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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e318277856f
Breast: Original Articles

Comprehensive Outcome and Cost Analysis of Free Tissue Transfer for Breast Reconstruction: An Experience with 1303 Flaps

Fischer, John P. M.D.; Sieber, Brady B.A.; Nelson, Jonas A. M.D.; Cleveland, Emily B.A.; Kovach, Stephen J. M.D.; Wu, Liza C. M.D.; Kanchwala, Suhail M.D.; Serletti, Joseph M. M.D.

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Author Information

Philadelphia, Pa.

From the Division of Plastic Surgery, Hospital of the University of Pennsylvania.

Received for publication June 12, 2012; accepted August 9, 2012.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

John P. Fischer, M.D.; Division of Plastic Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pa. 19104, john.fischer2@uphs.upenn.edu

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Abstract

Background: Free tissue transfer is standard for postoncologic reconstruction, yet it entails a lengthy operation and significant recovery. The authors present their longitudinal experience of free tissue breast reconstructions with an emphasis on predictors of major surgical and medical complications.

Methods: The authors reviewed their prospectively maintained free flap database and identified oncologic breast reconstruction patients from 2005 to 2011. Factors associated with surgical and medical complications were identified using univariate analyses and logistic regression to determine predictors of complications.

Results: Complications included major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)]. Obesity (p = 0.034), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with immediate complications. Similarly, delayed surgical complications were associated with obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), and prior radiation therapy (p = 0.06). Regression analysis demonstrated that flap choice (p = 0.024) was independently associated with major immediate complications, and patient comorbidities such as chronic obstructive pulmonary disease (p = 0.001) and obesity (p < 0.0001) were associated with delayed complications. Patients who developed an immediate surgical complication experienced longer hospital stays (p < 0.0001), higher operating costs (p < 0.001), and greater hospital costs (p < 0.001).

Conclusions: Early major complications are related to flap selection, whereas late major complications are associated with patient comorbidities. Overall, major surgical and medical complications are associated with increased hospital length of stay and greater cost in autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Free autogenous breast reconstruction is considered by many as the standard of care for postoncologic reconstruction because of its reliability and superior patient satisfaction.14 However, microsurgical breast reconstruction entails a lengthy operation, significant recovery, and risk of flap loss, with major complications.5 Free tissue transfer can be performed with success rates as high as 97 percent as defined by flap survival, but complications rates can approach 20 to 50 percent.6,7

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Despite the robust body of literature evaluating complications after free tissue transfer, there are limited data separately accounting for early and late complications or for associated medical complications.810 Complications can exert a significant impact on recovery time, patient satisfaction, and health care system costs.2,11,12 Thus, a more comprehensive investigation of postoperative complications and their economic impact on the health care systems is warranted. In this study, we aim to elucidate identifiable risk factors associated with surgical and medical complications following free autologous tissue transfer, and to quantify the fiscal impact of such complications.

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PATIENTS AND METHODS

Study Design

We reviewed our prospectively maintained free flap database and identified all oncologic breast reconstruction patients from 2005 to 2011 who underwent reconstruction at the Hospital of the University of Pennsylvania performed by the senior author (J.M.S.). This study was institutional review board approved. Variables examined included patient characteristics, oncologic history, reconstructive details, and intraoperative and postoperative surgical complications. Complications were categorized as minor (wound healing, seroma, infection, transfusion, partial flap loss, and fat necrosis), immediate major (any thrombosis and complete flap loss), and delayed major (hernia or donor-site dehiscence requiring intervention). We also evaluated medical complications derived from a hospitalwide database query. Financial data were used to derive costs associated with complications during free tissue transfer. Complication rates were uniformly calculated as a rate per patient, not per number of flaps, such that the denominator was consistent across all complications.

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Data Collection

A detailed review of hospital and office records included the following: preoperative history and physical examination, operative reports, anesthesia records, postoperative nursing records, discharge summaries, outpatient clinic notes, and laboratory data. In addition, the institutional hospital database was queried for medical complications and costs associated with each patient's initial reconstructive hospitalization.

