Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis

Abstract

Background There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction. Patients and Methods Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction. Results Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49–87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156–266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23–39%; p < 0.001) when compared with immediate. Conclusions Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-12896-0.

One-Stage Deep Inferior Epigastric Perforator Flap Salvage of Infected Tissue Expanders

“…Infected tissue expanders pose numerous problems to reconstructive surgeons and patients, including delays in receipt of adjuvant therapy and definitive reconstruction, 5,6 multiple unplanned reoperations and added costs, [7][8][9] and the emotional distress imparted by tissue expander complications and prolonged reconstructive courses or reconstructive burnout. [10][11][12][13] Accordingly, strategies to salvage infected tissue expanders and complete definitive reconstruction in a single surgery are needed.…”

“…1,2 However, while use of tissue expanders has well-established reconstructive benefits, particularly in patients receiving adjuvant chemoradiation, tissue expander-based breast reconstruction is associated with high complication rates with downstream implications for patient dissatisfaction and added costs to the healthcare system. Tissue expander infection rates exceed 30% in the literature 3,4 and have been associated with delays in receipt of adjuvant therapy and definitive reconstruction, 5,6 unplanned healthcare utilization and added costs, [7][8][9] and higher patient dissatisfaction after completion of reconstruction. [10][11][12][13] Traditionally, tissue expander infections are managed with explant followed by delayed reconstruction after several months, which may lead to prolonged reconstructive courses and even reconstructive burnout.…”

A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction

“…41 Future work around a textbook outcome for DIEP flap reconstruction should be correlated with patient-reported outcomes, quality of life, and health care costs to help further individualize patient care. The application of nomograms is one such avenue that may allow for the personalization of care with textbook outcomes, helping to determine the treatment pathway (eg, timing of reconstruction) 42 that is most likely to lead to a textbook outcome, further individualizing patient care. 10,43…”

The Effect of Bowel Anastomosis on Outcomes in Complex Abdominal Wall Reconstruction

“…25,26 However, immediate reconstruction was associated with better aesthetic outcomes, higher psychosocial well-being, and overall greater patient satisfaction. [25][26][27] Long-term satisfaction has been found by multiple studies to not have any correlation with timing of breast reconstruction, with staged, immediate, and delayed reconstruction reporting similar levels of satisfaction. [28][29][30] It is unclear whether some of these benefits, challenges, and complications would transfer from staged breast reconstruction to staged CAWR, but it does provide food for thought.…”

“…It may be beneficial to stage procedures; however, a more powerful randomized controlled trial would be more sufficient in drawing such a conclusion. When staged free-flap breast reconstructions were studied in comparison to immediate reconstruction, there was a greater incidence of complications, including wound healing, overall cost, and health care resource utilization 25,26 . However, immediate reconstruction was associated with better aesthetic outcomes, higher psychosocial well-being, and overall greater patient satisfaction 25–27 .…”