Effect of Immediate Reconstruction on Postmastectomy Surgical Site Infection

Article (PDF Available)inAnnals of surgery 256(2):326-33 · August 2012with340 Reads
DOI: 10.1097/SLA.0b013e3182602bb7 · Source: PubMed
Abstract
Surgical site infections (SSI) are a source of significant postoperative morbidity and cost. Although immediate breast reconstruction after mastectomy has become routine, the data regarding the incidence of SSI in immediate breast reconstruction is highly variable and series dependent. Using the National Surgical Quality Improvement Program database, all female patients undergoing mastectomy, with or without immediate reconstruction, from 2005 to 2009 were identified. Only "clean" procedures were included. The primary outcome was incidence of SSI within 30 days of operation. Stepwise logistic regression analysis was used to identify risk factors associated with SSI. A total of 48,393 mastectomies were performed during the study period, of which 9315 (19.2%) had immediate breast reconstruction. The incidence of SSI was 3.5% (330/9315) (95% CI [confidence interval]: 3.2%-4%) in patients undergoing mastectomy with reconstruction and 2.5% (966/39,078) (95% CI: 2.3%-2.6%) in patients undergoing mastectomy without reconstruction (P < 0.001). Independent risk factors for SSI include increased preoperative body mass index (BMI), heavy alcohol use, ASA (American Society of Anesthesiologists) score greater than 2, flap failure, and operative time of 6 hours or longer. Immediate breast reconstruction is associated with a statistically significant increase in risk of SSI in patients undergoing mastectomy (3.5% vs 2.5%). However, this difference was not considered to be clinically significant. In this large series, increased BMI, alcohol use, ASA class greater than 2, flap failure, and prolonged operative time were associated with increased risk of SSI.

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ORIGINAL ARTICL E
Effect of Immediate Reconstruction on Postmastectomy Surgical
Site Infection
T. JoAnna Nguyen, MD,Melinda A. Costa, MD,Evan N. Vidar, MA,Ahva Shahabi, MPH,Mirna Peric, BA,
Angela M. Hernandez, BA,Linda S. Chan, PhD,Stephen F. Sener, MD,and Alex K. Wong, MD
Introduction: Surgical site infections (SSI) are a source of significant post-
operative morbidity and cost. Although immediate breast reconstruction after
mastectomy has become routine, the data regarding the incidence of SSI in
immediate breast reconstruction is highly variable and series dependent.
Methods: Using the National Surgical Quality Improvement Program
database, all female patients undergoing mastectomy, with or without im-
mediate reconstruction, from 2005 to 2009 were identified. Only “clean”
procedures were included. The primary outcome was incidence of SSI within
30 days of operation. Stepwise logistic regression analysis was used to identify
risk factors associated with SSI.
Results: A total of 48,393 mastectomies were performed during the study
period, of which 9315 (19.2%) had immediate breast reconstruction. The inci-
dence of SSI was 3.5% (330/9315) (95% CI [confidence interval]: 3.2%–4%)
in patients undergoing mastectomy with reconstruction and 2.5% (966/39,078)
(95% CI: 2.3%–2.6%) in patients undergoing mastectomy without reconstruc-
tion (P<0.001). Independent risk factors for SSI include increased preop-
erative body mass index (BMI), heavy alcohol use, ASA (American Society
of Anesthesiologists) score greater than 2, flap failure, and operative time of
6 hours or longer.
Conclusions: Immediate breast reconstruction is associated with a statisti-
cally significant increase in risk of SSI in patients undergoing mastectomy
(3.5% vs 2.5%). However, this difference was not considered to be clini-
cally significant. In this large series, increased BMI, alcohol use, ASA class
greater than 2, flap failure, and prolonged operative time were associated with
increased risk of SSI.