Specific variables examined included baseline patient characteristics/comorbidities (age, body mass index, hypertension, chronic obstructive pulmonary disease, hyperlipidemia, active smoking, coronary artery disease, peripheral arterial disease), oncologic history (mastectomy type, preoperative and postoperative chemotherapy, and prior irradiation), reconstructive details (immediate versus delayed, unilateral versus bilateral, thrombotic events, flap type, and recipient vessel), intraoperative complications (venous or arterial thrombosis), postoperative surgical complications [any thrombosis, flap loss, delayed breast or donor-site wound complications, early infection (during hospitalization), delayed infection (outpatient infection), seroma, and blood transfusion]. Obesity was defined using the World Health Organization obesity classification system: class I obesity, body mass index of 30 to 34.9 kg/m2; class II obesity, body mass index of 35.0 to 39.9 kg/m2; and class III obesity, body mass index greater than 40 kg/m2.

Surgical complications were characterized as immediate major (any thrombosis or complete flap loss), delayed major (hernia or major wound complications requiring return to the operating room), or minor (delayed wound healing, seroma, infection, partial flap loss, transfusion, and fat necrosis). Delayed wound healing at the abdominal donor site and mastectomy flap were defined as skin necrosis or wound breakdown necessitating topical care or dressing changes for more than 3 weeks. Fat necrosis was defined as a palpable firmness greater than 1 cm in diameter present at follow-up but not related to cancer recurrence. Partial flap loss was defined as flap loss or atrophy of up to 50 percent but not requiring immediate return to the operating room. Superficial infection was defined as incisional cellulitis at either the donor site or breast that occurred within 30 days, only involved skin and subcutaneous tissue structures, was treated with antibiotics, and was documented as such by a physician. We also evaluated and analyzed medical complications occurring during the inpatient recovery period, including arrhythmia, congestive heart failure, myocardial infarction, deep venous thrombosis, pulmonary embolism, acute renal failure, urinary tract infection, respiratory failure, and infectious pneumonia.

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Cost Analysis

Financial data were obtained from the Department of Finance at the Hospital of the University of Pennsylvania. These data were used to derive costs associated with complications after free tissue transfer during the initial hospital admission for reconstruction. We obtained several cost figures for each patient, including total hospital charges, total hospital cost, direct variable cost, and operative room costs during primary admission. These cost figures did not include professional service fees or charges. Cost data were compared based on complication subtypes.

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Statistical Analysis

All data were entered into an Excel workbook (Microsoft Corp., Redmond, Wash.). Statistical analyses included chi-square and Fisher's exact tests for categorical variables and the Wilcoxon rank sum test and Kruskal-Wallis test for continuous variables. All variables and endpoints found to be significant in the univariate analyses were included in a multivariate logistic regression model in an effort to determine independent predictors of surgical and medical complications. All tests were two-tailed, and statistical significance was defined as p < 0.05. All analyses were performed using STATA IC 11.0 (StataCorp, College Station, Texas).

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RESULTS

General

Eight hundred forty-nine patients underwent 1303 free tissue transfers (395 unilateral and 454 bilateral flaps). Average follow-up was 7.5 months (range, 1 to 36 months). There was a zero percent mortality rate. All complications were reported as a per-patient incidence. Flaps included muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) (66.8 percent), deep inferior epigastric perforator (DIEP) (22.4 percent), superficial inferior epigastric artery (5.4 percent), gluteal artery perforator (3.8 percent), and transverse gracilis myocutaneous (1.6 percent). Overall, complete flap loss occurred at a rate of 2.1 percent per study patient. We evaluated surgical and medical complications, including major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)].

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Surgical Complications

Patients who experienced a major immediate surgical complication were compared with those who did not (Table 1). This univariate analysis demonstrated that obesity (p = 0.03), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with major immediate postoperative events. When a vessel other than the internal mammary or thoracodorsal artery was needed, there was a corresponding increased rate of early major complications likely related to technical difficulty, but this was not significant in a multivariate regression. A similar comparison was performed for delayed major surgical complications (Table 2). We determined that obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), and hypertension (p < 0.001) were associated with major delayed surgical complications. A separate analysis was performed for minor surgical complications (Table 3). Minor complications were associated with race (p = 0.038), diabetes mellitus (p = 0.001), obesity (p < 0.001), hypertension (p < 0.001), hyperlipidemia (p = 0.01), and active smoking (p = 0.002).

