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Towards a Definition of Frailty in Breast Surgery: A Cohort Study Identifying Risk Factors of Free Flap Failure following Autologous Breast Reconstruction
Sujay Rajkumar
2, Benjamin Rahmani
1, Maria J. Escobar
1, Helen Xun
1, Agustin Posso
1, Samantha Delapena
3, Ryan P. Cauley
1, Amir Behnam
3, Bernard T. Lee
1
1Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, USA; 2Drexel University College of Medicine, USA; 3 Plastic and Reconstructive Surgery, Tower Health, USA
Background: The integration of frailty assessments into pre-operative evaluation protocols is essential for enhancing surgical procedure safety. As autologous breast reconstruction (ABR) increases in popularity, it's important to stratify risk in patients with significant comorbidities with an ABR specific frailty model. The aim of this study was to identify comorbidities associated with ABR flap failure to develop a frailty index using a multi-institutional database.
Methods: The TriNetX database was queried for patients who underwent free flap breast reconstruction (CPT code 19364) between 2016 and 2024 across 89 healthcare institutions. Patients that experienced flap failure (ICD-10 T86.821) were identified; pre-operative comorbidities that occurred at a significantly different frequency were detected. Subsequently, univariate and multivariate logistic regression analyses were used to identify independent risk factors of free flap failure. Odds ratios were converted into a points-based scoring system to quantify risk in a randomized, model-naïve cohort.
Results: A total of 10,291 patients undergoing primary free flap ABR were identified. 120 (1.17%) patients experienced partial or total flap failure. Comorbidities of interest were seen amongst infectious, oncologic, hematologic, cardiovascular, gastrointestinal, and dermatologic systems. Significant risk factors on multivariate logistic regression included history of anemia (OR 2.87), breast abscess (OR 2.98), chronic obstructive pulmonary disease (OR 3.08), hypertension (OR 1.69), and body mass index≥30 (OR 2.37) (p<0.05 for all). Risk scores (range 0-9) were predictive of flap failure in an incremental manner (OR 1.55; 95% Confidence Interval [1.39-1.73]).
Conclusion: Select pre-operative comorbidities were identified as predictive of post-operative flap failure. Further research is warranted to validate these findings on additional cohorts and refine risk stratification. Future direction may also include identifying complications specific to certain flap techniques and within partial and total flap failures.
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