Download PDF
J Reconstr Microsurg 2019; 35(06): 417-424
DOI: 10.1055/s-0038-1677037
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Bleeding After Free Flap-Based Breast Reconstruction: A NSQIP Analysis

Jonah Parker Orr   *
1   Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina
,
Ronnie Labib Shammas   *
1   Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina
,
Analise B. Thomas
1   Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina
,
Tracy Truong
2   Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
,
Eugenia H. Cho
3   Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
,
Maragatha Kuchibhatla
2   Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
,
Scott Thomas Hollenbeck
1   Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina
› Author Affiliations
Further Information

Publication History

02 September 2018

11 November 2018

Publication Date:
07 January 2019 (online)

Also available at
    Permissions and Reprints

Abstract

Background Despite limited oncologic benefit for women without an increased risk for breast cancer, the rates of contralateral prophylactic mastectomy (CPM) have increased. Patients undergoing CPM are more likely to undergo bilateral and immediate breast reconstruction. This study assessed the relationship between the timing and laterality of free flap-based breast reconstruction and the risk of postoperative bleeding complications.

Methods Women undergoing postmastectomy free-flap based breast reconstruction from 2010 to 2015 were identified using the National Surgical Quality Improvement Program (NSQIP) dataset. Patients were categorized according to reconstructive laterality and timing. Modified Poisson regression was used to assess the risk of postoperative bleeding and complications across reconstructive procedures.

Results Of the 4,133 patients undergoing free flap-based breast reconstruction, 12% (n = 494) experienced postoperative bleeding complications. Bilateral immediate reconstruction was associated with the highest incidence of bleeding (16.6%, n = 188), followed by bilateral delayed (12.8%, n = 58), unilateral immediate (10%, n = 142), and unilateral delayed reconstruction (9.4%, n = 106). Among patients undergoing immediate reconstruction, bilateral, rather than unilateral, reconstruction was associated with a significantly elevated risk of bleeding complications (RR [rate ratio]  = 1.58; 95% CI [confidence interval] =1.19, 2.10; p = 0.0002). Furthermore, immediate bilateral reconstruction was associated with a significantly higher rate of return to the operating room (RR =1.39; 95% CI =1.06, 1.82; adjusted p = 0.009) when compared with a unilateral procedure.

Conclusion Patients undergoing immediate bilateral free flap-based breast reconstruction may be at an increased risk for experiencing acute postoperative bleeding complications and a return to the operating room. Patients undergoing CPM and considering immediate reconstruction should be counseled regarding the increased morbidity of a bilateral reconstructive procedure.

Keywords

postoperative complications - bleeding - free flap - plastic surgery - breast reconstruction - contralateral prophylactic mastectomy

Financial Disclosure Statement

None of the authors have any financial disclosure.


* These authors contributed equally to this work.


Supplementary Material

 

