Propensity-Matched, Longitudinal Outcomes Analysis of Complications and Cost Comparing Abdominal...

Accepted Manuscript

Propensity-Matched, Longitudinal Outcomes Analysis of Complications and CostComparing Abdominal Free Flaps and Implant-Based Breast Reconstruction

John P. Fischer, MD Ari M. Wes, BA Jonas A. Nelson, MD Marten Basta, BA JeffreyI. Rohrbach, MSN Liza C. Wu, MD FACS Joseph M. Serletti, MD FACS Stephen J.Kovach, MD

PII: S1072-7515(14)00306-8

DOI: 10.1016/j.jamcollsurg.2014.02.028

Reference: ACS 7364

To appear in: Journal of the American College of Surgeons

Received Date: 31 October 2013

Revised Date: 14 February 2014

Accepted Date: 17 February 2014

Please cite this article as: Fischer JP, Wes AM, Nelson JA, Basta M, Rohrbach JI, Wu LC, Serletti JM,Kovach SJ, Propensity-Matched, Longitudinal Outcomes Analysis of Complications and Cost ComparingAbdominal Free Flaps and Implant-Based Breast Reconstruction, Journal of the American College ofSurgeons (2014), doi: 10.1016/j.jamcollsurg.2014.02.028.

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http://dx.doi.org/10.1016/j.jamcollsurg.2014.02.028

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ACCEPTED MANUSCRIPTMatched modality outcome study

Propensity-Matched, Longitudinal Outcomes Analysis of Complications and Cost

Comparing Abdominal Free Flaps and Implant-Based Breast Reconstruction

John P Fischer, MD1, Ari M Wes, BA1, Jonas A Nelson, MD1, Marten Basta, BA1, Jeffrey I

Rohrbach, MSN2, Liza C Wu, MD1, FACS, Joseph M Serletti, MD1, FACS, Stephen J Kovach,

MD1

1Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of

Pennsylvania, Philadelphia, PA.

2Division of Finance, Perelman School of Medicine at the Hospital of the University of

Pennsylvania, Philadelphia, PA.

Disclosure: None of the authors listed have any conflicts of interest to report.

Disclosure Information: Nothing to disclose.

Correspondence address: John P. Fischer, MD University of Pennsylvania Division of Plastic Surgery 3400 Spruce Street Philadelphia, PA 19104 [email protected]

Running head: Matched Modality Outcomes Study

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Abstract

Background

Choosing a breast reconstructive modality after mastectomy is an important step in the

reconstructive process. The authors hypothesize that autologous tissue is associated with greater

success rates and cost-efficacy over time, relative to implant reconstructions.

Study Design

A retrospective review of patients undergoing free tissue (FF) transfer and expander

implant (E/I) reconstruction between 2005-2011 was performed. Variables evaluated included:

co-morbidities, surgical timing, complications, overall outcome, unplanned reoperations, and

costs. A propensity-matching technique was used to account for the non-randomized selection of

modality.

Results

A total of 310 propensity-matched patients underwent 499 reconstructions. No

statistically significant differences in preoperative variables were noted between propensity-

matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. E/I

reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs.

1.2%, P<0.001). E/I reconstructions were associated with higher rates of seroma (P=0.009),

lower rates of medical complications (P=0.02), but overall significantly higher rates of

unplanned operations (15.5% vs. 5.8%, P=0.002). The total cost of reconstruction did not differ

significantly between groups ($23,120.49±$6,969.56 vs. $22,739.91±$9,727.79, P=0.060), but

E/I reconstruction was associated with higher total cost for secondary procedures

($10,157.89±$8,741.77 vs. $3,200.71±$4,780.64, P<0.0001) and a higher cost of unplanned

revisions over time (P<0.05).

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Conclusions

Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate

using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost.

Although autologous reconstruction is not ideal for every patient, these findings can be used to

enhance preoperative discussions when choosing a reconstructive modality.

Level of Evidence: prognostic/risk category, level III

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Introduction

Breast reconstruction is known to provide a significant psychosocial and aesthetic benefit

for patients following mastectomy [1-4], yet complications can impact recovery[4],

satisfaction[5], and generate added reconstructive cost[6]. Free tissue (FF) transfer and expander

implant (E/I) reconstruction have established benefits and downsides. To date there is limited

data on the comparative surgical risk profiles, long-term outcomes, and costs associated with

these two common reconstructive modalities [7-12].

