A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010–2020 NSQIP Data

Abstract

Background While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality.

Methods The NSQIP 2010–2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed.

Results A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified.

Conclusion Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

Keywords

breast reconstruction - immediate breast reconstruction - delayed breast reconstruction - delayed immediate breast reconstruction - NSQIP

Authors' Contributions

All the authors appropriately contributed to the development of this manuscript. The conceptualization of the goals/aims of the article was driven by A.C.K., J.P.A., J.L.M., and J.S. The formal acquisition of the data was performed by J.L.M. and J.S. Data analysis was conducted by D.E. J.L.M., J.S., K.K., A.A.P., J.P.A., and A.C.K. were involved in drafting and revising the final version for submission.

Publikationsverlauf

Eingereicht: 01. September 2022

Angenommen: 21. Februar 2023

Accepted Manuscript online:
16. März 2023

Artikel online veröffentlicht:
11. April 2023

• References

• 1 Chen W, Lv X, Xu X, Gao X, Wang B. Meta-analysis for psychological impact of breast reconstruction in patients with breast cancer. Breast Cancer 2018; 25 (04) 464-469
• 2 Heiman AJ, Gabbireddy SR, Kotamarti VS, Ricci JA. A meta-analysis of autologous microsurgical breast reconstruction and timing of adjuvant radiation therapy. J Reconstr Microsurg 2021; 37 (04) 336-345
• 3 Shammas RL, Sergesketter AR, Taskindoust M. et al. An assessment of patient satisfaction and decisional regret in patients undergoing staged free-flap breast reconstruction. Ann Plast Surg 2021; 86 (6S, Suppl 5): S538-S544
• 4 Palve JS, Luukkaala TH, Kääriäinen MT. Predictive risk factors of complications in different breast reconstruction methods. Breast Cancer Res Treat 2020; 182 (02) 345-354
• 5 Masoomi H, Fairchild B, Marques ES. Frequency and predictors of 30-day surgical site complications in autologous breast reconstruction surgery. World J Plast Surg 2019; 8 (02) 200-207
• 6 Chao LF, Patel KM, Chen SC. et al. Monitoring patient-centered outcomes through the progression of breast reconstruction: a multicentered prospective longitudinal evaluation. Breast Cancer Res Treat 2014; 146 (02) 299-308
• 7 Falk Dahl CA, Reinertsen KV, Nesvold IL, Fosså SD, Dahl AA. A study of body image in long-term breast cancer survivors. Cancer 2010; 116 (15) 3549-3557
• 8 Avis NE, Crawford S, Manuel J. Quality of life among younger women with breast cancer. J Clin Oncol 2005; 23 (15) 3322-3330
• 9 Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002; 109 (06) 1919-1924 , discussion 1925–1926
• 10 Carlson GW, Page AL, Peters K, Ashinoff R, Schaefer T, Losken A. Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg 2008; 60 (05) 568-572
• 11 Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 2005; 115 (01) 84-95
• 12 Shammas RL, Cason RW, Sergesketter AR. et al. A comparison of surgical complications in patients undergoing delayed versus staged tissue-expander and free-flap breast reconstruction. Plast Reconstr Surg 2021; 148 (03) 501-509
• 13 Albino FP, Patel KM, Smith JR, Nahabedian MY. Delayed versus delayed-immediate autologous breast reconstruction: a blinded evaluation of aesthetic outcomes. Arch Plast Surg 2014; 41 (03) 264-270
• 14 ACO S. About ACS NSQIP. Accessed August 1, 2022 at: https://www.facs.org/quality-programs/acs-nsqip/about
• 15 Kwok AC, Edwards K, Donato DP. et al. Operative time and flap failure in unilateral and bilateral free flap breast reconstruction. J Reconstr Microsurg 2018; 34 (06) 428-435