Keywords: breast reconstruction, surgical site infection, mastectomy,
NSQIP, risk factors
(Ann Surg 2012;256: 326–333)
Surgical site infections (SSI), defined as infections at or near surgi-
cal incision sites after an operation, represent the most common
nosocomial infections among surgical patients.1SSI is a major cause
of postoperative morbidity, extending hospital stay,2and significantly
increasing cost of care.2,3 Previously established risk factors for SSI
include diabetes,4smoking,2,4 obesity,2,4 concurrent infection,2,4 in-
creased age,5excessive blood loss,5and long procedures.2,5
From the Division of Plastic and Reconstructive Surgery; Division of Breast and
Soft Tissue Surgery; and Department of Surgery, Keck School of Medicine,
University of Southern California, Los Angeles.
Disclosure: The American College of Surgeons National Surgical Quality Improve-
ment and the hospitals participating in the ACS NSQIP are the source of the
data used herein; they have not verified and are not responsible for the statistical
validity of the data analysis or the conclusions derived by the authors.
Reprints: Alex K. Wong, MD, Division of Plastic and Reconstructive Surgery,
Department of Surgery, University of Southern California, Keck School of
Medicine, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033. E-
mail: Alex.Wong@med.usc.edu. OR Stephen F. Sener, MD, Division of Breast
and Soft Tissue Surgery, Department of Surgery, University of Southern Cal-
ifornia, 1441 Eastlake Avenue, Suite 7415, Los Angeles, CA 90033. E-mail:
sener@med.usc.edu.
Copyright C2012 by Lippincott Williams & Wilkins
ISSN: 0003-4932/12/25602-0326
DOI: 10.1097/SLA.0b013e3182602bb7
Risk factors specific for SSI in mastectomy patients include
preoperative chemoradiation,6–9 age more than 50 years,6,9,10 high
serum glucose (>150 mg/dL),6and transfusion of red blood cells.11
Several cited studies stated that the risk for SSI was increased by as
much as fivefold in mastectomy patients undergoing breast recon-
struction with immediate implant or tissue expander placement.11– 14
Immediate breast reconstruction is widely practiced and onco-
logically sound.15–18 It allows the avoidance of a postmastectomy
deformity and its associated psychological sequelae. In addition,
it may provide superior esthetic outcomes as compared to delayed
reconstruction.15, 19 Nevertheless, immediate reconstruction may be
associated with increased complication rates compared to mastec-
tomy alone.11 In the literature, infection rates for mastectomy with or
without immediate reconstruction range from 1.74% to 10.7%.20, 21
However, there is no large multicenter study that assesses the risk
of SSI in this patient population. The primary aim of this study
was to determine the risk of SSI in patients undergoing immediate
breast reconstruction as compared to mastectomy alone using the
American College of Surgeons’ National Surgical Quality Improve-
ment database. The second objective was to identify independent risk
factors for SSI in patients undergoing mastectomy with immediate
reconstruction.
METHODS
A secondary data analysis of the American College of Sur-
geons’ National Surgical Quality Improvement was performed. All
cases involving mastectomy as either primary or secondary proce-
dure as defined by Current Procedural Terminology codes were in-
cluded. The Current Procedural Terminology codes for mastectomy
and breast reconstruction are listed in Table 1.
Exclusion criteria were male gender, cases with unrelated
surgical procedures (eg, appendectomy, cholecystectomy), cases
where nipple/areola complex reconstruction (19,350) or breast
reconstruction with other techniques (19,366) were performed,
“clean/contaminated” wounds, “contaminated wounds,” “dirty”
wounds, and death within 30 days of surgery.