Through a deeper understanding of long-term, modality-specific risk, and outcomes, cost-

conscious and efficacious breast reconstruction can be performed. Longitudinal outcomes data

can be employed by reconstructive surgeons to assist patients better navigate the modality

selection process. The authors hypothesis that autologous tissue reconstruction (FF) is associated

with higher success rates and cost-efficacy over time, relative to implant-based breast

reconstructions.

Methods

(i.) Study Design

We performed a retrospective review of our prospectively maintained breast

reconstruction database and identified patients from June 2005 through May 2011 who

underwent either abdominally-based free autologous breast reconstruction (FF) or E/I

reconstruction at the Hospital of the University of Pennsylvania. Breast reconstruction was

performed by three surgeons (JMS, LCW, and SJK).

E/I reconstructions were uniformly performed as two-staged procedures with sub-

muscular coverage of tissue expanders using pectoralis majorand serratus muscle/fascia flaps

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with a secondary staged implant exchange. We compared overall outcomes and cost between the

two modalities over the study period. This study was approved by our institutional review board.

(ii.) Data collection

A detailed review of hospital and office records included the following: preoperative

history and physical, operative reports, anesthesia records, postoperative nursing records,

discharge summaries, and outpatient clinic notes. Additionally, the institutional hospital database

was queried for institutional costs associated with each patient’s reconstructive hospitalization,

subsequent operative course, and unplanned admissions or operations. Revenue generated from

breast reconstruction related to surgeon professional fees was not collected or reported.

Similarly, downstream revenue from cancer care, such as chemotherapy or radiation treatment,

was not included in this analysis.

Specific variables examined included baseline patient characteristics such as age, body

mass index (BMI), hypertension (HTN), chronic obstructive pulmonary disease (COPD),

hyperlipidemia (HL), smoking (active or previous), and coronary artery disease (CAD).

Variables indicating patient demographics, comorbidities, and perioperative risk factors were

selected for analysis. These included baseline health characteristics, past medical and surgical

history, and American Society of Anesthesiologists (ASA) physical status. The World Health

Organization definition of obesity was used to classify patients with a BMI <30 kg/m2 as non-

obese, class I obese (BMI = 30.0-34.9 kg/m2), class II obese (BMI=34.9-39.9 kg/m2), and class

III obese (BMI ≥ 40 kg/m2)[13].

We characterized oncologic factors (mastectomy type, pre- and postoperative

chemotherapy and radiation), reconstructive details (immediate versus delayed, unilateral versus

bilateral, and flap type), and directly comparable complications (hematoma, seroma, delayed

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breast healing, cellulitis, and reconstructive failure). Specific complication rates were expressed

on a per reconstruction basis unless otherwise noted (failure, mastectomy flap necrosis, seroma,

etc.). Overall complications defined throughout the reconstruction process were defined on a per

patient basis. Modality-specific complications related to donor-site morbidity and fat necrosis in

FF and implant-related complications in the E/I cohort were also reported.

Reconstructive failure was defined as total flap loss or tissue expander/implant removal

secondary to either infection or exposure. Capsular contraction requiring revision or implant

exchange was defined as an unplanned surgical revision procedure as opposed to a reconstructive

failure. Delayed wound healing at the abdominal donor site and mastectomy flap were defined as

skin necrosis or wound breakdown necessitating topical care or dressing changes for more than

three weeks. Fat necrosis was defined as a palpable firmness on clinical examination greater than

1 cm in diameter present at follow-up but not related to cancer recurrence. Superficial infection

was defined as incisional cellulitis at either the donor site or breast that occurred within 30 days

of surgery, only involving skin and subcutaneous tissue structures, treated with antibiotics, and

was documented by a physician.

We also evaluated the incidence of nipple areolar reconstruction, overall complications

(major and minor), total hospital days, number of clinic visits, and unplanned surgical revisions.

