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Choosing a breast reconstructive modality after mastectomy is an important step in the reconstructive process. The authors hypothesized that autologous tissue is associated with a greater success rate and cost efficacy over time, relative to implant reconstruction.A retrospective review was performed of patients undergoing free tissue (FF) transfer and expander implant (E/I) reconstruction between 2005 and 2011. Variables evaluated included comorbidities, surgical timing, complications, overall outcomes, unplanned reoperations, and costs. A propensity-matching technique was used to account for the nonrandomized selection of modality.A total of 310 propensity-matched patients underwent 499 reconstructions. No statistically significant differences in preoperative variables were noted between propensity-matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. The E/I reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs 1.2%, p0.001). Expander implant reconstructions were associated with higher rates of seroma (p = 0.009) and lower rates of medical complications (p = 0.02), but overall significantly higher rates of unplanned operations (15.5% vs 5.8%, p = 0.002). The total cost of reconstruction did not differ significantly between groups ($23,120.49 ± $6,969.56 vs $22,739.91 ± $9,727.79, p = 0.060), but E/I reconstruction was associated with higher total cost for secondary procedures ($10,157.89 ± $8,741.77 vs $3,200.71 ± $4,780.64, p0.0001) and a higher cost of unplanned revisions over time (p0.05).Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost. Although autologous reconstruction is not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.

Early prosthesis loss is an infrequent but serious complication after breast reconstruction. We assessed perioperative risk factors associated with early device loss after immediate breast reconstruction (IBR) using the ACS-NSQIP datasets.We reviewed the 2005 to 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 with those who did not with respect to perioperative characteristics.We identified 14,585 patients with an average age of 50.9 ± 10.6 years. A multivariate regression analysis determined that age (55 years) (odds ratio [OR] 1.66, p = 0.013) (risk score = 1), class II obesity (OR 3.17, p0.001) (risk score = 3), class III obesity (OR 2.41, p = 0.014) (risk score = 3), active smoking (OR 2.95, p0.001) (risk score = 3), bilateral reconstruction (OR 1.67, p = 0.007) (risk score = 1), and direct-to-implant (DTI) reconstruction (OR 1.69, p = 0.024) (risk score = 1) were associated with early 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) groups. The risk of device loss was significantly higher with increased risk score (0.39% vs 1.48% vs 3.86%, p0.001).Early device loss following IBR is a complex multifactorial process related to identifiable preoperative risk factors. This study demonstrated that age, obesity, smoking, bilateral procedures, and DTI reconstructions are associated with increased risk of implant loss.

Surgical complications after breast reconstruction can be associated with significant morbidity, dissatisfaction, and cost. We used the ACS-NSQIP datasets from 2005 to 2011 to derive predictors of morbidity and to stratify risk after immediate breast reconstruction (IBR).Surgical complications after implant and autologous reconstruction were assessed using the ACS-NSQIP 2005 to 2011 datasets. Patient demographics, clinical characteristics, and operative factors were associated with the likelihood of experiencing a surgical complication. A "model cohort" of 12,129 patients was randomly selected from the study cohort to derive predictors. Weighted odds ratios derived from logistic regression analysis were used to create a composite risk score and to stratify patients. The remaining one-third of the cohort (n = 6,065) were used as the "validation cohort" to assess the accuracy value of the risk model.On adjusted analysis, autologous reconstruction (odds ratio [OR] 1.41, p0.001), American Society of Anesthesiologists physical status ≥ 3 (OR 1.25, p = 0.004), class I obesity (OR 1.38, p0.001), class II obesity (OR 1.91, p0.001), class III obesity (OR 1.70, p0.001), and active smoking (OR 1.46, p0.001) were associated with complications. Risk factors were weighted and patients were stratified into low (0 to 2, n = 9,133, risk = 7.14%), intermediate (3 to 4, n = 1,935, risk = 10.90%), high (5 to 7, n = 1,024, risk = 16.70%), and very high (8 to 9, n = 37, risk = 27.02%) risk categories based on their total risk score (p0.001). Internal validation of the "model cohort" using the "validation cohort" was performed demonstrating accurate prediction of risk across groups: low (7.1% vs 7.1%, respectively, p = 0.9), intermediate (10.9% vs 12.0%, respectively, p = 0.38), high (16.7% vs 16.8%, respectively, p = 0.95), and very high (27.0% vs 30.0%, respectively, p = 1.0).Surgical complications after IBR are related to preoperatively identifiable factors that can be used to accurately risk stratify patients, which may assist with counseling, selection, and perioperative decision-making.