  • References

  • 1 Jerome-DʼEmilia B, Kushary D, Suplee PD. Rising rates of contralateral prophylactic mastectomy as a treatment for early-stage breast cancer. Cancer Nurs 2019; 42 (01) 12-19
    CrossrefPubMedGoogle Scholar
  • 2 Lostumbo L, Carbine N, Wallace J, Ezzo J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev 2004; 18 (04) CD002748
    PubMedGoogle Scholar
  • 3 Tuttle TM, Abbott A, Arrington A, Rueth N. The increasing use of prophylactic mastectomy in the prevention of breast cancer. Curr Oncol Rep 2010; 12 (01) 16-21
    CrossrefPubMedGoogle Scholar
  • 4 Albornoz CR, Matros E, Lee CN. , et al. Bilateral mastectomy versus breast-conserving surgery for early-stage breast cancer: the role of breast reconstruction. Plast Reconstr Surg 2015; 135 (06) 1518-1526
    CrossrefPubMedGoogle Scholar
  • 5 Osman F, Saleh F, Jackson TD, Corrigan MA, Cil T. Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database. Ann Surg Oncol 2013; 20 (10) 3212-3217
    CrossrefPubMedGoogle Scholar
  • 6 Hunt KK, Euhus DM, Boughey JC. , et al. Society of surgical oncology breast disease working group statement on prophylactic (risk-reducing) mastectomy. Ann Surg Oncol 2017; 24 (02) 375-397
    CrossrefPubMedGoogle Scholar
  • 7 Pien I, Caccavale S, Cheung MC. , et al. Evolving trends in autologous breast reconstruction: is the deep inferior epigastric artery perforator flap taking over?. Ann Plast Surg 2016; 76 (05) 489-493
    CrossrefPubMedGoogle Scholar
  • 8 Leff DR, Bottle A, Mayer E. , et al. Trends in immediate postmastectomy breast reconstruction in the United Kingdom. Plast Reconstr Surg Glob Open 2015; 3 (09) e507
    CrossrefPubMedGoogle Scholar
  • 9 Panchal H, Matros E. Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg 2017; 140 (5S, Advances in Breast Reconstruction): 7S-13S
    CrossrefPubMedGoogle Scholar
  • 10 Kamali P, Paul MA, Ibrahim AMS. , et al. National and regional differences in 32,248 postmastectomy autologous breast reconstruction using the updated national inpatient survey. Ann Plast Surg 2017; 78 (06) 717-722
    CrossrefPubMedGoogle Scholar
  • 11 Wong SM, Freedman RA, Sagara Y, Aydogan F, Barry WT, Golshan M. Growing use of contralateral prophylactic mastectomy despite no improvement in long-term survival for invasive breast cancer. Ann Surg 2017; 265 (03) 581-589
    CrossrefPubMedGoogle Scholar
  • 12 Albornoz CR, Bach PB, Mehrara BJ. , et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131 (01) 15-23
    PubMedGoogle Scholar
  • 13 Pusic AL, Matros E, Fine N. , et al. Patient-reported outcomes 1 year after immediate breast reconstruction: results of the mastectomy reconstruction outcomes consortium study. J Clin Oncol 2017; 35 (22) 2499-2506
    CrossrefPubMedGoogle Scholar
  • 14 Hu ES, Pusic AL, Waljee JF. , et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship Period. Plast Reconstr Surg 2009; 124 (01) 1-8
    PubMedGoogle Scholar
  • 15 Frasier LL, Holden S, Holden T. , et al. Temporal trends in postmastectomy radiation therapy and breast reconstruction associated with changes in national comprehensive cancer network guidelines. JAMA Oncol 2016; 2 (01) 95-101
    CrossrefPubMedGoogle Scholar
  • 16 Fischer JP, Nelson JA, Sieber B. , et al. Transfusions in autologous breast reconstructions: an analysis of risk factors, complications, and cost. Ann Plast Surg 2014; 72 (05) 566-571
    CrossrefPubMedGoogle Scholar
  • 17 Nwaogu IY, Bommarito K, Olsen MA, Margenthaler JA. Economic impact of bleeding complications after mastectomy. J Surg Res 2015; 199 (01) 77-83
    CrossrefPubMedGoogle Scholar
  • 18 Ferraris VA, Hochstetler M, Martin JT, Mahan A, Saha SP. Blood transfusion and adverse surgical outcomes: the good and the bad. Surgery 2015; 158 (03) 608-617
    CrossrefPubMedGoogle Scholar
  • 19 American College of Surgeons: ACS NSQIP participant use data file. Availableat: https://www.facs.org/quality-programs/acs-nsqip/participant-use . Accessed March 28, 2018
    PubMed
  • 20 Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg 2009; 250 (03) 363-376
    CrossrefPubMedGoogle Scholar
  • 21 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
    CrossrefPubMedGoogle Scholar
  • 22 Kwok AC, Goodwin IA, Ying J, Agarwal JP. National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012. Am J Surg 2015; 210 (03) 512-516
    CrossrefPubMedGoogle Scholar
  • 23 Fischer JP, Nelson JA, Au A, Tuggle III CT, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction--a review of 16,063 cases from the 2005-2010 NSQIP datasets. J Plast Surg Hand Surg 2014; 48 (02) 104-114
    CrossrefPubMedGoogle Scholar
  • 24 Ilonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: a ten-year analysis of trends and immediate postoperative outcomes. Breast 2017; 32: 7-12
    CrossrefPubMedGoogle Scholar
  • 25 Lymperopoulos NS, Sofos S, Constantinides J, Koshy O, Graham K. Blood loss and transfusion rates in DIEP flap breast reconstruction. Introducing a new predictor. J Plast Reconstr Aesthet Surg 2013; 66 (12) 1659-1664
    CrossrefPubMedGoogle Scholar