Major unplanned operative complications included any operative intervention for a postoperative

complication. Specifically, in the FF cohort such complications included postoperative

thrombotic events, flap loss, hematoma, major wound breakdown, or hernia, whereas those for

E/I were implant replacement for infection or exposure, hematoma, seroma, or wound

complications requiring operative interventions. Minor complications included non-operative

complications. Unplanned surgical revisions were separately defined as surgical interventions

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related to postoperative complications following the initial reconstructive period, specifically

after the initial discharge from the primary reconstructive procedure.

(iii.) Cost analysis

Financial data were obtained from the Department of Finance at the Hospital of the

University of Pennsylvania to characterize the hospital, institution-specific cost. These data were

used to derive costs associated with the completion of breast reconstruction using E/I or FF

within our health system. Specifically, we obtained all cost data for each patient in the post-

operative period by characterizing the cost of each episode of care related to reconstruction. Cost

was defined for the complete reconstructive course as “all”, or for events of care and operations

following the initial completion of reconstruction “subsequent” (i.e., everything after the initial

reconstruction). We obtained several cost figures for each patient, including: total hospital cost,

total direct variable cost, and operative room costs. Direct variable cost represents the

institutional cost without overhead or labor, essentially representing the opportunity cost of

doing one more procedure. Operating room costs reflect the cost of operating room utilization,

implants and devices, and the use of other equipment. These cost figures did not include

professional service fees or charges, nor did we attempt to obtain any downstream revenue

created by performing breast reconstruction.

(iv.) Propensity matching

Propensity scores were incorporated into this analysis to reduce the risk of selection bias

due to the non-randomized assignment of modality and retrospective nature of this study [14-16].

A propensity score for modality selection (autologous reconstruction) was calculated by

assessing perioperative factors associated with autologous reconstruction (yes or no) in a

multivariate logistic regression. Specifically, the propensity score represented the probability of

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having an autologous reconstruction based on preoperative patient characteristics. The

propensity score ranged from 0, representing the lowest probability of autologous reconstruction,

to 1, representing the highest probability of autologous reconstruction. Patients were matched

using a caliper of 0.005.

(v.) Statistical analysis

Bivariate analysis was performed using Pearson Chi Square for categorical variables and

Wilcoxon rank-sum test for continuous variables. All tests were two-sided, with statistical

significance set at a probability value of ≤0.05. Analyses were performed using STATA IC 10.0

(StataCorp, College Station, Texas).

Results

A total of 1,083 patients (1,634 reconstructions) were identified; 842 patients underwent

FF reconstruction and 241 patients underwent E/I reconstruction with an average follow-up of

21±16 months and 25±17 months, respectively (P=0.001). The overall rate of successful

reconstruction was 98.3%. A summary of reconstructive modality and number by year is found

in Figure 1. A multivariate regression analysis of preoperative factors associated with FF

reconstruction was performed (Table 1). Independent factors associated with FF reconstruction

were age (P<0.001), BMI (P<0.001), preoperative radiation (P=0.006), Surgeon C (P=0.011),

and laterality (P=0.002). Propensity-matched FF’s (N=155) and E/I’s (N=155) were compared

with respect to preoperative characteristics, operative variables, and postoperative outcomes and

cost. A total of 310 patients who underwent 499 reconstructions were matched through a

propensity analysis. No statistically significant preoperative variables differed between

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propensity-matched FF and E/I (Table 2). Matched patients were of similar age (P=0.454), BMI

(P=0.357), ASA physical status (P=0.693), and smoking status (P=0.301). A higher rate of

postoperative radiation was noted in FF patients (P=0.012). Reconstructions were predominantly

immediate – FF (89.7%) and E/I (90.3%). Operative characteristics were similar between FF and

E/I reconstructions, with a higher rate of simple mastectomies in E/I (P=0.002). The most

commonly used FF was the TRAM (unilateral: 28.4%; bilateral: 34.2%)(Table 3).

Procedure-specific complications are summarized in Table 4. Major surgical

complications in matched patients were significantly higher in E/I reconstructions (20.0% vs.

11.0%, P=0.028), but overall complications were higher in FF reconstructions (63.9% vs. 32.9%,

P<0.001). The incidence of donor-site morbidity in the FF cohort was 25.6%. The rate of

unplanned operative complications of E/I reconstrictions over-time tended to increase at

significantly greater rate compared to FF (Fig. 2). The overall rate of unplanned surgical

interventions was higher for E/I at <6 months (3.9% vs. 5.2%) (P=0.562), <12 months (4.5% vs.