Data Source
Data were obtained from the American College of Surgeons’
National Surgical Quality Improvement registry, which is a nation-
wide database that provides validated, risk-adjusted surgical outcomes
from both academic and community hospitals. Information is col-
lected from patients’ medical records and includes demographics,
laboratory values, operative information, preoperative and periopera-
tive risk factors, and postoperative outcomes within 30 days of the in-
dex operation. Reviewers periodically conduct blinded, observational
studies.22 On-site auditing programs allow standardization of data
collection and ensure consistency and reliability of data. The use of
the database was approved by the National Surgical Quality Improve-
ment Program Participation Use Data Agreement that implements the
Health Insurance Portability and Accountability Act of 1996 and the
American College of Surgeons’ National Surgical Quality Improve-
ment Hospital Participation Agreement. To avoid sampling bias, all
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326 |www.annalsofsurgery.com Annals of Surgery rVolume 256, Number 2, August 2012
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Annals of Surgery rVolume 256, Number 2, August 2012 SSI in Immediate Breast Reconstruction
TABLE 1. Procedures and Corresponding Current
Procedural Terminology (CPT) Codes Included in This
Study
CPT Code Procedure
Mastectomy
19300 (19140) Mastectomy for gynecomastia
19301 (19160) Partial mastectomy (lumpectomy, tylectomy,
quadrantectomy, segmentectomy)
19302 (19162) Partial mastectomy W/LN Removal (with
axillary lymphadenectomy)
19303 (19180) Mastectomy, simple, complete
19304 (19182) Mastectomy, subcutaneous
19305 (19200) Mastectomy, radical (including pectoral
muscles, axillary lymph nodes)
19306 (19220) Mastectomy, radical, urban type (including
pectoral muscles, axillary and internal
mammary lymph nodes)
19307 (19240) Mastectomy, modified radical (including
axillary lymph nodes, with or without
pectoralis minor muscle, but excluding
pectoralis major muscle)
Breast reconstruction
19340 Immediate breast prosthesis
19357 Breast reconstruction (immediate or delayed,
with tissue expander, including subsequent
expansion)
19361 Breast reconstruction (with latissimus dorsi
flap, without prosthetic implant)
19364 Breast reconstruction (with free flap)
19367 Breast reconstruction (with TRAM flap)
19368 Breast reconstruction (with TRAM flap,
single pedicle, including closure of donor
site; with microvascular anastomosis
[supercharging])
19369 Breast reconstruction (with TRAM flap,
double pedicle, double pedicle, including
closure of donor site)
The procedures included in this study along with the Current Procedural Ter-
minology (CPT) codes are listed in this table. In 2007, CPT codes were changed,
and codes used before 2007 are listed in the parentheses. TRAM indicates trans-
verse rectus abdominus myocutaneous.
data are collected on 8 day-cycles on the first 40 consecutive cases
of the month and are continuously submitted and monitored through
data audits on the www.acsnsqip.org website.
Data Collection
The clinically relevant risk factors included in this study are
shown in Table 2. The list includes demographic, preoperative, intra-
operative, and postoperative factors. Clinical risk factors with more
than 20% missing data were not included in analysis.
Body mass index (BMI) was calculated from height and weight
data (BMI =mass [kg] / height [cm2]). Patients with a preopera-
tive diagnosis of diabetes mellitus, who required oral hypoglycemic
agents and/or insulin, were considered to have diabetes; those whose
diabetes was controlled by diet alone were not categorized as dia-
betic. Patients who smoked cigarettes in the year before admission
for surgery were considered to be smokers. Alcohol use was defined
as the consumption of more than 2 alcoholic beverages per day in the
2 weeks before admission. The standard American Society of Anes-
thesiologists (ASA) classification was used to categorize severity of
illness: 1—normal healthy patient; 2—patient with mild systemic dis-
ease; 3—patient with severe systemic disease; 4—patient with severe
systemic disease that is a constant threat to life; 5—moribund pa-
TABLE 2. Potential Risk Factors for SSI After Mastectomy and
Immediate Reconstruction Included in Study
Preoperative Intraoperative Postoperative Outcome
Factors Factors Factors Variable
Age
Ethnicity
Inpatient versus
outpatient
BMI
Diabetes
Smoking
Alcohol use
ASA classification
Steroid therapy
Chemotherapy
Irradiation
Open
wound/wound
infection
RBC units
transfused
Total operation
time
Type of immediate
reconstruction
(ie, TE
placement,
prosthesis,
latissimus dorsi
flap, free flap,
TRAM flap)
Presence of graft/
prosthesis/flap
failure
complications
SSI
RBC indicates red blood cell; TE, tissue expander; TRAM, transverse rectus ab-
dominus myocutaneous.
