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Optimizing Length of Stay after Abdominally Based Autologous Breast Free-Flap Reconstruction: An Analysis of 4,582 Flaps
Habarth-Morales, Theodore E. Nguyen, Tien Thuy Lemdani, Mehdi S. Davis, Harrison D. Amro, Chris Rhemtulla, Irfan A. Broach, Robyn B. Serletti, Joseph M. Azoury, Said C.
Habarth-Morales, Theodore E.
Nguyen, Tien Thuy
Lemdani, Mehdi S.
Davis, Harrison D.
Amro, Chris
Rhemtulla, Irfan A.
Broach, Robyn B.
Serletti, Joseph M.
Azoury, Said C.
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2024-01-01
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https://doi.org/10.1097/01.gox.0001006140.28125.d1
Abstract
Background: Despite previous cost-utility studies suggesting 3 post-operative days (POD) as the most cost-effective length-of-stay after abdominal-based autologous breast reconstruction (AABR), optimal length-of-stay remains controversial. Prior analyses suggest that healthcare cost of inpatient flap monitoring begins to increase rapidly after POD 2, exceeding a willingness-to-pay threshold of $100,000/quality adjusted life-year. We aimed to utilize a prospectively managed breast reconstruction database to evaluate the incidence and risk factors for flap complications and flap loss after POD 2.
Methods: All patients who underwent AABR after mastectomy from 2005-2019 were included. The incidence and timing of flap complications and losses were quantified. Risk-adjusted logistic regression was then performed to evaluate the factors independently associated with flap loss after POD 2.
Results: A total of 2,847 patients who underwent 4,582 free flaps were identified. The majority (3,490, 76.1%) were performed immediately after mastectomy. The mean age of the cohort was 51 (SD 9.8) years and had a mean BMI of 29.2 (SD 5.9). Two-hundred and forty-four (8.4%) patients were current smokers, 222 (7.8%) were diabetics, and 745 (26.2%) had hypertension. The mean length of procedure was 399.5 (SD 124.1) minutes and mean length of stay was 4.2 (SD 1.2) days. Overall, 141 (5.0%) vascular complications were identified intraoperatively and revised. Ten of the flaps with intraoperative complications went on to have some degree of flap loss (7.1%) compared to 53 (2.0%) in the overall cohort (P<0.001). Subsequently, 69 (2.4%) microvascular complications occurred in the post-operative period, of which 50 (72.5%) of these occurred by or on POD2 (Figure 1A). Fifteen (29%%) were venous and 15 (29%%) were arterial complications, while the rest were classified as “other” (i.e. mechanical compression). There were 32 total flap losses, the majority (59.4%) of which occurred by or on POD 2. Predictors of flap loss after POD2 were current tobacco use (OR 2.65 [95% CI: 1.05-6.68], P=0.039) and higher BMI (OR 1.08 [95% CI: 1.04-1.14], P=0.001; FIGURE 1B). Intraoperative microvascular complications/revisions were not predictive of post-operative flap failure.
Conclusion: With microvascular compromise occurring most often by POD2, patients undergoing AABR without predictive risk factors may be discharged early (ie. <POD3) with clinical monitoring at home to reduce unnecessary cost to the healthcare system.
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Plastic & Reconstructive Surgery-Global Open 12(1S1):p 54, January 2024. | DOI: 10.1097/01.GOX.0001006140.28125.d1
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Plastic and Reconstructive Surgery - Global Open, Vol. 12, Iss. 1S1
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