surgery is higher than the general population. In our study, 22 patients presented to plastic surgeons because of skin malignancies. Among these patients undergoing relatively simple soft tissue excisions with local flap coverage, there were no complications.
We saw no significant association of wound healing complications with any particular immunosuppressant. A larger sample size is indicated to further investigate the interactions of these complex, long-term medications. Previous work outlined the theoretical impedance of wound healing by immunomodulating medications [6]. However, when patients did not present with existing infection, wound healing complication prevalence was in line with the general population.
There was one death in the series in a 69-year-old kidney transplant patient who underwent a complex ventral hernia repair   Limitations to this study include surgeon-specific patient selection, reliance on medical records for source of data, and inclusion of only procedures performed by plastic surgery faculty at an academic center. Patient selection factors underestimate potential complication prevalence of surgery in SOTRs, since patients recommended to undergo surgery may have relatively few comorbid conditions. Medical records may have inaccurate or incomplete reporting of information. Procedures performed by plastic surgery faculty at an academic tertiary care center may lead to different complication prevalence compared to other practice settings.
The population assessed is representative of SOTRs at an academic tertiary care center. We reported our cohort's transplant history and plastic surgery case mix for comparison to other populations. It is important to note that at our institution, there is a robust interdisciplinary transplant surgery program that oversees the care of all patients with a history of solid organ transplantation. The transplant surgery service works closely with medical teams and surgical subspecialty teams to optimize the care of these patients ( Figure 1).
As the incidence of solid organ transplantation continues to rise, an increasing number of transplant recipients require plastic and reconstructive surgeons [7,11,12]. Some guidelines exist for surgical intervention in SOTRs, though not specifically in the field of plastic surgery [13][14][15]. In addition, many SOTRs on current immunosuppressive regimens go on to lead relatively normal lives and would like to have access to elective plastic surgery procedures. As this demand expands, an assessment of ongoing surgical safety and outcomes in this potentially morbid patient population is warranted.

Conclusion
As solid organ transplantation becomes increasingly common, plastic surgeons will have more interactions with transplant patients in both emergent and elective settings. This study estimates an overall plastic surgery complication prevalence of 23.9% in SOTRs for all indications, with lower complication prevalence in elective and cosmetic cases (6% and 4% respectively). This provides insight on complication risk when assessing the risk-benefit ratio of pursuing plastic surgery procedures in the immunosuppressed SOTR. It also restates the importance of early intervention and adequate debridement to avoid wound complications in cases requiring urgent attention. The STROBE guidelines were followed in the preparation of this manuscript [16,17].