Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value

 

by Mericli, Alexander F.; Chu, Carrie K.; Sisk, Geoffroy C.; Largo, Rene D.; Schaverien, Mark V.; Liu, Jun; Villa, Mark T.; Garvey, Patrick B. 

 

Plastic and Reconstructive Surgery: February 2022 - Volume 149 - Issue 2 - p 338-348

 

Background: Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs.

Methods: The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors’ institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon’s impact on outcomes and costs.

Results: The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, −107 minutes; p < 0.001) and cost (change in total cost, −$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, −132 minutes; change in total cost, −$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates.

Conclusion: The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

 

Optimal Timing of Expander-to-Implant Exchange after Irradiation in Immediate Two-Stage Breast Reconstruction

 

 

by Kim, Ara; Bae, Juyoung; Bang, Sa-Ik; Pyon, Jai-Kyong 

 

Plastic and Reconstructive Surgery: February 2022 - Volume 149 - Issue 2 - p 185e-194e

 

Background: Time intervals for expander-to-implant exchange from radiation therapy have been reported to reduce device failure. This study investigated the optimal timing of expander-to-implant exchange after irradiation in terms of short- and long-term outcomes.

Methods: This retrospective review enrolled consecutive patients who underwent immediate two-stage breast reconstruction and radiation therapy to tissue expanders from 2010 to 2019. Receiver operating characteristic curves and the Youden index were used to estimate the optimal time from radiation therapy to implant placement in terms of 49-day (early) and 2-year (late) complications. Logistic regression analysis was performed to identify the risk factors for each complication.

Results: Of the 1675 patients, 133 were included. The 49-day and 2-year complication rates were 8.3 percent and 29.7 percent, respectively. Capsular contracture was the most common 2-year complication. The Youden index indicated that implant placement at 131 days after radiation therapy was most effective in reducing the 49-day complications, but that the 2-year complication was less significant, with lower sensitivity and area under the curve. Modified radical mastectomy, expander fill volume at radiation therapy, and size of permanent implant increased the odds of 49-day complications; none of them was associated with the odds of 2-year complications.

Conclusions: To reduce short-term complications, the best time point for permanent implant placement was 131 days after radiation therapy. However, there was no significant time interval for reducing long-term complications. Capsular contracture was an irreversible complication of radiation injury that was not modified by postirradiation variables including the time from irradiation or size of permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

 

Risk of Developing Breast Reconstruction Complications: A Machine-Learning Nomogram for Individualized Risk Estimation with and without Postmastectomy Radiation Therapy

 

by Naoum, George E.; Ho, Alice Y.; Shui, Amy; Salama, Laura; Goldberg, Saveli; Arafat, Waleed; Winograd, Jonathan; Colwell, Amy; Smith, Barbara L.; Taghian, Alphonse G. 

 

Plastic and Reconstructive Surgery: January 2022 - Volume 149 - Issue 1 - p 1e-12e

 

Background: 

The purpose of this study was to create a nomogram using machine learning models predicting risk of breast reconstruction complications with or without postmastectomy radiation therapy.

Methods: 

Between 1997 and 2017, 1617 breast cancer patients undergoing mastectomy and breast reconstruction were analyzed. Those with autologous, tissue expander/implant, and single-stage direct-to-implant reconstruction were included. Postmastectomy radiation therapy was delivered either with three-dimensional conformal photon or proton therapy. Complication endpoints were defined based on surgical reintervention operative notes as infection/necrosis requiring débridement. For implant-based patients, complications were defined as capsular contracture requiring capsulotomy and implant failure. For each complication endpoint, least absolute shrinkage and selection operator–penalized regression was used to select the subset of predictors associated with the smallest prediction error from 10-fold cross-validation. Nomograms were built using the least absolute shrinkage and selection operator–selected predictors, and internal validation using cross-validation was performed.