Table 1
Table 1
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Table 2
Table 2
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Table 3
Table 3
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Medical Complications

We separately analyzed risk factors for the following medical complications: arrhythmia, congestive heart failure, myocardial infarction, deep venous thrombosis, pulmonary embolism, acute renal failure, urinary tract infection, respiratory failure, and infectious pneumonia (Table 4). Medical complications overall were associated with chronic obstructive pulmonary disease (p < 0.001), diabetes mellitus (p = 0.01), increased body mass index (p = 0.048), and bilateral flaps (p = 0.006).

Table 4
Table 4
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Risk Factor Analysis

To characterize independent risk factors for each subtype of surgical and medical complications, a separate multivariate regression analysis was performed on each subgroup (Table 5). This analysis demonstrates that flap choice (OR, 1.44; p = 0.024) was the one factor independently associated with major immediate surgical complications. In contrast, the regression analysis for major delayed complications showed that patient comorbidities including chronic obstructive pulmonary disease (OR, 10.1; p = 0.001) and obesity (OR, 1.71; p < 0.0001) were associated with major delayed complications (Table 6). Minor surgical complications were independently associated with diabetes mellitus (OR, 1.87; p = 0.03), hypertension (OR, 1.19; p = 0.03), and current smoking status (OR, 1.16; p = 0.07). Medical complications were independently associated with chronic obstructive pulmonary disease (OR, 17.2; p < 0.001), body mass index (OR, 1.04; p = 0.025), and bilateral flaps (OR, 2.37; p = 0.01).

Table 5
Table 5
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Table 6
Table 6
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Cost Analysis

We performed a separate cost analysis to determine the financial impact of surgical and medical complications on the health system (Table 7). Patients who experienced a major immediate surgical complication experienced longer hospital stay (6.1 days versus 4.2 days; p < 0.0001), higher operating room cost ($1459 versus $1044; p < 0.001), and greater hospital cost ($28,261 versus $19,106; p < 0.001). Patients experiencing medical complications consumed greater health care resources as well, including length of stay (5.9 days versus 4.8 days; p < 0.001) and hospital cost ($26,445 versus $19,045; p < 0.0001).

Table 7
Table 7
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Experience over Time

We compared the incidence of complication between surgeons with more than 5 years of experience to those with less than 5 years of experience at the time of surgery (Table 8). This comparison revealed several interesting findings. First and somewhat counterintuitively, the intraoperative thrombosis rate was higher with greater experience (5.6 percent versus 2.5 percent; p = 0.025). Importantly, this increased intraoperative thrombosis rate did not translate into a higher flap loss rate (1.7 percent versus 2.7 percent; p = 0.28). We also compared complications by year and found that our rates of complication were relatively stable with time (Table 9). There was a trend toward fewer delayed major complications (p = 0.24). There were also fewer minor complications with time (p = 0.006) and fewer venous thrombotic events (p = 0.02).

Table 8
Table 8
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Table 9
Table 9
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DISCUSSION

The data provided in this study represent a comprehensive, longitudinal analysis of complications in over 1300 free tissue transfers for breast reconstruction. Importantly, we describe a separate set of risk factors for early and late major surgical complications. We show that early major complications are related to flap selection8, whereas late major complications are associated with patient comorbidities (e.g., obesity and chronic obstructive pulmonary disease). Overall, complications lead to significantly longer hospitalizations and greater health care costs.

To date, there is a paucity of literature describing the financial impact of surgical complications in autologous breast reconstruction. Several studies have compared cost-efficacy between DIEP and muscle-sparing TRAM flaps, and the use of a pedicled TRAM flap compared with a free TRAM flap, but there are limited data regarding the added cost of complications across these reconstructive modalities.1315 Thus, one of the aims of this study was to evaluate the financial impact of medical and surgical complications. In our analysis, we determined that immediate major surgical complications added approximately 2 hospital days and over $9000 in direct costs. Similarly, medical complications added close to 2 hospital days and approximately $7000 in cost. These findings emphasize the impact complications exert on health care cost, patient morbidity and, likely by association, satisfaction.11 Overall, complications after microsurgical breast reconstruction can result in a significant burden to both the patient and health care system because of the associated added cost of care, need for further surgery, increased length of hospital stay, greater resource use, and higher morbidity.16 Our experience and results have remained consistent over time and likely relate to adherence to a protocolized management pathway and the use of consistent microsurgical technique regardless of surgeon.

