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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.

Plastic and Reconstructive Surgery: February 2013 - Volume 131 - Issue 2 - p 195–203
doi: 10.1097/PRS.0b013e318277856f
Breast: Original Articles
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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.



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,

©2013American Society of Plastic Surgeons