Results: 

Median follow-up was 6.6 years. Among 1617 patients, 23 percent underwent autologous reconstruction, 39 percent underwent direct-to-implant reconstruction, and 37 percent underwent tissue expander/implant reconstruction. Among 759 patients who received postmastectomy radiation therapy, 8.3 percent received proton-therapy to the chest wall and nodes and 43 percent received chest wall boost. Internal validation for each model showed an area under the receiver operating characteristic curve of 73 percent for infection, 75 percent for capsular contracture, 76 percent for absolute implant failure, and 68 percent for overall implant failure. Periareolar incisions and complete implant muscle coverage were found to be important predictors for infection and capsular contracture, respectively. In a multivariable analysis, we found that protons compared to no postmastectomy radiation therapy significantly increased capsular contracture risk (OR, 15.3; p < 0.001). This was higher than the effect of photons with electron boost versus no postmastectomy radiation therapy (OR, 2.5; p = 0.01).

Conclusion: 

Using machine learning, these nomograms provided prediction of postmastectomy breast reconstruction complications with and without radiation therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE: 

Risk, III.

 

 

 

An Analysis of the Modified Five-Item Frailty Index for Predicting Complications following Free Flap Breast Reconstruction

 

by Magno-Pardon, David A.; Luo, Jessica; Carter, Gentry C.; Agarwal, Jayant P.; Kwok, Alvin C. 

 

Plastic and Reconstructive Surgery: January 2022 - Volume 149 - Issue 1 - p 41-47

 

Background:

The modified five-item frailty index is a validated and effective tool for assessing risk in surgical candidates. The authors sought to compare the predictive ability of the modified five-item frailty index to established risk factors for complications in free flap breast reconstruction.

Methods:

The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for free flap breast reconstructive procedures. Univariate and multivariate regression analysis models were used to assess how modified five-item frailty index and factors commonly used to risk stratify (age, body mass index, American Society of Anesthesiologists classification, and history of smoking) were associated with complications.

Results: Of the total 10,550 cases, 24.1 percent experienced complications. A high modified five-item frailty index score is associated with a higher overall rate of postoperative complications (p < 0.001). This significant trend was demonstrated in both surgical (p < 0.001) and medical (p < 0.001) complications. When controlling for other risk factors commonly used for risk stratification such as age, body mass index, American Society of Anesthesiologists classification, and history of smoking, the modified five-item frailty index was significantly associated with medical (OR, 1.75; 95 percent CI, 1.37 to 2.22; p = 0.001) and any complications (OR, 1.58; 95 percent CI, 1.29 to 1.93; p < 0.001) and had the largest effect size. Assessing for specific complications, the modified five-item frailty index is the strongest independent predictor of reoperation (OR, 1.41; 95 percent CI, 1.08 to 1.81; p = 0.009).

Conclusion: The modified five-item frailty index is a useful predictor of postoperative outcomes in patients undergoing free flap breast reconstruction when compared to other historically considered risk factors for surgical complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

 

Fat Grafting before Delayed Prophylactic Mastectomy and Immediate Implant Reconstruction for Patients at High Risk of Complications

 

by Lesniak, David M.; Sarfati, Isabelle; Meredith, Ineke; Millochau, Jenny; Wang, Kuan-Chi; Nos, Claude; Clough, Krishna B. 

 

Plastic and Reconstructive Surgery: January 2022 - Volume 149 - Issue 1 - p 52-56

 

The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, 

Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: a multi-institutional validation study

 

Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: a multi-institutional validation study

by Seung Yeun Chung, Jee Suk Chang, Kyung Hwan Shin, Jin Ho Kim, Won Park, Haeyoung Kim, Kyubo Kim, Ik Jae Lee, Won Sup Yoon, Jihye Cha, Kyu-Chan Lee, Jin Hee Kim, Jin Hwa Choi, Sung-Ja Ahn, Boram Ha, Sun Young Lee, Dong Soo Lee, Jeongshim Lee, Sei One Shin, Sea-Won Lee, Jinhyun Choi, Mi Young Kim, Yeon Joo Kim, Jung Ho Im, Chang-Ok Suh, Yong Bae Kim 

 

The Breast :  VOLUME  56, P7-13, APRIL 01, 2021 (published online: January 20, 2021)

Purpose

Emerging data suggest that higher radiation doses in post-mastectomy radiotherapy may be associated with an increased risk of reconstruction complications. This study aimed to validate previous findings regarding the impact of radiation dose on complications among women with breast cancer using a multi-center dataset.

Methods

Fifteen institutions participated, and women with breast cancer who received radiotherapy after either autologous or prosthetic breast reconstruction were included. The primary endpoint was major post-radiation therapy complications requiring re-operation for explantation, flap failure, or bleeding control.