Our study reports a low rate of major complications (5 to 7 percent), but the financial impact is clinically and economically significant. During the study period, the total added direct cost of immediate surgical complications was approximately $306,000 compared with $350,000 for medical complications. Preventative strategies geared toward reducing either major surgical or medical complications might translate into significant health care savings. In addition, these data may prove useful in guiding flap selection, counseling patients, using identifiable risk factors for preoperative screening, and improving health care resource consumption.

One of the critical findings of our study is that gluteal artery flaps are associated with a higher flap loss rate than abdominally based flaps. Gluteal artery flaps have been described for breast reconstruction but are known to be associated with higher flap loss rates and greater technical difficulty because of the shorter pedicle and vessel size discrepancy.1719 We tend to use gluteal artery based flaps only as a secondary or tertiary option in free autologous reconstructions because of their higher complication rates and required intraoperative repositioning.

Another important set of findings provided by these data are that patient comorbidities were also independent predisposing risk factors for medical complications. There is little in the literature about medical complications after autologous breast reconstruction, and we feel this is an important consideration and addition to the literature. Patients who developed medical complications consumed more health care resources, had longer inpatient stays, and experienced greater morbidity. Not surprisingly, patients who experienced medical complications had various comorbidities at baseline. In such patients with multiple comorbid conditions, it may be advantageous to have a high level of suspicion for medical complications postoperatively.

As an example, in patients with chronic obstructive pulmonary disease, initiating early aggressive incentive spirometry and pulmonary toilet or considering preoperative pulmonary evaluation may be of benefit. In obese patients, ensuring appropriate venous thromboembolic prophylaxis and encouraging early ambulation and counseling regarding added risk of postoperative surgical and medical complications may be of benefit.

Obesity has been shown to be associated with overall higher rates of flap complications, including flap loss, hernia, seroma, and wound healing complications.4,2023 In our study, obesity was independently associated with major delayed complications. These results agree with previously published reports that delayed complications tend to be associated with patient comorbidities.24 One of the critical findings presented in this study is the strong association between major surgical and medical complications and chronic obstructive pulmonary disease. Patients with chronic obstructive pulmonary disease were at 10-fold greater risk for delayed surgical complications and 17-fold greater risk for medical complications. These findings suggest that free tissue transfer should be carefully considered and discussed with the chronic obstructive pulmonary disease patient. The significantly increased risk is not necessarily attributable to the chronic obstructive pulmonary disease itself but is more likely secondary to the other comorbid conditions that coexist in this patient population. However, it should be noted that although these findings were significant, the overall prevalence of chronic obstructive pulmonary disease in our surgical population was very low.

The results presented in this study provide the practicing breast microsurgeon with useful risk-stratifying data and cost-efficiency results that can be implemented to enhance and optimize outcomes through careful patient selection and counseling (Table 10). As an institution and health system, the plastic surgery team has implemented infrastructural and pathway protocols to standardized care and management of our free flap patients. Briefly, some of these include anesthesiologists intimately familiar with free flap physiology and intraoperative management. This strategy continues as patients are transferred to the microsurgical stepdown unit where a free flap protocol is initiated. We feel that our success has largely been dictated by consistent microsurgical technique, intraoperative collaboration and open communication with anesthesia, close clinical observation of flap performance in a stepdown unit, and early recognition and treatment of vascular complications. A better understanding of complications and risk factors has allowed us to better preoperatively counsel our patients. This open discussion has facilitated patient autonomy and enhanced our management of complications, which in turn has created greater patient satisfaction.

Table 10
Table 10
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Despite the large number of patients included in our study, there remain several limitations. First, it is a retrospective study and may be prone to observer bias, recording bias, and selection bias overall. However, there are few preoperative patient variables or comorbidities that our surgeons would consider as contraindications for performing autologous reconstruction in patients. This helps to decrease the possibility of selection bias. Conclusions that we have drawn are not yet supported by prospective data, and at this point we are only able to associate variables with outcomes. In addition, our cost data are based on the University of Pennsylvania Health System cost figures and direct variable cost, which does not include labor or overhead costs. It is also important to recognize that these cost figures only reflect one component of the economic impact of breast reconstruction. This analysis does not take into account lost productivity or work days missed secondary to a prolonged recovery or for additional physician visits. Such costs are much more difficult to directly quantify. Overall, surgical and medical complications after autologous breast reconstruction, although infrequent in our study, are independently linked to identifiable patient risk factors and associated with significant morbidity and cost.