11.0%) (P=0.017), <24 months (4.5% vs.13.5%)(P=0.003), and overall (5.8% vs. 15.5%)

(P=0.006) (Figure 2). E/I reconstruction was associated with a significantly higher rate of

reconstructive failure (5.6% vs. 1.2% P<0.001). Kaplan-Meier curve demonstrated earlier and

less frequent failures with FF and more frequent, but delayed device failures with prosthetic

reconstructions over time (Fig. 3).

E/I reconstructions were associated with lower rates of medical complications (P=0.02),

but higher rates of seroma (P=0.009). Patients receiving FF reconstruction more frequently

received nipple areolar reconstruction (74.2% vs. 54.8%, P<0.001) and did so sooner (9.8±6.8

vs. 13.8±9.2 months, P<0.001) (Table 4). FF patients required longer total hospital length of stay

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(4.5±1.8 vs. 2.1±0.9 days, P<0.0001), but significantly fewer postoperative clinic visits (9.8±4.9

vs. 19.0±8.4, P<0.0001) (Table 5).

Cost differences between propensity-matched E/I and FF patients are summarized in

Table 5. E/I reconstruction was associated with higher total direct variable operative costs (“all”)

($1,332.98±$1,143.04 vs. $3,767.63±$1,838.36, P<0.0001) and total direct variable costs for

reconstruction (“all”) ($2,485.72±$1,288.62 vs. $5,652.97±$2,258.40, P<0.0001). The total cost

(“all”) of reconstruction did not differ significantly between groups ($23,120.49±$6,969.56 vs.

$22,739.91±$9,727.79, P=0.060), but E/I reconstruction was associated with higher total cost for

“subsequent” procedures ($3,200.71±$4,780.64 vs. $10,157.89±$8,741.77, P<0.0001). The

overall cost of unplanned operative revisions was significantly higher after one year for E/I

reconstructions (Fig. 4).

Discussion

Comprehensive outcomes and cost data examining reconstructive modalities is lacking in

the current literature [7, 8, 17-20]. This study is the first longitudinal, propensity-matched, multi-

surgeon outcome and cost analysis of two breast reconstructive modalities (FF and E/I). Our

study focuses on modality performance and hospital-associated cost between two common

reconstructive modalities, and includes more than 1,000 patients who underwent over 1,600

reconstructions with an average follow-up period of 2 years. Propensity-matching techniques

provided a useful statistical tool which mitigated modality selection bias. Data derived from this

analysis can be employed to guide perioperative decision-making, optimize informed consent,

and better counsel patients. Our findings demonstrate time-dependent modality-specific risk and

cost profiles, such that autologous tissue reconstructions are associated with higher rates of 2-

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year reconstructive success and lower rates of cumulative, unplanned surgical reoperation and

cost. These data are relatively early postoperative endpoints, since device-related complications

and implant maintenance will inevitably accrue over time and further contribute to the notable

early cost divergence presented herein[21]. Additionally, prosthetic-based reconstructive

techniques used by the surgeons at our institutional use a sub-muscular only technique rarely, if

ever, using ADM which would otherwise create significantly greater cost[22]. Several findings

merit further discussion.

Our group recently reported the outcomes of a 3-year experience by our senior surgeon

(JMS) which demonstrated higher rates of reconstructive success in FF, but this study did not

include a matched analysis nor did it include as many patients[7]. Recent work by Mioton et al

(2013) attempted to compare perioperative outcomes between autologous reconstruction and

implant reconstruction using a large, national database, National Surgical Quality Improvement

Dataset (NSQIP), and demonstrated higher rates of prosthesis/flap failure in autologous

reconstruction (3.13% vs. 0.85%, P<0.001)[20]. However, there are clear limitations of these

data due to the clustering of autologous reconstructions (pedicled and microsurgical flaps) and

the short-term follow-up (30-day) which creates significant selection bias favoring lower rates of

complications in the implant cohort. Our current analysis directly compares, matched FF and E/I

patients with respect to complications and cost. Important to note is that our current study is only

on average 2 years follow-up and likely does not capture the longer term complications and

associated cost linked to implant reconstruction both related to device complications and needed

implant maintenance over time.

