Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients.

BACKGROUND: Recent health care legislation institutes penalties for surgical readmissions secondary to complications. There is a paucity of evidence describing risk factors for readmission after breast reconstruction procedures. METHODS: Patients undergoing breast reconstruction in 2011 were identified in the National Surgical Quality Improvement Program database. Patients were grouped as purely immediate implant/tissue-expander reconstructions or purely autologous reconstruction for analysis. Reconstructions involving multiple types of procedures were excluded due to difficulty with classification. Perioperative variables were analyzed using χ and Student t test as appropriate. Multivariate regression modeling was used to identify risk factors for readmission. RESULTS: Of 5012 patients meeting inclusion criteria, 3960 and 1052 underwent implant/expander and autologous reconstructions, respectively. Implant/expander and autologous cohorts experienced similar readmission rates (4.34% vs 5.32%, respectively; P = 0.18). However, autologous reconstructions experienced a higher rate of overall complications than implant/expander reconstructions (19.96% vs 5.86%, respectively; P < 0.05), as well as higher rates of reoperation (9.7% vs 6.5%, respectively; P < 0.05). Common predictors of readmission for implant/expander and autologous cohorts included operative time, American Society of Anesthesiologist class 3 and 4, and superficial surgical site infection. Smoking, sepsis, deep wound infection, organ space infection, and wound disruption were predictive of readmission for implant/expander reconstruction only, whereas hypertension was predictive of readmission after autologous reconstruction only. CONCLUSIONS: This is the first study of readmission rates after breast reconstruction. Knowledge of specific risk factors for readmission may improve patient outcomes, steer strategies for optimizing reconstructive outcomes, and minimize readmissions.

Anemia is not a predictor of free flap failure: a review of NSQIP data.

BACKGROUND: Thrombosis is a common cause of flap failure in microvascular tissue transfer, which questions the effects of anemia on this outcome. This article seeks to contribute a large, multi-institutional data analysis to this debate. METHODS: Free tissue transfer patients were identified in the National Surgical Quality Improvement database through a specified Current Procedural Terminology algorithm. Bivariate analysis compared anemic and nonanemic groups with respect to flap failure and other outcomes. Multivariable logistic regression was used to determine risk factors for flap failure. RESULTS: Of the 864 patients who met inclusion criteria, 244 were anemic and 620 were not. Bivariate analysis showed no significant difference between groups with respect to flap failure (3.28% vs. 4.03%, P = 0.0603). Multivariate regression analysis supported this (OR 95% CI = 0.371-1.912). CONCLUSIONS: These findings, based on the largest sample in the literature, show anemia is neither a predictor of free tissue transfer failure nor is it protective.

A multi-institutional perspective of complication rates for elective nonreconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010.

BACKGROUND: As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. OBJECTIVE: The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. RESULTS: Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). CONCLUSIONS: Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

Tracking the aesthetic outcomes of prosthetic breast reconstructions that have complications.

BACKGROUND: Aesthetic results following breast reconstruction have been shown to be a major contributor to patient satisfaction. While many presume that complications after reconstruction impact final aesthetic results, little data exist to substantiate this putative relationship. OBJECTIVE: To track and evaluate aesthetic outcomes following implant reconstructions with complications. METHODS: A chart review was conducted on a series of consecutive expander-implant breast reconstructions performed by the senior author between 2004 and 2012. Included patients completed their prosthetic reconstruction or converted to autologous methods and had a minimum follow-up period of 130 days. Four blinded members of the division of plastic surgery independently rated postoperative anterior photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains: breast mound volume, contour, placement, scarring and inframammary fold. RESULTS: Of the 172 patients who met the inclusion criteria, 36 experienced a complication. The tissue expander in one-half of these patients was salvaged and the remaining patients converted to autologous reconstruction. The average aesthetic scores for each domain did not differ significantly between patients who experienced a complication and retained their expander and those who did not experience a complication. Patients who converted to autologous tissue reconstruction after experiencing a complication had the highest aesthetic scores. DISCUSSION: The ability to obtain aesthetic results following a complication that were not statistically different from results in those without complications may reflect the surgeon's refined attempt to salvage the initial implant reconstruction; in other circumstances, the improved cosmesis was achieved through conversion to an autologous tissue-based method. CONCLUSION: The present study quantitatively assessed the impact of complications on aesthetic outcomes following implant breast reconstruction. Continuance of prosthetic reconstruction and conversion to autologous reconstruction serve as viable options to obtain adequate aesthetic scores following a complication. Information gained from the present analysis will help manage patient expectations.