Results

In total, 314 patients were included. Radiotherapy was performed using both conventional fractionation and hypofractionation in various schedules. The range of the radiation therapy dose in Equivalent Dose in 2 Gy fractions (EQD2; α/β = 3.5) varied from 43.4 to 71.0 Gy (median dose: 48.6 Gy). Boost radiation therapy was administered to 49 patients. Major post-radiation therapy complications were observed in 24 (7.6%) patients. In multivariate analysis, an increasing EQD2 per Gy (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.26–1.98; p < 0.001), current smoking status (OR: 25.48, 95% CI: 1.56–415.65; p = 0.023), and prosthetic breast reconstruction (OR: 9.28, 95% CI: 1.84–46.70; p = 0.007) were independently associated with an increased risk of major complications.

Conclusion

A dose-response relationship between radiation dose and the risk of complications was validated in this multi-center dataset. In this context, we hypothesize that the use of hypofractionated radiotherapy (40 Gy in 15 fractions) may improve breast reconstruction outcomes. Our multi-center prospective observational study (NCT03523078) is underway to further validate this hypothesis.

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

 

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

 

 

by Avila, Azalia; Bartholomew, Alex J.; Sosin, Michael; Deldar, Romina; Griffith, Kayla F.; Willey, Shawna C.; Song, David H.; Fan, Kenneth L.; Tousimis, Eleni A.

 

Plastic and Reconstructive Surgery:  December 2020 - Volume 146 - Issue 6 - p 715e-720e

 

Background:

Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement.

Methods:

A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes.

Results:

A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange.

Conclusions:

Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. Clinical Question/Level of Evidence: Therapeutic, III.

A Systematic Review and Meta-analysis on the Effect of Neoadjuvant Chemotherapy on Complications Following Immediate Breast Reconstruction

 

A Systematic Review and Meta-analysis on the Effect of Neoadjuvant Chemotherapy on Complications Following Immediate Breast Reconstruction

The Breast: VOLUME  55, P55-62, FEBRUARY 01, 2021

by Jajini Varghese, Shireen S. Gohari, Hirah Rizki, F.R.C.S. ichael Faheem, Benjamin Langridge, Sherko Kümmel, Laura Johnson, Peter Schmid

 

Background

The impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not.

Methods

PubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals.

Results

A total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I2 = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I2 = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30).

Conclusion

Immediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.

Complications of Contralateral Prophylactic Mastectomy: Do They Delay Adjuvant Therapy?

 

Complications of Contralateral Prophylactic Mastectomy: Do They Delay Adjuvant Therapy?

 

by Sharabi, Safa E.; Baumann, Donald P.; Selber, Jesse C.; Killon, Elizabeth; Mericli, Alexander F.; Liu, Jun; Caudle, Abigail S.; Smith, Benjamin D.; Chavez-MacGregor, Mariana; Schaverien, Mark V.

 

Plastic and Reconstructive Surgery: November 2020 - Volume 146 - Issue 5 - p 945-953

 

Background:

There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the index breast cancer may delay adjuvant therapy. The study objective was to examine the effect of simultaneous contralateral prophylactic mastectomy with immediate breast reconstruction on the complication rate and adjuvant therapy timing.

Methods:

A retrospective study was conducted of consecutive patients who underwent contralateral prophylactic mastectomy with immediate breast reconstruction and received adjuvant therapy over a 6-year period. Demographic, treatment, and outcomes data were collected, and relationships between multiple variables and outcomes were evaluated.

Results:

Of 241 patients (482 breasts) included, 186 (372 breasts) underwent simultaneous index breast mastectomy and contralateral prophylactic mastectomy with immediate breast reconstruction followed by adjuvant therapy (immediate group), and 55 (110 breasts) underwent index mastectomy, then adjuvant therapy, followed by delayed contralateral prophylactic mastectomy with immediate breast reconstruction (delayed group). Demographics were similar, although breast cancer stage (p < 0.001), tumor category (p = 0.0072), and nodal category (p < 0.001) were significantly higher in the delayed group. In the immediate group, complications before adjuvant therapy occurred in 31 patients (16.7 percent), and in six patients (3.2 percent) complications occurred only in the contralateral prophylactic mastectomy breast; delay to adjuvant therapy occurred in 11 patients (5.9 percent), in four (2.2 percent) of whom the contralateral prophylactic mastectomy breast was responsible for the delay.

