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Free Tissue Transfer for Breast Reconstruction in the Community and University Settings: Is There a Difference?
Carrie Stransky, MD, Joseph Serletti, MD, Jonas Nelson, MD, John Fisher, MD, Joshua Fosnot, MD, Liza Wu, MD.
University of Pennsylvania, Philadelphia, PA, USA.

Background: Free tissue transfer is a well-known option for successful autologous breast reconstruction. Due to its complex nature, the procedure is often performed in the university setting at a large institution. We aim to compare outcomes of free tissue transfer for breast reconstruction in the community and university settings in order to determine if the latter is necessary for successful performance of this complex procedure.
Methods: All free tissue transfer procedures for breast reconstruction from one university hospital and one community hospital performed between March 2005 and July 2011 were included. All procedures were performed by the same two surgeons at both institutions. Evaluation of demographics as well as outcome measures such as complication rates, operative time, and blood loss were evaluated.
Results: 1293 free tissue breast reconstructions were performed, 99 (7.7%) in the community and 1194 (92.3%) at a university hospital. There was no statistical difference between race, patient comorbidities, breast cancer diagnosis, or type of free tissue reconstruction between the two hospital settings. The average number of hospital days was 5.2 and 5.3 between the community and university (p=.44). Operative time differed by one hour on average with 7.3 hours in the community and 8.3 in the university (p<.0001). Estimated blood loss was statistically higher in the community with an average of 330cc per case versus 248cc in the university (p<.0001). Blood transfusions were also more prevalent in the community setting with 17 (24.6%) patients undergoing transfusion versus 65 (8.3%) in the university (p<.0001). There was a higher rate of abdominal wound infections in the community setting at 7.2% versus 2.6% in the university (p=.03). There was no difference between complication rates including flap loss, skin necrosis, fat necrosis, hematoma, seroma, or delayed wound healing. (Table 1) Flap loss occurred in 2 (2%) of community performed flaps and 22 (1.8%) of university performed flaps. There was no difference between intraoperative or post operative vascular complications including arterial and venous thrombosis. (Table 2) Intraoperative arterial thrombosis occurred in 6 (6.1%) and 36 (3%) of community and university flaps respectively.
Conclusions: When comparing free tissue transfer for breast reconstruction at the university and community levels, there is little statistical difference in complication rates and flap loss. There was a difference in estimated blood loss and transfusion rate, as well as abdominal wound infections, all increased in the community. However, length of operative time was increased in the university setting. Based on these observations, the key to a successful free tissue transfer reconstruction is in the expertise of the surgeon, and despite its complexity is safely and successfully performed in the community setting. Further research is necessary to evaluate the reason for increased blood loss and transfusion in the community setting.
Table 1. Surgical Site Complications CommunityUniversityP value
Number (%)
fat necrosis
breast3 (3.0)68 (5.7)0.26
abdomen0 (0)3 (.4)0.606
wound infection
breast6 (6.1)54 (4.5)0.49
abdomen5 (7.2)20 (2.6)0.03
skin flap necrosis
breast12 (12.1)182 (15.2)0.40
abdomen1 (1.4)5 (.6)0.44
breast2 (2.0)27 (2.3)0.88
abdomen0 (0)1 (0.1)0.77
breast3 (3.0)32 (2.7)0.84
abdomen1 (1.4)10 (1.3)0.91
delayed wound healing
breast 18 (18.2)305 (25.5)0.10
abdomen13 (18.8)136 (17.5)0.77

Table 2. Vascular Complications
CommunityUniversityP value
Number (%)
intraoperative arterial thrombosis6 (6.1)36 (3.0)0.10
intraoperative vein thrombosis0 (0)7 (0.6)0.45
technical difficulties7 (7.1)44 (3.7)0.10
delayed arterial thrombosis1 (1.0)17 (1.4)0.74
delayed vein thrombosis1 (1.0)15 (1.3)0.83
flap loss2 (2.0)22 (1.8)0.90

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