• 16 Yoon AP, Qi J, Brown DL. et al. Outcomes of immediate versus delayed breast reconstruction: results of a multicenter prospective study. Breast 2018; 37: 72-79
• 17 Wilkins EG, Hamill JB, Kim HM. et al. Complications in postmastectomy breast reconstruction: one-year outcomes of the Mastectomy Reconstruction Outcomes Consortium (MROC) Study. Ann Surg 2018; 267 (01) 164-170
• 18 Angarita FA, Dossa F, Hermann N, McCready DR, Cil TD. Does timing of alloplastic breast reconstruction in older women impact immediate postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Breast 2019; 48: 58-64
• 19 Sullivan SR, Fletcher DRD, Isom CD, Isik FF. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg 2008; 122 (01) 19-28
• 20 Mak JC, Kwong A. Complications in post-mastectomy immediate breast reconstruction: a ten-year analysis of outcomes. Clin Breast Cancer 2020; 20 (05) 402-407
• 21 Sanati-Mehrizy P, Massenburg BB, Rozehnal JM. et al. A comparison of postoperative outcomes in immediate versus delayed reconstruction after mastectomy. Eplasty 2015; 15: e44
• 22 Allan J, Goltsman D, Moradi P, Ascherman JA. The effect of operative time on complication profile and length of hospital stay in autologous and implant-based breast reconstruction patients: an analysis of the 2007-2012 ACS-NSQIP database. J Plast Reconstr Aesthet Surg 2020; 73 (07) 1292-1298
• 23 Mitchell D, Asaad M, Slovacek C. et al. Outcomes of autologous free flap reconstruction following infected device explantation. J Reconstr Microsurg 2023; 39 (05) 327-333
• 24 Christopher AN, Morris MP, Broach RB, Serletti JM. A comparative analysis of immediate and delayed-immediate breast reconstruction after postmastectomy radiation therapy. J Reconstr Microsurg 2022; 38 (06) 499-505
• 25 Fracol ME, Basta MN, Nelson JA. et al. Bilateral free flap breast reconstruction after unilateral radiation: comparing intraoperative vascular complications and postoperative outcomes in radiated versus nonradiated breasts. Ann Plast Surg 2016; 76 (03) 311-314
• 26 Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 2010; 125 (02) 463-474
• 27 Schechter NR, Strom EA, Perkins GH. et al. Immediate breast reconstruction can impact postmastectomy irradiation. Am J Clin Oncol 2005; 28 (05) 485-494
• 28 Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med 2008; 75 (Suppl. 01) S30-S33
• 29 Dickey RM, Amaya J, Teotia SS, Haddock NT. Influence of triple-negative versus luminal a breast cancer subtype on choice of autologous versus implant-based delayed-immediate breast reconstruction. J Reconstr Microsurg 2023; 39 (04) 264-271
• 30 Pittelkow E, DeBrock W, Christopher L. et al. Advantages of the delayed-immediate microsurgical breast reconstruction: extending the choice. J Reconstr Microsurg 2022; 38 (07) 579-584
• 31 Magno-Padron DA, Collier W, Kim J, Agarwal JP, Kwok AC. A nationwide analysis of early and late readmissions following free tissue transfer for breast reconstruction. J Reconstr Microsurg 2020; 36 (06) 450-457
• 32 Lee KT, Bae J, Jeon BJ, Pyon JK, Mun GH, Bang SI. Adjuvant chemotherapy in two-stage tissue expander/implant breast reconstruction: does it affect final outcomes?. Ann Surg Oncol 2021; 28 (04) 2191-2198
• 33 Holoyda KA, Simpson AM, Ye X, Agarwal JP, Kwok AC. Immediate bilateral breast reconstruction using abdominally based flaps: an analysis of the nationwide inpatient sample database. J Reconstr Microsurg 2019; 35 (08) 594-601
• 34 Kwok AC, Simpson AM, Ye X, Tatro E, Agarwal JP. Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases. J Reconstr Microsurg 2019; 35 (01) 74-82