Addressing some of the limitations of using national datasets and our prior study, our

current analysis provides a propensity-matched, homogeneous, generalizable comparison of two

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commonly used modalities—the abdominally-based free flap and the two-staged implant

reconstruction. In performing this analysis, we were able to control for multiple preoperative

variables which may impact reconstructive modality selection. The ultimate result following

propensity-matching was two cohorts of patients which are virtually identical as demonstrated by

the lack of significant differences in preoperative characteristics. Our current analysis allows for

a more accurate comparison of outcomes and overall generalizable outcomes.

The rate of tissue expander loss has been reported to occur at a rate of 0.9-2.7% in the

current literature[9, 23-26], and these figures compare favorably with our overall 5.6% rate of

two-stage implant reconstruction loss at an average of two years. Few studies cite an overall rate

of reconstructive success, such that the outcome variable represents successful breast

reconstruction with the initially planned modality, as in our current study does. Thus, there is a

2-year 94.4% reconstructive success rate with E/I patients and a 98.8% success rate with free

tissue transfer with regards to the initial chosen modality at just less than two years of follow-up.

These findings underscore the reliability of both the two-stage implant based breast

reconstruction and free flap breast reconstruction at a high-volume center, but also show that

autologous tissue is superior over time. Furthermore, unplanned reoperation rates were lower in

FF reconstruction (5.8% vs.16.8%, P=0.002), with the rate of implant revisions comparing

favorably with published results from Spear et al. (2008) at 11.3%[27]. Unplanned reoperations

for this analysis were defined specifically as surgical interventions that occurred after the initial

discharge for primary reconstruction that were performed due to a complication. Additionally,

the authors report an overall operative complication variable (“major surgical complications”)

which is inclusive of all operative complications and demonstrates a higher risk of complications

in E/I reconstructions (11.0% vs 20.0%, P=0.028).. Second stage implant exchanges, nipple

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reconstruction, and planned aesthetic refinements were not considered unplanned reoperations.

Additionally, minor revisions to scars performed in conjunction with planned procedures

(implant exchange or nipple reconstruction) were not included in the analysis of complications.

Procedure-specific complications for FF included, hernia, wound complications, fat necrosis,

partial flap excision, hematoma, and seroma were considered for FF. Wound complications,

hematoma, seroma, device loss, capsular contracture, and device malposition were considered

for E/I. Of note our analysis demonstrated a significant rise in the rate of unplanned surgical

interventions over time for E/I relative to FF, which also mirror the rate of unplanned cost over

time (Fig. 2 and 4). Furthermore, FF reconstructions tended to experience failure early, whereas

device losses for E/I reconstructions tended to occur statistically more frequent and later during

the study period (Fig. 3). These findings underscore the fact the autologous reconstruction,

although associated with a greater upfront operation, surgical risk, and cost, tends to perform

better over time and is likely more cost-efficient.

The down side of FF reconstruction can be appreciated by the significantly higher overall

complication profile in the matched cohort (63.9% vs. 32.9%, P<0.001). The higher rate of

surgical complications likely relates to wound complications and donors-site complications

which occurred in 25.4% of the FF matched cohort [28, 29]. These data provide important

information for counseling patients regarding expected risk of minor wound complications and

donor-site complications including a risk of hernia/bulge in upwards of 4% of our cohort[30].

The importance of meticulous donor-site closure and management has been established in the

literature, and remains an important consideration in preoperative risk counseling, particularly in

the obese patient [29-34].

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Autologous tissue reconstruction, and specifically free tissue transfer, represents a larger

upfront operation with a greater risk of complications related to donor-site morbidity, early

microsurgical complication, and medical complications[6]. Previous work from our institution

has shown a higher rate of perioperative medical morbidity related to autologous reconstruction

and this larger, matched analysis confirms these findings[7]; FF patients experienced higher rates

of postoperative medical complications (5.8% vs. 0.6%, P=0.02). These data are useful in

preoperative risk discussions, informed consent, expectation management, and in planning and

discussing the anticipated time course and reconstruction-specific risk profiles of these two

modalities.