tient who is not expected to survive without operation.23 Open wound
infection was defined as preoperative evidence of an open wound com-
municating with the air by direct exposure, regardless of the presence
of cellulitis or purulent exudates. Steroid therapy was defined as the
regular administration of oral or parenteral corticosteroid medications
for a chronic medical condition in the 30 days before surgery. Use of
chemotherapy was defined as the administration of chemotherapeutic
agents for the treatment of a malignancy within the 30 days before
surgery. Radiation use was defined as radiation therapy given within
the 90 days before surgery. Finally, graft/prosthesis/flap failure was
defined as nonviable myocutaneous flaps or skin flaps requiring a
return to the operating room within 30 days of the operation.24
For analysis, race was categorized into non-Hispanic white,
African-American, Hispanic white, Asian/Pacific Islander, and
Other/Unknown. BMI was categorized into the clinically defined cat-
egories of normal (<25 kg/m2), overweight (25–29 kg/m2), obese
(30–34 kg/m2), and morbidly obese (35 kg/m2). ASA of severity
was combined into 2 groups—classes 1 to 2 and 3 to 5. The number of
intraoperatively transfused red blood cell units was also dichotomized
as less than 2 versus 2 or more units. Operative time was grouped
into cases that lasted less than 3, 3 to 6, and 6 or more hours.
Outcome Measures
The primary outcome was SSI within 30 days of the index
operation,24 which included superficial incisional, deep incisional,
and organ space infection. A case reported to have any of these 3
types of infections was considered positive for SSI.
Statistical Analysis
Incidence of SSI was estimated with 95% confidence intervals
(CIs). The SSI incidence rate was compared between those having
mastectomy with immediate breast reconstruction and those having
mastectomy only using the 2-sided Fisher exact test. We also evaluated
the clinical significance of the difference of the rates of SSI between
the 2 groups by establishing a zone of minimal clinical importance
difference and assessing the location of the 95% CI with respect to
the minimal clinical importance difference.
To assess the clinical significance of the relative risk between
mastectomy with immediate reconstruction and mastectomy without
reconstruction, we used the overall SSI rate of 2.5% in those who
underwent mastectomy without reconstruction as the reference and
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2012 Lippincott Williams & Wilkins www.annalsofsurgery.com |327
Nguyen et al Annals of Surgery rVolume 256, Number 2, August 2012
established that an SSI incidence rate of 5% would be clinically im-
portant. This translates to a relative risk of 2.0. We used 0.5 and 2.0
to be the zone of clinical indifference. Using this minimal clinical
importance difference, we evaluated the clinical significance of the
relative risk as follows: 95% CIs that fall within the minimal clinical
importance difference were considered as established evidence of no
effect; 95% CIs that fall outside the minimal clinical importance dif-
ference were considered as established effect, indicating that the risk
of developing a particular complication is either higher (to the left)
or lower (to the right) in the immediate breast reconstruction group;
and 95% of the CIs that crossed the minimal clinical importance dif-
ference were considered as inconclusive, indicating that an effect of
immediate reconstruction could not be established.
Univariate analysis was performed to assess the association of
each risk factor with each complication outcome. The 2-sided Student
ttest was used to assess the differences of the means for continuous
variables and the Pearson χ2test or the 2-sided Fisher exact test was
used to determine the differences of proportions between groups. For
each risk factor, the odds ratio and its 95% CI were derived for each
complication outcome using univariate logistic regression.
