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Three Words to the Wise

High-Risk Algorithm

Nahabedian, Maurice Y. M.D.

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Plastic and Reconstructive Surgery: January 2014 - Volume 133 - Issue 1 - p 198-199
doi: 10.1097/01.prs.0000435842.10799.ef
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A primary goal and responsibility of plastic surgeons is to maintain a low incidence of adverse events and to do everything possible to minimize their occurrence. That said, there seems a growing disparity between surgeons when evaluating surgical outcomes following breast reconstruction using prosthetic devices. There are a handful of seasoned and experienced plastic surgeons that report very low complication rates, especially when it comes to infection and seroma.1,2 In contrast, there is a growing number of plastic surgeons that are experiencing higher rates of complications than what has been typically reported in the literature. Some thoughts on why this may be are reviewed.

As the number of mastectomies performed in the United States continues to increase, more women are choosing immediate reconstruction with prosthetic devices because of the relative simplicity of this operation, age younger than 40 years, a more rapid recovery, and a high likelihood of achieving a good to excellent result. In addition, the technology related to prosthetic reconstruction has improved with the availability of better tissue expanders, silicone gel implants, and acellular dermal matrices. These factors have facilitated our ability to achieve good to excellent outcomes more predictably and reproducibly based on individual algorithms for prosthetic reconstruction. These algorithms have typically included patients with a body mass index less than 30, small to medium breast volume, and good health.1,3 Using these parameters, overall complication rates have remained at acceptable levels with low rates of infection, seroma, and delayed healing.

As a result of these improved techniques and better outcomes, it has been a personal observation that reconstructive algorithms have been less adhered to. Women that at one time were considered poor candidates for immediate prosthetic reconstruction were now being offered and choosing this option. Some of these patients are obese (body mass index >30), use tobacco products, have poorly controlled comorbidities, and have severe mammary hypertrophy. This evolution has occurred based on our previously obtained good outcomes in low-risk patients. Plastic surgeons recognized that prosthetic reconstruction had a high likelihood for success and the prevailing consensus was that if there was a simpler way for a patient to get a good to great result, why not use a prosthetic device instead of a flap.

As a consequence of these algorithmic modifications, complications including infection, seroma, and delayed healing increased. Like many plastic surgeons, my initial response was that because my technique had not changed and the various expanders and implants were better, the acellular dermal matrix was the most likely culprit. In response, I reverted to my traditional techniques that included total and partial muscle coverage without acellular dermal matrices. Because more high-risk patients were being referred, I continued to offer prosthetic reconstruction to them. Much to my chagrin, the incidence of complications did not change. At that point, I realized that my initial success using acellular dermal matrices was because prosthetic reconstruction had been performed in relatively low-risk patients and that my more recent failures were because of those high-risk patients. The complications were not because I was using acellular dermal matrices; they were because of patient factors related primarily to obesity, severe mammary hypertrophy, poorly controlled comorbidities, and tobacco use.

As a result, I have reverted to my traditional algorithm and make every effort to restrict prosthetic reconstruction to women with a body mass index less than 30. I no longer offer immediate breast reconstruction to patients with “high-risk” factors such as tobacco use, poorly controlled diabetes mellitus, and morbid obesity. This applies not only to patients considering prosthetic reconstruction but also to those considering autologous reconstruction. These patients are advised to have a mastectomy and then consider delayed reconstruction. The mandate is to stop smoking for at least 1 month, control their comorbidities, and lose weight before breast reconstruction. As a result, the incidence of complications and adverse events has reverted to my previous low incidence.

In some cases, patient-related risk factors are not the sole issue and technical factors come into play. Sometimes, the decision to avoid immediate reconstruction is made in the operating room because the skin flaps may be too thin following a skin-sparing mastectomy or perfusion to the nipple-areola complex may be questionable in the setting of nipple-sparing mastectomy. To offer immediate reconstruction to a patient that has a high risk of reconstructive failure should be carefully considered. There is nothing wrong with performing a delayed reconstruction 2 to 4 weeks after the mastectomy in a patient at higher risk of reconstructive failure. It is a known fact that complications are reduced in the setting of delayed reconstruction and following weight loss and avoidance of tobacco products.4

Some plastic surgeons will undoubtedly consider this to be unrealistic because they do not have the luxury of denying a high-risk patient immediate breast reconstruction. They see a limited number of patients and do not want to give up breast reconstruction. They fear that, by doing so, breast surgeons will refer patients to other plastic surgeons, with the ultimate consequence that they will lose their referral base. Although there may be some truth to this, the reality is that these complications can be devastating for both the patient and the surgeon. Poor outcomes are not silent, and patients will avoid referring other patients and referring surgeons will blame the adverse events on the plastic surgeon, with the ultimate effect of loss of referrals and patients.

As we enter the era of reducing adverse events at all costs, it would be wise for plastic surgeons to select their patients wisely and adopt an algorithm for dealing with high-risk patients. Hospitals, administrators, and insurance companies are tracking adverse events and complications. By exercising proper patient selection, good judgment, and sound surgical technique, all surgeons should be able to reduce complications and continue to deliver safe and effective operations. By gently and kindly addressing these concerns with patients, will not be angry or frustrated but we will find most of our patients rather relieved that their surgeon has placed their well-being ahead of a desire to operate.


1. McCarthy CM, Mehrara BJ, Riedel E, et al. Predicting complications following expander/implant breast reconstruction: An outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg. 2008;121:1886–1892
2. Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson E. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 2011;127:514–524
3. Nahabedian MY. Breast reconstruction: A review and rationale for patient selection. Plast Reconstr Surg. 2009;124:55–62
4. Sullivan SR, Fletcher DR, Isom CD, Isik FF. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg. 2008;122:19–28
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