Conclusions: Contralateral prophylactic mastectomy with immediate breast reconstruction can be performed safely at the time of the index mastectomy in carefully selected patients. These findings will engage patients seeking contralateral prophylactic mastectomy in shared decision-making regarding optimal timing with respect to the risks and benefits. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement

Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement

by Willey, Shawna C.; Fan, Kenneth L.; Luvisa, Kyle; Graziano, Francis D.; Lau, Stephanie H. Y.; Black, Cara K.; Song, David H.; Pittman, Troy

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 251e-262e

Background: The authors refine their anatomical patient selection criteria with a novel midclavicular-to–inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach.

Methods: Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained.

Results: One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch–to-nipple distance, was strongly correlated with midclavicular-to–inframammary fold measurement on linear regression (R2 = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to–inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to–inframammary fold measurement was less than 30 cm.

Conclusions: Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to–inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to–inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

By Roy, Mélissa; Sebastiampillai, Stephanie; Zhong, Toni; Hofer, Stefan O. P.; O’Neill, Anne C. 

Plastic and Reconstructive Surgery: July 2019 - Volume 144 - Issue 1 - p 1e-8e

Background: Microvascular breast reconstruction is a complex procedure that can be associated with high complication rates. Although a number of individual predictors of perioperative complications have been identified, few studies have explored interaction between risk factors. Understanding the synergistic effects of multiple risk factors is central to accurate and personalized preoperative risk prediction.

Methods: The authors conducted a retrospective cohort study of patients who underwent microvascular breast reconstruction at their institution between 2009 and 2017. All intraoperative and postoperative complications were recorded. A multivariable logistic regression exploratory model identified independent predictors of complications. Interactions between individual variables were then assessed using the relative excess risk index (RERI) and the synergy index (SI).

Results: Nine hundred twelve patients were included in the study and 26.1 percent experienced at least one perioperative complication. Obesity (OR, 1.54; p = 0.009), immediate reconstruction (OR, 1.49; p = 0.028), and comorbidities (OR, 1.43; p = 0.033) were identified as independent predictors of complications. Obesity and comorbidities had significant synergistic interactions with immediate reconstruction (RERI, 0.86; SI, 2.35; p = 0.0002; and RERI, 0.54; SI, 1.78; p = 0.001), bilateral reconstruction (RERI, 0.12; SI, 1.15; p = 0.002; and RERI, 0.59; SI, 3.16; p = 0.005), and previous radiotherapy (RERI, 0.62; SI, 4.43; p = 0.01; and RERI, 0.11; SI, 1.23; p = 0.040). Patients undergoing immediate breast reconstruction who were both obese and smokers had a 12-fold increase in complication rates (OR, 12.68; 95 percent CI, 1.36 to 118.46; p = 0.026) with a very strong synergistic interaction between variables (RERI, 10.55; SI, 10.33).

Conclusion: Patient- and treatment-related variables interact in a synergistic manner to increase the risk of complications following microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction

Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction

by Cohen, Oriana; Lam, Gretl; Choi, Mihye; Ceradini, Daniel; Karp, Nolan  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 299–305

Background: Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, the authors determine how postoperative complications impact chemotherapy timing, and identify factors associated with greater risk for delays. Methods: Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of postoperative complications and time to chemotherapy. Results: A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86 percent) reconstructions did not experience postoperative complications, and 34 (13.9 percent) did. Patients who experienced postoperative complications had an older mean age (53.6 years versus 48.1 years; p = 0.002) and higher rates of diabetes (23.5 percent versus 3.8 percent; p < 0.001). The complication group had delays in initiation of chemotherapy (56 versus 45 days; p = 0.017). Patients who initiated chemotherapy more than 48.5 days after reconstruction were of older mean age (55.9 years versus 50.7 years; p = 0.074) and had increased rates of diabetes (36.8 percent versus 6.7 percent; p = 0.053) and immediate autologous reconstruction (31.6 percent versus 0 percent; p = 0.027). A predictive model determined that patients with at least one of these three risk factors have a 74 percent chance of experiencing prolonged times to chemotherapy initiation. Conclusions: Risk factors for delayed chemotherapy in the context of postoperative complications are age older than 51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.