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Risk Analysis for Post-Operative Complications After Immediate Tissue Expander Breast Reconstruction (TE-IBR)
Gabriel Klein, M.D.1, Bret T. Phillips, MD, MBA2, Wilmina Landford, B.S.1, A. Laurie Shroyer, PhD1, Duc Bui, M.D.1, Alex Dagum, M.D.1, Sami Khan, M.D.1.
1Stony Brook University Hospital, Stony Brook, NY, USA, 2Duke University, Division of Plastic, Maxillofacial and Oral Surgery, Durham, NC, USA.
Alloplastic breast reconstruction utilizing tissue expanders is currently the most common method for post-mastectomy breast reconstruction. Premature tissue expander removal, either for infectious or tissue related complications, remains a significant risk of TE-IBR. The purpose of this study was to describe the rates of post-operative complications and to identify patient-specific and breast-specific characteristics associated with the presence of at least one complication.
After IRB approval, we performed a retrospective cohort study of all immediate tissue expander breast reconstructions performed from February 2009-April 2013 at our institution. Patient-specific and breast-specific characteristics were extracted including: demographic data, medical co-morbidities, cancer stage, pre- and post-operative radiation and/or chemotherapy treatment, and presence of post-operative complications. Primary endpoint was premature tissue expander loss. Secondary endpoints included cellulitis/infection, wound dehiscence, seroma formation, and skin necrosis. Univariate logistic regression was used to screen each patient or breast-related variables for multivariable regression modeling with a Generalized Linear Mixed Effect Model (GLMM) fitted using breast-level variables along with a subject-specific random effect used with statistical significance set at p = 0.05.
275 patients were identified who underwent 434 mastectomies followed by TE-IBR during the study period. 89 patients (32.4%) had one or more of the defined endpoint complications: 17.5% cellulitis, 10.9% wound dehiscence, 6.2% seroma, 8.7% skin necrosis, and 18.2% premature tissue expander removal.
Interestingly, complication rates decreased dramatically over time from 39.6% (2010) to 5.0% (2013). Statistically significant associations were identified between key patient-specific and breast-specific factors related to the presence/absence of the complications studied. Specifically, post-operative radiation therapy, sentinel or axillary node dissection, and a history of prior breast surgery were strongly correlated with the risk of suffering at least one defined post-operative complication (p-value 0.02, <0.0001, and 0.0029, respectively). Cellulitis was correlated with sentinel or axillary node dissection, diabetes, obesity, and prior breast surgery (p-value 0.0025, 0.0049, 0.0003, and 0.0001, respectively). Seroma was associated with only a history of prior breast surgery (p-value 0.011). Skin necrosis was linked with axillary/sentinel lymph node biopsy (p-value 0.042). Development of an open wound was correlated with autoimmune disease and axillary/sentinel node dissection (p-value 0.0074 and 0.0054, respectively). Removal of tissue expander was associated with advanced stage tumors, obesity, and hypertension (p-value 0.0051, 0.007, and 0.0025, respectively). Alloplastic breast reconstruction patients who had axillary/sentinel node dissections were more than 9 times more likely to have at least one complication as compared to patients without an axillary/sentinel node dissection (odds ratio = 9.17, 95% CI: 1.99 - 26.03, p<0.0001).
Building upon the well-established literature-based associations between radiation, obesity, diabetes, and chemotherapy with complications after TE-IBR, our study identified that a history of a previous breast surgery and axillary/sentinel node biopsy were additional factors associated with increased rate of post-operative complications. As the exact mechanisms can only be speculated, further research appears warranted to identify how to appropriately risk stratify women considering TE-IBR in order to minimize the occurrence of post-operative complications as well as to improve clinical outcomes.
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