Operative Time and Flap Failure in Unilateral and Bilateral Free Flap Breast Reconstruction

Abstract

Background There is an increasing trend toward bilateral breast reconstruction. Using the National Surgical Quality Improvement Program (NSQIP) database, we sought to understand the association between unilateral and bilateral free flap breast reconstruction and operative time and flap failure.

Methods We selected a cohort of patients undergoing free flap breast reconstruction using the 2005 to 2010 NSQIP database. Cases were divided into unilateral and bilateral reconstruction. Subgroup analyses were performed dividing cases into delayed and immediate reconstruction. The effect of patient characteristics including age, body mass index (BMI), history of diabetes, and the American Society of Anesthesiologists' classification on operative time and flap failure was examined using univariable and multivariable regression models. Rates and odds ratios (OR) were reported using the multivariable gamma and logistic regression models, respectively.

Results There were 691 free flap breast reconstructions performed in the cohort and 29.1% were bilateral cases. There was a 78-minute increase in the median operative time when comparing unilateral and bilateral reconstruction (p = 0.005). Patients undergoing bilateral reconstructions were generally younger and had fewer comorbidities compared with unilateral reconstructions. There was no significant association between bilateral reconstruction and flap failure. Immediate bilateral reconstructions had a significant increase in median operative time compared with immediate unilateral reconstructions (563 versus 480 minutes, p = 0.002) but no significant increase in operative time was noted when comparing delayed unilateral and delayed bilateral reconstructions. Prolonged operative time was associated with flap failure after adjusting for age and BMI (OR 1.17, p < 0.001).

Conclusions Bilateral free flap breast reconstruction can be performed safely despite an increase in operative time when compared with unilateral reconstruction.

Keywords

breast reconstruction - free flap failure - operative time

Note

Presented at the Mountain West Society of Plastic Surgeons Annual Meeting in Park City, UT, March 2017

Disclosure

The ACS NSQIP and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

• References

• 1 National Cancer Institute. Breast Cancer Risk in American Women. http://www.cancer.gov/types/breast/risk-fact-sheet . Accessed July 15, 2016
• 2 Mamtani A, Morrow M. Why are there so many mastectomies in the United States?. Annu Rev Med 2017; 68: 229-241
• 3 Chang EI, Chang EI, Soto-Miranda MA. , et al. Evolution of bilateral free flap breast reconstruction over 10 years: optimizing outcomes and comparison to unilateral reconstruction. . Plast Reconstr Surg 2015; 135 (06) 946e-953e
• 4 Wormald JC, Wade RG, Figus A. The increased risk of adverse outcomes in bilateral deep inferior epigastric artery perforator flap breast reconstruction compared to unilateral reconstruction: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2014; 67 (02) 143-156
• 5 Lin IC, Nelson JA, Wu LC, Kovach 3rd SJ, Serletti JM. Assessing surgical and medical complications in bilateral abdomen based free flap breast reconstructions compared with unilateral free flap breast reconstructions. Ann Plast Surg 2016; 77 (01) 61-66
• 6 Peersman G, Laskin R, Davis J, Peterson MG, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2006; 2 (01) 70-72
• 7 Kessler S, Kinkel S, Käfer W, Puhl W, Schochat T. Influence of operation duration on perioperative morbidity in revision total hip arthroplasty. Acta Orthop Belg 2003; 69 (04) 328-333.
• 8 Chamberlain RS, Patil S, Minja EJ, Kordears IV K. Does residents' involvement in mastectomy cases increase operative cost? If so, who should bear the cost?. J Surg Res 2012; 178 (01) 18-27
• 9 Kwok AC, Agarwal JP. Unplanned reoperations after microvascular free tissue transfer: An analysis of 2,244 patients using the American College of Surgeons National Surgical Quality Improvement Program database. Microsurgery 2017; 37 (03) 184-189
• 10 Las DE, de Jong T, Zuidam JM, Verweij NM, Hovius SE, Mureau MA. Identification of independent risk factors for flap failure: a retrospective analysis of 1530 free flaps for breast, head and neck and extremity reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (07) 894-906
• 11 Offodile II AC, Aherrera A, Wenger J, Rajab TK, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2017; 37 (01) 12-20
• 12 Seidenstuecker K, van Waes C. Munder Bl, et al. DIEP flap for safe definitive autologous breast reconstruction. Breast 2016; 26: 59-66
• 13 Fischer JP, Fox JP, Nelson JA, Kovach SJ, Serletti JM. A longitudinal assessment of outcomes and healthcare resource utilization after immediate breast reconstruction-comparing implant- and autologous-based breast reconstruction. Ann Surg 2015; 262 (04) 692-699
• 14 Fischer JP, Sieber B, Nelson JA. , et al. Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps. Plast Reconstr Surg 2013; 131 (02) 195-203
• 15 Gart MS, Smetona JT, Hanwright PJ. , et al. Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2013; 216 (02) 229-238
• 16 Serletti JM, Higgins JP, Moran S, Orlando GS. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg 2000; 106 (01) 66-70
• 17 Khuri SF, Henderson WG, Daley J. , et al; Principal Investigators of the Patient Safety in Surgery Study. Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg 2008; 248 (02) 329-336
• 18 ACS NSQIP. About ACS NSQIP. https://www.facs.org/quality-programs/acs-nsqip/about . Accessed October 25, 2016
• 19 ACS NSQIP. Data collection, analysis, and reporting. https://www.facs.org/quality-programs/acs-nsqip/program-specifics/data . Accessed October 25, 2016
• 20 ACS NSQIP. User guide for the 2014 ACS NSQIP Participant Use Data File. https://www.facs.org/~/media/files/quality%20programs/nsqip/nsqip_puf_userguide_2014.ashx . Accessed October 25, 2016
• 21 ACS NSQIP. ACS NSQIP Participant Use Data File. https://www.facs.org/quality-programs/acs-nsqip/program-specifics/participant-use . Accessed March 23, 2017
• 22 Kwok AC, Pannucci CJ, Agarwal JP. The American College of Surgeons National Surgical Quality Improvement Program flap failure data are inaccurate after 2010. Plast Reconstr Surg 2016; 138 (03) 570e-571e
• 23 Centers for Disease Control and Prevention. Assessing your weight. https://www.cdc.gov/healthyweight/assessing/ . Accessed March 17, 2017.
• 24 Vemula R, Bartow MJ, Freeman M. , et al. Outcomes comparison for microsurgical breast reconstruction in specialty surgery hospitals versus tertiary care facilities. Plast Reconstr Surg Glob Open 2017; 5 (10) e1514
• 25 Yim JH, Lee YH, Kim YC. , et al. Time and speed of vascular pedicle dissection in deep inferior epigastric artery perforator flap elevation. J Reconstr Microsurg 2017; 33 (08) 557-562
• 26 Fitzgerald O'Connor E, Rozen WM, Chowdhry M, Band B, Ramakrishnan W, Griffiths M. Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications. Gland Surg 2016; 5 (02) 96-98
• 27 Gösseringer N, Mani M, Cali-Cassi L, Papadopoulou A, Rodriguez-Lorenzo A. Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: experience in a Swedish medical center. Microsurgery 2017; 37 (05) 416-420
• 28 Bauermeister AJ, Zuriarrain A, Newman M, Earle SA, Medina 3rd MA. Impact of continuous two-team approach in autologous breast reconstruction. J Reconstr Microsurg 2017; 33 (04) 298-304
• 29 Razdan SN, Panchal HJ, Hespe GE. , et al. The impact of the cosurgeon model on bilateral autologous breast reconstruction. J Reconstr Microsurg 2017; 33 (09) 624-629