Our analysis also assessed reconstructive course and follow-up between the two

modalities and revealed that patients undergoing E/I reconstructions required longer follow-up

(P=0.0025) and more postoperative clinic visits (P<0.0001), likely due to longer follow-up

length (P=0.001). These findings are intuitive but the ability to explain preoperatively that an

implant reconstruction will require more visits for a longer period of time can provide useful

information in the informed consent process to assist with modality selection.

This study also incorporates a cost analysis, which revealed that the 2 year reconstructive

cost does not statistically differ between modalities (P=0.06). A more in-depth analysis however,

reveals that E/I reconstruction was associated with higher total direct variable operative costs of

approximately $2,400 per patient (P<0.0001) and a higher total direct variable costs for

reconstruction of approximately $3,400 per patient (P<0.0001). The “subsequent” cost of E/I

reconstruction was associated with higher total cost of approximately $7,000 per patient which

included the staged procedure and all subsequent procedures (P<0.0001).

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Another important consideration is that TRAM is cost efficient and profitable for

hospitals (19) (20). We report that although the total cost for the upfront hospitalization for the

two reconstructive modalities are similar (P=0.06), the direct variable cost, a reliable marker of

efficiency, and opportunity cost demonstrate that FF were less expensive by about $2,400

(P<0.0001). Other studies have shown a greater cost associated with two-stage implant based

reconstructions compared to TRAMs (21), especially over time (22). The current study enabled

an average of just less than two years of follow up. It is likely that many of the implant

reconstructions would eventually require further procedures including implant exchange and

conversion to autologous reconstruction[35]. Such long term procedures were not captured in

this analysis, but should be kept in mind when critically thinking about the results we

demonstrate.

Important differences in the matched cohorts which should be noted since there was a

higher rate of modified radical mastectomy and postoperative radiation in FF patients. These

differences may contribute to higher postoperative complications in FFs, but recent work has

shown that postoperative radiation does not increase the reoperation rate in autologous breast

reconstruction [36].

Despite the large number of patients included in our study, there remain several

limitations. First, we are comparing two different techniques of breast reconstruction with

inherently different patient selection criteria and bias which cannot be controlled despite

matching. We attempted to reconcile this by using a propensity-matching technique to find

patients from both cohorts that exhibited similar preoperative features. We concede that at our

institution we tend to utilize abdominally-based free tissue transfer more than I/E which

inevitably has generated a degree of selection bias. Additionally, our cost data is based on the

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one health system’s cost figures and direct variable cost, which does not include labor or

overhead costs. Several other important factors related to cost are worth noting. First, this

analysis did not attempt to define or compare professional fees related to reconstruction, as this

did not fall within the scope of cost, rather revenue. Similarly no downstream revenue for the

large referall base created by a busy reconstructive center for radiation or chemotherapy was

quantified. Second, our practice does not routinely use ADM which would have further increase

the cost of E/I reconstruction. Furthermore, the outcome variables assessed in this study are all

objective and do not account for the more subjective patient variables such as ultimate

satisfaction with reconstruction. However, we believe the strengths of our study design and

rigorous analysis, alongside with the strong relevance to patient care and perioperative decision-

making, outweigh these limitations.

Conclusion

Autologous reconstruction is an efficacious and cost-effective reconstructive modality

that is associated with favorable 2-year outcomes and cost relative to E/I reconstruction. Overall

the performance of free flaps appears to be stable over time, be associated with lower

reconstructive failures, and fewer unplanned operative interventions compared to E/I.

Acknowledgment: We would like to acknowledge and thank Nancy Folsom, BSN for her

assistance in the organization and preparation of the IRB for this study.

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23. Fischer JP, Nelson JA, Serletti JM, Wu LC. Peri-operative risk factors associated with

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9305 patients from the 2005-2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg

2013;66:1504-1512.

24. Fischer JP, Wes AM, Tuggle CT 3rd, et al. Risk analysis of early implant loss after

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25. Disa JJ, Ad-El DD, Cohen SM, et al. The premature removal of tissue expanders in breast

reconstruction. Plast Reconstr Surg 1999;104:1662-1665.