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CONCLUSIONS

We show that free tissue transfer is safe and effective, but several critical patient-related comorbidities and intraoperative factors are associated with postoperative patient morbidity. Early major complications tend to be related to flap selection and technical factors, whereas late major complications were associated with patient comorbidities. Overall, complications were associated with an added 2 days of hospitalization and an additional $9000 in hospital charges per patient. Careful patient selection, counseling, and preventative measures can optimize postoperative performance, minimize surgical and medical morbidity, and conserve health care resources.

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REFERENCES

1. Yueh JH, Slavin SA, Adesiyun T, et al.. Patient satisfaction in postmastectomy breast reconstruction: A comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125:1585–1595.

2. Momoh AO, Colakoglu S, Westvik TS, et al.. Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg. 2012;69:19–23.

3. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769–776.

4. Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg. 2011;127:1086–1092.

5. Vega S, Smartt JM Jr, Jiang S, et al.. 500 Consecutive patients with free TRAM flap breast reconstruction: A single surgeon's experience. Plast Reconstr Surg. 2008;122:329–339.

6. Selber JC, Kurichi JE, Vega SJ, Sonnad SS, Serletti JM. Risk factors and complications in free TRAM flap breast reconstruction. Ann Plast Surg. 2006;56:492–497.

7. Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA. A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg. 2007;59:137–142.

8. Nahabedian MY, Momen B, Manson PN. Factors associated with anastomotic failure after microvascular reconstruction of the breast. Plast Reconstr Surg. 2004;114:74–82.

9. Chen CM, Halvorson EG, Disa JJ, et al.. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg. 2007;120:1477–1482.

10. Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: Experience with 1195 flaps. Plast Reconstr Surg. 2006;118:1100–1109; discussion 1110–1111.

11. Colakoglu S, Khansa I, Curtis MS, et al.. Impact of complications on patient satisfaction in breast reconstruction. Plast Reconstr Surg. 2011;127:1428–1436.

12. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: Patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110:466–475; discussion 476–477.

13. Kaplan JL, Allen RJ. Cost-based comparison between perforator flaps and TRAM flaps for breast reconstruction. Plast Reconstr Surg. 2000;105:943–948.

14. Thoma A, Khuthaila D, Rockwell G, Veltri K. Cost-utility analysis comparing free and pedicled TRAM flap for breast reconstruction. Microsurgery 2003; 23:287–295.

15. Thoma A, Veltri K, Khuthaila D, Rockwell G, Duku E. Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: A cost-effectiveness analysis. Plast Reconstr Surg. 2004;113:1650–1661.

16. Hamdi M, Andrades P, Thiessen F, et al.. Is a second free flap still an option in a failed free flap breast reconstruction? Plast Reconstr Surg. 2010;126:375–384.

17. Allen RJ. The superior gluteal artery perforator flap. Clin Plast Surg. 1998;25:293–302.

18. Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps: A critical analysis of 142 cases. Ann Plast Surg. 2004;52:118–125.

19. Mirzabeigi MN, Au A, Jandali S, Natoli N, Sbitany H, Serletti JM. Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction. Plast Reconstr Surg. 2011;128:614e–624e.

20. Chang DW, Wang B, Robb GL, et al.. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg. 2000;105:1640–1648.

21. Greco JA III, Castaldo ET, Nanney LB, et al.. Autologous breast reconstruction: The Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes. J Am Coll Surg. 2008;207:49–56.

22. Kroll SS, Netscher DT. Complications of TRAM flap breast reconstruction in obese patients. Plast Reconstr Surg. 1989;84:886–892.

23. Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, Dalio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg. 2008;121:1519–1526.

24. Scheer AS, Novak CB, Neligan PC, Lipa JE. Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap. Ann Plast Surg. 2006;56:355–358.

Cited By:

This article has been cited 1 time(s).

Journal of the American College of Surgeons
Impact of Obesity on Outcomes in Breast Reconstruction: Analysis of 15,937 Patients from the ACS-NSQIP Datasets
Fischer, JP; Nelson, JA; Kovach, SJ; Serletti, JM; Wu, LC; Kanchwala, S
Journal of the American College of Surgeons, 217(4): 656-664.
10.1016/j.jamcollsurg.2013.03.031
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