Flap Failure and Wound Complications in Autologous Breast Reconstruction: A National Perspective.
OBJECTIVE
There are many options for breast reconstruction following a mastectomy, and data on outcomes are greatly needed for both the patient and the care provider. This study aims to identify the prevalence and predictors of adverse outcomes in autologous breast reconstruction in order to better inform patients and surgeons when choosing a surgical technique.


METHODS
This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified each autologous breast reconstruction performed between 2005 and 2012. Of the 6855 autologous breast reconstructions, there were 2085 latissimus dorsi (LD) flap procedures, 2464 pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedures, and 2306 free flap procedures that met the inclusion criteria. The prevalence of complications in each of the three procedures was calculated and compared using χ(2) analysis for binomial categorical variables. Univariate and multivariate logistic regression analyses identified independent risk factors for adverse outcomes in autologous reconstruction as a whole.


RESULTS
The prevalence of general complications was 10.8% in LD flaps, 20.6% in TRAM flaps, and 26.1% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of wound complications was 4.3% in LD flaps, 8.1% in TRAM flaps, and 6.2% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of flap failure was 1.1 % in LD flaps, 2.7% in TRAM flaps, and 2.4% in free flaps for autologous breast reconstruction (p < 0.001). Multivariate regression analysis showed that obesity [odds ratio (OR) 1.495, p = 0.024], hypertension (OR 1.633, p = 0.008), recent surgery (OR 3.431, p < 0.001), and prolonged operative times (OR 1.944, p < 0.001) were independently associated with flap failure in autologous breast reconstruction procedures. When controlling for confounding variables, TRAM flaps were twice as likely (OR 2.279, p = 0.001) and free flaps were three times as likely (OR 3.172, p < 0.001) to experience flap failure when compared to LD flaps.


CONCLUSIONS
Latissimus dorsi flaps are associated with the fewest short-term general complications and free flaps are associated with the most short-term general complications in autologous breast reconstruction. Free flaps are the most likely to experience flap failure, though there is no significant difference when compared to pedicled TRAM flaps. Free and TRAM flaps remain as the widely acceptable forms of breast reconstruction in the patient without many risk factors for flap failure or wound complications. The identified risk factors will aid in surgical planning and risk adjustment for both the patient and the care provider. Though many other factors will be taken into consideration with surgical planning of autologous breast reconstruction, the presence of these identified risk factors may encourage the use of a surgical technique associated with fewer adverse outcomes, like the LD flap.


METHODS
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA. ben.massenburg@mssm.edu.
Benjamin B
BB
Massenburg
Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA. Paymon.sanati-mehrizy@mssm.edu.
Paymon
P
Sanati-Mehrizy
Division of Plastic and Reconstructive Surgery, Department of Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 E 98th Street, 14th Floor, New York, NY, 10029, USA. Michael.Ingargiola@mountsinai.org.
Michael J
MJ
Ingargiola
Division of Plastic and Reconstructive Surgery, Department of Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 E 98th Street, 14th Floor, New York, NY, 10029, USA. Jonatan.HernandezRosa@mountsinai.org.
Jonatan Hernandez
JH
Rosa
Division of Plastic and Reconstructive Surgery, Department of Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 E 98th Street, 14th Floor, New York, NY, 10029, USA. Peter.taub@mountsinai.org.
Peter J
PJ
Taub
D005260:Female; D058752:Free Tissue Flaps; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects* / Q000379:methods*; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013529:Surgical Wound Dehiscence / Q000209:etiology*; D013530:Surgical Wound Infection / Q000209:etiology*; D017211:Treatment Failure
Breast reconstruction; Flap failure; Free Flap; Latissimus dorsi; NSQIP; Outcomes; TRAM