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Background: Surgical site infections (SSIs) are a continued metric for hospital quality, as these complications are responsible for prolonged hospitalizations and higher costs to the health system. As reimbursement is increasingly linked to perioperative outcomes, an examination of risk factors for SSIs in autologous breast reconstruction utilizing a generalizable, national database can lead to a more directed focus on at risk patients. The purpose of this study was to determine the incidence of SSIs following reconstruction with free transverse rectus abdominus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps and determine which risk factors are predictive of their occurrence
Methods: Utilizing the 2005-2012 American College of Surgeons - National Surgical Quality Improvement Program dataset (ACS-NSQIP), all patients undergoing autologous breast reconstruction with free tissue transfer from the abdomen were identified utilizing 2010 CPT codes and examined for the incidence of 30 day surgical site infections. Surgical site infections included both superficial and deep infections as defined by the NSQIP. Patients who developed SSIs were compared to those who did not in terms of preoperative and intraoperative characteristics. A multivariate logistic regression was performed to identify factors independently associated with increased odds of SSI.
Results: The 2005-2012 ACS-NSQIP dataset included 2899 patients who underwent breast reconstruction. Of these, 143 (4.9%) patients developed wound complications. Those who developed wound complications were more likely to be smokers (18.2% vs. 8.4%, p<0.001) and diabetic (9.8% vs. 3.4%, p< 0.001) with cardiac (54.5% vs. 36.7%, p<0.001) and pulmonary (4.5% vs. 1.3%, p = 0.01) histories. SSI also tended to occur in patients at higher ASA (p = 0.003) and WHO obesity (p<0.001) classes. On multivariate regression analysis, surgical site infections were significantly associated with smoking (OR = 3.37, p<0.001) and cardiac history (OR = 1.84, p = 0.03).
Conclusions: Using the large, heterogeneous patient population included in the ACS-NSQIP dataset, this study identifies risk factors for surgical site infections after autologous breast reconstruction. Patients with a cardiac history and who are active smokers should be identified and counseled preoperatively regarding their increased risk. Tailoring preoperative counseling and postoperative management for these high-risk patients may help providers prevent the psychological burden and expense of superficial skin infections.

Multivariate Regression Analysis

	Odds Ratio	Standard Error	P value	95% Confidence Interval	95% Confidence Interval
Pulmonary History	0.36	0.46	0.42	0.03	4.51
Cardiac History	1.84	0.53	0.03	1.05	3.25
Diabetes	2.27	1.16	0.11	0.83	6.16
BMI 30-34.9	1.25	0.56	0.62	0.52	3.00
BMI 35-39.9	1.59	0.87	0.40	0.54	4.62
BMI >40	0.85	0.27	0.59	0.46	1.56
Smoking	3.37	1.10	<0.001	1.78	6.37