HISTORIQUE: Il est démontré que les résultats esthétiques après une reconstruction mammaire contribuent énormément à la satisfaction des patientes. On présume souvent que les complications observées après une reconstruction nuisent aux résultats esthétiques finaux, mais il existe peu de données pour corroborer ce prétendu lien. OBJECTIF: Suivre et évaluer les résultats esthétiques après des reconstructions par prothèse s'associent à des complications. MÉTHODOLOGIE: Les chercheurs ont examiné les dossiers consécutifs de reconstructions mammaires par prothèses d'expansion effectuées par l'auteur principal entre 2004 et 2012. Les patientes participantes ont subi une reconstruction prothétique complète ou sont passées à une méthode autologue et ont été suivies pendant au moins 130 jours. Quatre membres de la division de chirurgie plastique ont évalué de manière indépendante et en insu les photographies postopératoires antérieures des seins des patientes au moyen d'une échelle d'évaluation validée dans cinq domaines esthétiques : volume du monticule mammaire, contour, emplacement, cicatrices et pli inframammaire. RÉSULTATS: Chez les 172 patientes qui respectaient les critères d'inclusion, 36 ont présenté une complication. La moitié d'entre elles ont pu conserver leur prothèse d'expansion, mais les autres sont passées à une reconstruction autologue. Les résultats esthétiques moyens de chaque domaine ne différaient pas de manière significative entre les patientes qui avaient subi une complication et conservé leur prothèse et celles qui n'avaient pas subi de complication. Les patientes qui sont passées à une reconstruction par tissus autologues après une complication obtenaient les meilleurs résultats esthétiques. EXPOSÉ: Les résultats esthétiques après une complication qui n'étaient pas statistiquement différents de ceux des patientes n'ayant pas vécu de complication reflètent peut-être la tentative perfectionnée du chirurgien de sauvegarder la prothèse initiale. Dans les autres situations, la conversion aux tissus autologues favorisait une meilleure esthétique. CONCLUSION: La présente étude visait à obtenir une évaluation quantitative des effets des complications sur les résultats esthétiques après une reconstruction mammaire par prothèse. Le maintien de la reconstruction par prothèse et la conversion à une reconstruction autologue permettaient d'obtenir des résultats esthétiques satisfaisants après une complication. L'information tirée de la présente analyse contribuera à gérer les attentes des patients.

Differences in breast aesthetic outcomes due to radiation: A validated, quantitative analysis of expander-implant reconstruction.

BACKGROUND: The potential ramifications of radiation use can be of particular concern in the breast reconstruction population, in which both surgical and aesthetic outcomes are important. Presently, there remains a paucity of data detailing the influence of radiation on specific reconstruction aesthetic outcomes. OBJECTIVE: To conduct a quantitative evaluation of aesthetic outcomes for expander-implant breast reconstruction in radiated and nonradiated patients using a validated scoring scale. METHODS: A series of consecutive expander-implant breast reconstruction operations performed by the senior author between 2004 and 2012 were reviewed. Four blinded members of the Division of Plastic and Reconstructive Surgery at Northwestern University (Illinois, USA) independently rated postoperative photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains. RESULTS: Of the 206 patients meeting the inclusion criteria, 69 received radiotherapy and 137 did not. The radiated cohort had lower scores in each aesthetic domain, with significant differences in contour (1.33 versus 1.51; P=0.041) and placement (1.45 versus 1.73; P<0.001). Linear regression analysis revealed a significant association between placement scores and radiation, and radiated patients had a significantly higher overall rate of complications. DISCUSSION: Variances in scores may represent the relative difficulty of expansions and proper implant placement in irradiated tissue, with possible skin fibrosis and decreased flexibility hindering prosthesis manipulation. CONCLUSION: Radiation adversely impacts breast contour and placement, with possible negative contributions to volume, scarring and inframammary fold definition, and results in higher rates of complications. Such detailed evaluation of the impact of radiation on aesthetics will enhance the management of patient expectations.

HISTORIQUE: Les ramifications potentielles du recours aux radiations peuvent être particulièrement inquiétantes dans la population de patientes qui subissent une reconstruction mammaire, pour qui les résultats chirurgi-caux sont tout aussi importants que les résultats esthétiques. Il existe peu de données détaillant l'influence des radiations sur les résultats esthétiques de la reconstruction. OBJECTIFS: Au moyen d'un barème de classement validé, procéder à une évaluation quantitative des résultats esthétiques d'une reconstruction mammaire par expandeur et implant chez des patientes ayant ou non subi des radiations. MÉTHODOLOGIE: Les chercheurs ont analysé une série d'opérations de reconstruction mammaire par expandeur et implant effectuée par l'auteur principal entre 2004 et 2012. Quatre membres en insu de la division de chirurgie plastique et reconstructive de l'université Northwestern, en Illinois, aux Etats-Unis ont classé de manière indépendante les photographies postopératoires des seins des patientes au moyen d'un barème de classement validé dans cinq domaines esthétiques distincts. RÉSULTATS: Sur les 206 patientes qui respectaient les critères d'inclusion, 69 ont subi une radiothérapie, et 137, non. La cohorte sous radiothérapie présentait un indice plus faible dans le domaine esthétique et des différences significatives sur le plan du contour (1,33 par rapport à 1,51; P=0,041) et de l'emplacement (1,45 par rapport à 1,73; P<0,001). L'analyse de régression linéaire a révélé une association significative entre le classement de l'emplacement et la radiation, et les patientes ayant subi une radiation présentaient un taux global de complications considérablement plus élevé. EXPOSÉ: La variation des classements peut témoigner de la difficulté relative des expansions et de la bonne mise en place des implants dans les tissus irradiés, l'éventuelle fibrose cutanée et réduction de la flexibilité nuisant à la manipulation de la prothèse. CONCLUSION: La radiation nuit au contour et à l'emplacement des seins et peut avoir des conséquences négatives sur le volume, la cicatrisation et la définition des plis intramammaires, ce qui peut entraîner un taux plus élevé de complications. Cette évaluation très détaillée des effets des radiations sur l'esthétique permettra de mieux réagir aux attentes des patientes.

Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients?

BACKGROUND: There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes. METHODS: Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL). RESULTS: A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes. CONCLUSIONS: Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.