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26. McCarthy CM, Mehrara BJ, Riedel E, et al. Predicting complications following

expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk.


27. Spear SL, Newman MK, Bedford MS, et al. A retrospective analysis of outcomes using

three common methods for immediate breast reconstruction. Plast Reconstr Surg 2008;122:340-

347.

28. Vyas RM, Dickinson BP, Fastekjian JH, et al. Risk factors for abdominal donor-site

morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008;121:1519-1526.

29. Fischer JP, Nelson JA, Sieber B, et al. Free tissue transfer in the obese patient: an

outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast

Reconstr Surg 2013;131:681e-692e.

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2013;217:656-664.

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morbidity after immediate breast reconstruction. J Am Coll Surg 2013;217:780-787.

33. Ozturk CN, Kundu N, Bernard S, et al. Breast reconstruction with abdominal-based free

flaps in high body mass index population: postoperative complications and impact of weight

loss. Ann Plast Surg 2013 Mar 28.

34. Jandali S, Nelson JA, Sonnad SS, et al. Breast reconstruction with free tissue transfer

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35. Tadiparthi S, Staley H, Collis N, O'Donoghue JM. An analysis of the motivating and risk

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2010;126:12-16.

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Table 1. Multivariate Regression Analysis of Perioperative Factors Associated with Autologous

Reconstruction

Odds Ratio Confidence Interval p Value

Age 1.04 1.02 – 1.06 <0.001

Diabetes 0.84 0.33 – 2.13 0.715

Body mass index 1.21 1.16 – 1.27 <0.001

ASA physical status 0.69 0.44 – 1.06 0.09

Hypertension 0.92 0.56 – 1.53 0.76

Preoperative radiation 2.06 1.23 – 3.47 0.006

Preoperative

chemotherapy 1.39 0.92 – 2.12 0.122

Surgeon B 1.35 0.95 – 1.93 0.099

Surgeon C 0.44 0.24 – 0.83 0.011

Laterality 0.57 0.40 – 0.81 0.002

Reconstructive timing 1.32 0.82 – 2.11 0.254

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Table 2. Bivariate Analysis of Preoperative Difference between Propensity-Matched Free Flaps

and Implant Reconstructions

Abdominal free flap,

n=155

Tissue

expander,

n=155 p Value

Age, y (SD) 48.5 (9.1) 47.9 (11.6) 0.454

Body mass index, kg/m2 (SD) 25.4 (4.2) 25.4 (5.4) 0.357

Chronic obstructive pulmonary

disease, % 1.3 1.3 1

Diabetes, % 5.2 4.5 1

Obesity, % 0.376

Non-obese 83.9 84.5

Class I 12.9 10.3

Class II 2.6 1.9

Class III 0.6 3.2

ASA physical status, % 0.693

1 5.8 7.7

2 78.1 78.1

3 16.1 13.5

4 0.0 0.6

Hypertension, % 18.7 16.1 0.549

Coronary artery disease, % 0.6 2.6 0.371

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Smoking, % 0.301

Never 64.5 60.6

Current 12.3 9.0

Quit 23.2 30.3

Preoperative radiation, % 16.8 16.8 1

Postoperative radiation, % 28.4 16.8 0.012

Preoperative chemotherapy, % 25.2 30.3 0.31

Postoperative chemotherapy, % 40.0 47.7 0.202

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Table 3. Bivariate analysis of preoperative difference between propensity-matched free flaps and

implant reconstructions.

Abdominal free

flap, n=155, %

Tissue expander,

n=155, % p Value

Surgeon 0.959

A 54.8 54.2

B 37.4 38.7

C 7.7 7.1

Laterality 0.727

Unilateral 38.1 40.0

Bilateral 61.9 60.0

Flap timing 0.089

Immediate 89.7 90.3

Delayed 10.3 7.1

Mixed 0.0 2.6

Ipsilateral mastectomy defect 0.002

Simple 58.7 75.5

Modified radical 32.9 15.5

Nipple sparing 1.3 3.2

Unknown 7.1 5.8

Contralateral mastectomy defect 0.063

Simple 57.4 54.8

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Modified radical 0.0 3.2

Nipple sparing 2.6 3.9

Unknown 0.6 0.0

Acellular dermal matrix n/a 3.7 n/a

Flap type, unilateral n/a

TRAM 28.4 n/a

DIEP 9.0 n/a

SIEA 0.6 n/a

Flap type, bilateral n/a

TRAM/TRAM 34.2 n/a

TRAM/DIEP 13.5 n/a

DIEP/DIEP 6.5 n/a

TRAM/SIEA 4.5 n/a

DIEP/SIEA 2.6 n/a

SIEA/SIEA 0.6 n/a

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Table 4. Bivariate analysis of complications between propensity-matched free flaps and implant

reconstructions.

