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BACKGROUND:
Early prosthesis loss is a dreaded complication following breast reconstruction. We assess perioperative risk factors associated with tissue expander (TE) or implant loss following immediate breast reconstruction (IBR) using the ACS-NSQIP datasets from 2005-2011.Methods:
We reviewed the 2005-2011 ACS-NSQIP databases identifying encounters for CPT codes 19357 and 19340. Patients were identified as experiencing a “loss of graft/prosthetic” based on a standard dataset variable. Patients who experienced a device loss were compared to those who did not with respect to perioperative characteristics. Weighted odds ratios derived from multivariable logistic regression analysis were used to create a composite risk score and to stratify patients.
Results:
14,585 patients were identified from the 2005-2011 ACS-NSQIP datasets with an average age of 50.9 ± 10.6 years and body mass index (BMI) (kg/m2) of 26.8 ± 6.3 kg/m2. The majority of reconstructions were tissue expanders (TE) (85.0%) with DTI reconstructions totaling 2,190 patients (N=15.0%). Of the study cohort, 4.6% were diabetic, 13.6% were active smokers, 25.7% were obese (BMI ? 30 kg/m2), and 22.9% had hypertension. Operative time on average for unilateral reconstructions was 182.2 ± 78.2 minutes and 230.4 ± 87.8 minutes for bilateral reconstructions. Acellular dermal matrix (ADM) was used in 18.5% of reconstruction. Implant loss occurred in 129 patients (0.8%). Patients experiencing early prosthesis loss tended to have higher BMI (P<0.0001) and be older (P<0.001), more often be obese (P<0.001), have diabetes (P=0.04), be active smokers (P<0.001), and have hypertension (P=0.001). Patients experiencing loss also more frequently underwent direct-to-implant (DTI) reconstruction (P=0.04) and bilateral reconstruction (P=0.009). Patients with loss also had longer operative times (P=0.0002) and total length of stay (P=0.0001). A multivariate regression analysis determined that advanced age (>55 years) (OR=1.66, P=0.013) (risk score=1), class II obesity (OR=3.17, P<0.001) (risk score=3), class III obesity (OR=2.41, P=0.014) (risk score=3), active smoking (OR=2.95, P<0.001) (risk score=3), bilateral reconstruction (OR=1.67, P=0.007) (risk score=1), and DTI reconstruction (OR=1.69, P=0.024) (risk score=1) were associated with device loss. Odds ratios were used to assign weighted risk scores to each patient, and risk categories were broken into: low risk (0 to 1, N=9,349), intermediate risk (2 to 5, N=5,001), and high risk (?6, N=233). The risk of device loss was significantly higher with increased risk score (0.39% vs. 1.48% vs. 3.86%, P<0.001).
Discussion:
Early prosthetic loss following IBR is a complex multifactorial process related to identifiable preoperative risk factors. The current study demonstrates age, obesity, smoking, and bilateral DTI reconstructions are associated with increased risk of implant loss. These factors can be used to preoperatively risk stratify patients which may assist in risk counseling, patient selection, and perioperative.