  • 26 Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: experience with 1195 flaps. Plast Reconstr Surg 2006; 118 (05) 1100-1109 , discussion 1110–1111
    CrossrefPubMedGoogle Scholar
  • 27 Thorarinsson A, Fröjd V, Kölby L. , et al. Blood loss and duration of surgery are independent risk factors for complications after breast reconstruction. J Plast Surg Hand Surg 2017; 51 (05) 352-357
    CrossrefPubMedGoogle Scholar
  • 28 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
    CrossrefPubMedGoogle Scholar
  • 29 Pirro O, Mestak O, Vindigni V. , et al. Comparison of patient-reported outcomes after implant versus autologous tissue breast reconstruction using the BREAST-Q. Plast Reconstr Surg Glob Open 2017; 5 (01) e1217
    CrossrefPubMedGoogle Scholar
  • 30 Eltahir Y, Werners LL, Dreise MM, Zeijlmans van Emmichoven IA, Werker PM, de Bock GH. Which breast is the best? Successful autologous or alloplastic breast reconstruction: patient-reported quality-of-life outcomes. Plast Reconstr Surg 2015; 135 (01) 43-50
    PubMedGoogle Scholar
  • 31 Kuykendall LV, Tugertimur B, Agoris C, Bijan S, Kumar A, Dayicioglu D. Unilateral versus bilateral breast reconstruction: is less really more?. Ann Plast Surg 2017; 78 (6S, Suppl 5): S275-S278
    CrossrefPubMedGoogle Scholar
  • 32 Blondeel N, Vanderstraeten GG, Monstrey SJ. , et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50 (05) 322-330
    CrossrefPubMedGoogle Scholar
  • 33 Butler PD, Wu LC. Abdominal perforator vs. muscle sparing flaps for breast reconstruction. Gland Surg 2015; 4 (03) 212-221
    Google Scholar
  • 34 Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?. Plast Reconstr Surg 2005; 115 (02) 436-444 , discussion 445–446
    CrossrefPubMedGoogle Scholar
  • 35 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 2018 Doi: 10.1055/s-0038-1667046
    PubMedGoogle Scholar
  • 36 Ting J, Rozen WM, Le Roux CM, Ashton MW, Garcia-Tutor E. Predictors of blood transfusion in deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg 2011; 27 (04) 233-238
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Appleton SE, Ngan A, Kent B, Morris SF. Risk factors influencing transfusion rates in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; 127 (05) 1773-1782
    CrossrefPubMedGoogle Scholar
  • 38 Elliott LF, Eskenazi L, Beegle Jr PH, Podres PE, Drazan L. Immediate TRAM flap breast reconstruction: 128 consecutive cases. Plast Reconstr Surg 1993; 92 (02) 217-227
    CrossrefPubMedGoogle Scholar
  • 39 Lennox PA, Clugston PA, Beasley ME, Bostwick III J. Autologous blood transfusion in TRAM breast reconstruction: is it necessary?. Ann Plast Surg 2004; 53 (06) 532-535
    CrossrefPubMedGoogle Scholar
  • 40 Holley DT, Toursarkissian B, Vásconez HC. , et al. The ramifications of immediate reconstruction in the management of breast cancer. Am Surg 1995; 61 (01) 60-65
    PubMedGoogle Scholar
  • 41 Hoskin TL, Hieken TJ, Degnim AC, Jakub JW, Jacobson SR, Boughey JC. Use of immediate breast reconstruction and choice for contralateral prophylactic mastectomy. Surgery 2016; 159 (04) 1199-1209
    CrossrefPubMedGoogle Scholar
  • 42 Zhong T, Hu J, Bagher S. , et al. A comparison of psychological response, body image, sexuality, and quality of life between immediate and delayed autologous tissue breast reconstruction: a prospective long-term outcome study. Plast Reconstr Surg 2016; 138 (04) 772-780
    CrossrefPubMedGoogle Scholar
  • 43 Fernández-Delgado J, López-Pedraza MJ, Blasco JA. , et al. Satisfaction with and psychological impact of immediate and deferred breast reconstruction. Ann Oncol 2008; 19 (08) 1430-1434
    CrossrefPubMedGoogle Scholar
  • 44 Billig J, Jagsi R, Qi J. , et al. Should immediate autologous breast reconstruction be considered in women who require postmastectomy radiation therapy? A prospective analysis of outcomes. Plast Reconstr Surg 2017; 139 (06) 1279-1288
    CrossrefPubMedGoogle Scholar
  • 45 Albornoz CR, Cordeiro PG, Farias-Eisner G. , et al. Diminishing relative contraindications for immediate breast reconstruction. Plast Reconstr Surg 2014; 134 (03) 363e-369e
    CrossrefPubMedGoogle Scholar
  • 46 Gerber B, Marx M, Untch M, Faridi A. Breast reconstruction following cancer treatment. Dtsch Arztebl Int 2015; 112 (35-36): 593-600
    Google Scholar
  • 47 Mirzabeigi MN, Smartt JM, Nelson JA, Fosnot J, Serletti JM, Wu LC. An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy. Ann Plast Surg 2013; 71 (02) 149-155
    CrossrefPubMedGoogle Scholar
  • 48 Bowen ME, Mone MC, Buys SS, Sheng X, Nelson EW. Surgical outcomes for mastectomy patients receiving neoadjuvant chemotherapy: a propensity-matched analysis. Ann Surg 2017; 265 (03) 448-456
    CrossrefPubMedGoogle Scholar
  • 49 Beugels J, Hoekstra LT, Tuinder SM, Heuts EM, van der Hulst RR, Piatkowski AA. Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: a multicentre study. J Plast Reconstr Aesthet Surg 2016; 69 (09) 1291-1298
    CrossrefPubMedGoogle Scholar
  • 50 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
    CrossrefPubMedGoogle Scholar