title: Outcomes and Cost Analysis in High-Risk Patients Undergoing Simultaneous Free Flap Breast Reconstruction and Gynecologic Procedures.
abstract: BACKGROUND
  For patients with BRCA mutations, a simultaneous procedure that combines risk-reducing operation of the ovaries with mastectomy and breast reconstruction is an attractive option. The purpose of this study was to assess the outcomes and associated cost of performing simultaneous mastectomy, free flap breast reconstruction (FFR), and gynecologic procedure.
  
  
  METHODS
  A retrospective chart review was performed on patients who underwent bilateral FFR from 2005 to 2012. Four hundred twenty-two patients were identified who underwent bilateral breast reconstruction without a simultaneous gynecologic procedure. Forty-two patients were identified who underwent simultaneous FFR and gynecologic procedure. Clinical outcomes, medical and surgical complications, and hospital costs were analyzed and compared between the 2 groups.
  
  
  RESULTS
  A total of 928 free flaps were performed on 464 patients. Forty-two patients had a simultaneous gynecologic procedure at the time of breast reconstruction. Twenty-three (54.8%) patients within the study group underwent simultaneous bilateral salpingo oophorectomy (BSO), whereas the other 19 (45.2%) underwent both total abdominal hysterectomy and BSO. Eighty-four free flaps were performed in this cohort (n = 48 muscle-sparing transverse rectus abdominis myocutaneous, n = 28 deep inferior epigastric perforator, n = 4 superficial inferior epigastric perforator, n = 4 transverse upper gracilis). Mean operative time was 573 minutes. Mean hospitalization was 5.3 days. Postoperatively, 4 patients experienced an anastomotic thrombosis; 2 patients had an arterial thrombosis and 2 patients had a venous thrombosis. There were 2 flap failures, 2 patients with mastectomy skin flap necrosis, 11 patients who developed breast wound healing complications, and 6 patients who developed abdominal wound healing complications. Surgical and medical complication rates did not differ significantly between those who had simultaneous procedures, and those who did not. There was a statistically significant difference in the average total cost when comparing the group of patients receiving prophylactic mastectomy/FFR/total abdominal hysterectomy and/or BSO versus the patients who did not have combined gynecologic procedures at the time of reconstruction ($22,994.52 vs $21,029.23, P = 0.0004).
  
  
  CONCLUSIONS
  For the high-risk breast cancer patient, a combined mastectomy, free flap reconstruction, and gynecologic procedure represents an attractive and safe option.
authors.affiliation: From the Division of Plastic and Reconstructive Surgery, University of Pennsylvania Health Systems, Philadelphia, PA.
authors.forename: Gabriel A
authors.initials: GA
authors.lastname: Del Corral
authors.forename: Ari M
authors.initials: AM
authors.lastname: Wes
authors.forename: John P
authors.initials: JP
authors.lastname: Fischer
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Serletti
authors.forename: Liza C
authors.initials: LC
authors.lastname: Wu
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000191:economics / Q000517:prevention & control; D005260:Female; D058752:Free Tissue Flaps / Q000191:economics* / Q000637:transplantation; D005833:Genital Neoplasms, Female / Q000191:economics / Q000517:prevention & control; D013509:Gynecologic Surgical Procedures / Q000191:economics*; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006801:Humans; D016462:Mammaplasty / Q000191:economics* / Q000379:methods; D008408:Mastectomy / Q000191:economics*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010414:Pennsylvania; D011183:Postoperative Complications / Q000191:economics; D065286:Prophylactic Surgical Procedures / Q000191:economics*; D012189:Retrospective Studies