Abdominal free

flap, n=155

Tissue

expander,

n=155 p Value

Flap specific complications n/a

Thrombosis 2.0% n/a

Flap loss 1.2% n/a

Fat necrosis 4.8% n/a

Donor-site cellulitis 5.6% n/a

Delayed donor healing 14.8% n/a

Donor hernia/bulge 3.9% n/a

Donor seroma 1.3% n/a

Any donor site complication 25.6% n/a

Implant specific complications n/a

Implant exposure n/a 3.6

Implant infection n/a 7.3

Implant rupture n/a 3.2

Nipple areolar reconstruction 74.2% 54.8% <0.001

Time to nipple areolar reconstruction,

mo (SD) 9.8 (6.8) 13.8 (9.2) <0.001

Major surgical complication 11.0% 20.0% 0.028

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Any complication 63.9% 32.9% <0.001

Reconstructive failure 1.2% 5.6% 0.01

Breast hematoma 2.8% 2.4% 1

Breast seroma 2.8% 8.1% 0.009

Delayed mastectomy healing 17.5% 12.5% 0.085

Medical complication 5.8% 0.6% 0.02

Unplanned 30-day readmission 6.5% 4.5% 0.454

Unplanned operation 5.8% 16.8% 0.002

No. of unplanned operations 0.04

1 3.9% 8.4%

2 1.3% 5.2%

3 0.6% 2.6%

4 0.0% 0.6%

5 0.0% 0.0%

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Table 5. Bivariate analysis of cost differences between propensity-matched free flaps and

implant reconstructions.

Abdominal free

flap, n=155

Tissue expander,

n=155 p Value

Total hospital stay, d (SD) 4.5 (1.8) 2.1 (0.9) <0.0001

Follow-up, d (SD) 624 (479) 780 (509) 0.0025

No. of postoperative visits

(SD) 9.8 (4.9) 19.0 (8.4) <0.0001

OR direct variable cost, all

(SD)

$1,332.98

($1,143.04)

$3,767.63

($1,838.36) <0.0001

OR direct variable cost,

subsequent (SD)

$217.01

($714.11)

$1,386.47

($1,669.26) <0.0001

Total direct variable cost, all

(SD)

$2,485.72

($1,288.62)

$5,652.97

($2,258.40) <0.0001

Total direct variable cost,

subsequent (SD)

$402.76

($873.87)

$2,651.91

($1,759.51) <0.0001

Total cost, all (SD)

$23,120.49

($6,969.56)

$22,739.91

($9,727.79) 0.0603

Total cost, subsequent (SD)

$3,200.71

($4,780.64)

$10,157.89

($8,741.77) <0.0001

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FIGURE LEGENDS

Figure 1. Number of patients receiving either free tissue transfer reconstruction or expander

implant reconstruction, by year. Data for the calendar year 2011 were not complete and thus not

included. Blue bar, free tissue transfer reconstruction; red bar, expander implant reconstruction;

green bar, total reconstructions.

Figure 2. Total cumulative incidence of unplanned reoperations between modalities. *p<0.05.

Blue bar, autologous; red bar, expander/implant.

Figure 3. Kaplan-Meier curve estimates of flap and device failure over time, days.

Figure 4. Cumulative added cost of unplanned reoperations between modalities. *p<0.05. Red

bar, autologous; blue bar, expander/implant.

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Precis

Our matched outcomes analysis demonstrates a higher overall, 2-year success rate using free

tissue transfer reconstruction and a significantly lower rate of unplanned surgical revisions and

cost. Although autologous reconstruction is not ideal for every patient, these findings can be used

to enhance preoperative discussions when choosing a reconstructive modality.

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