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Mastectomy Weight and Tissue Expander Fill Volume Predict Skin Necrosis and Increased Costs Associated with Breast Reconstruction
Georgia C. Yalanis, MSc, BS1, Shayoni Nag, BA1, Jakob R. Georgek, BS2, Carisa M. Cooney, MPH1, Michele A. Manahan, MD1, Gedge D. Rosson, MD1, Justin M. Sacks, MD1.
1The Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Rensselaer Polytechnic Institute, Troy, NY, USA.
Purpose: Impaired vascular perfusion in breast reconstruction following mastectomy and tissue expander (TE) placement can result in skin necrosis, infection, and implant loss. Increased mastectomy weight, TE fill volume, and patient comorbidities may impair mastectomy flap perfusion. We investigated factors associated with mastectomy flap necrosis in TE breast reconstruction as well as the actual cost to patients who experienced adverse sequelae.
Methods: A retrospective review of 169 women who underwent immediate TE placement following mastectomy between May 2009 and May 2013 was performed. Patient demographics, comorbidities, mastectomy weight and type, intraoperative TE fill volumes, and postoperative outcomes were collected. Logistic regression analysis on individual variables and outcomes was performed. For breast-dependent outcomes, standard errors were adjusted for within-patient correlation using clustering for bilateral operations. Billing data was obtained to determine the additional financial burden associated with mastectomy flap necrosis.
Results: 251 immediate TE placements with acellular dermal matrix for 169 women were analyzed. Skin necrosis occurred in 20 mastectomy flaps for 15 patients (8.9%). Patients with hypertension (HTN) had 8 times the odds of developing skin necrosis compared to patients without (OR: 8.10, p<0.001). When adjusted for HTN, patients with intraoperative fill volumes greater than 300cc had 10 times greater odds of developing skin necrosis (OR: 10.13, p=0.012). Fill volumes greater than 400cc resulted in a 14 times greater odds of developing skin necrosis (OR: 14.78, p=0.003). Mastectomy specimens weighing over 500g had a 10 times higher odds of skin necrosis and flaps weighing over 1000g had an 18 times higher odds of skin necrosis (OR: 9.91 and OR: 18.00, respectively; p<0.001). Body Mass Index (BMI) >30 was associated with skin necrosis (p=0.0034). Race, smoking status, and diabetes mellitus showed no association in multivariate regression analysis and should be studied in a larger population. Patients with skin flap necrosis had 15 times higher odds of developing a post-operative infection (OR: 15.12, p<0.001) and almost 16 times higher odds of requiring their TE to be prematurely removed (OR: 15.83, p<0.001). 10/15 patients with skin necrosis required re-admission with intravenous antibiotics, surgical debridement, and removal of the TE (67%). The remaining patients were treated conservatively with oral antibiotics. Patients with flap necrosis were matched to patients in the same sample without mastectomy flap necrosis by race, age, year of surgery, type of mastectomy, BMI, smoking status, and HTN status. Patients with mastectomy flap necrosis requiring surgical debridement suffered an average additional inpatient cost 49% higher than patients who did not require reoperation.
Conclusions: Mastectomy flap necrosis is associated with hypertension, increased intraoperative TE fill volume, and mastectomy weight. Conservative TE fill volumes should be considered for patients with HTN, larger BMI’s, and larger mastectomy specimens. Reoperation due to mastectomy flap necrosis poses a significant financial and emotional burden to the patient. Clinical outcomes can be improved using these parameters as guidelines in staged breast reconstruction.
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