Factors with P<0.20 from the univariate analysis were entered
into the multivariate logistic regression model to identify independent
risk factors for SSI. Adjusted odds ratio and its 95% CI for each
independent risk factor were derived. Overall statistical significance
was set at P<0.05. All statistical analyses were performed using
STATA version 11 (College Station, TX). Values are reported as
mean ±standard deviation, as raw percentages, as odds ratio (OR)
or adjusted odds ratio (AOR), and ±95% CIs, wherever applicable.
RESULTS
From 2005 to 2009, 48,393 mastectomies were performed. Of
these 48,393 women, 9315 (19%) underwent mastectomy with imme-
diate breast reconstruction and 39,078 (81%) had mastectomy without
immediate reconstruction. Among the 9315 patients in the immedi-
ate reconstruction group, 6520 (70%) had at least 1 tissue expander
placed, 1396 (15%) had a permanent implant placed, 1008 (11%)
had a transverse rectus abdominus myocutaneous flap, 645 (7%) had
a latissimus dorsi flap, and 339 (4%) had free-flap reconstruction.
Overall, 2.7% (1296/48,393; 95% CI: 2.5%–2.8%) of patients devel-
oped an SSI within 30 days of surgery. The incidence of SSI was
3.5% (330/9315; 95% CI: 3.2%–4.0%) in patients undergoing mas-
tectomy with immediate reconstruction and 2.5% (966/39,078; 95%
CI: 2.3%–2.6%) in patients undergoing mastectomy alone. Of the
330 cases with SSIs in the immediate reconstruction group, 47%
(156/330) had superficial incisional infections, 35% (114/330) had
deep incisional infections, and 20% (65/330) had organ space infec-
tions.
The relative risk of SSI for those with versus without immediate
construction was 1.4 (95% CI: 1.3–1.7, P<0.001). (Fig.) The 95% CI
is within the zone of clinical indifference, indicating that the relative
risk is not clinically significant, although it is statistically significant
(P<0.001).
Risk Factors and SSI in the Immediate
Reconstruction Patients
A list of preoperative and intraoperative potential risk factors
for SSI included in the study is provided in Table 2. A comparison
of the demographic and clinical characteristics between patients with
SSI and those without SSI in patients with immediate reconstruction
is provided in Table 3. A statistically significant difference was found
between the groups in the following risk factors: inpatient status,
increased BMI, diabetes mellitus, more than 2 drinks per day in the
2 weeks before admission, ASA class greater than 2, occurrence of
FIGURE. Zone of minimal clinical importance difference. The
relative risk of SSI for those with versus without immediate
construction was 1.4 (95% CI: 1.3, 1.7, P<0.001). The 95%
CI is within the zone of clinical indifference, indicating that the
relative risk is not clinically significant, although it is statistically
significant (P<0.001).
flap failure, and increased intraoperative time. The difference in age
and ethnicity was marginal. No significant differences were found
between the groups in the other risk factors studied.
The odds ratio for SSI and its 95% CI for each significant risk
factor are presented in Table 4 in which the adjusted odds ratio and
its 95% CI from the multivariable analysis are also presented. Factors
significantly associated with SSI in univariate analysis included age
50 years or more, inpatient status, increased BMI, diabetes, alcohol
consumption, ASA class greater than 2, inpatient status, flap failure,
and intraoperative time of 3 hours or longer. After adjustment, the
factors that remained significantly associated with SSI included the
following: BMI 25 or higher, alcohol use, ASA class 3 to 5, flap
failure, and operative time longer than 6 hours. Being overweight,
obese, and morbidly obese were significant risk factors for SSI, with
the odds of developing SSI increasing with increasing BMI. Using
those with normal BMI (<25) as the reference group, the likelihood
of infection versus no infection was 1.61 times more in the overweight
group (BMI 25, <30) (adjusted odds ratio: 1.61; 95% CI: 1.19–
2.18; P=0.002), 2.28 times more in those who were obese (BMI
30, <35) (adjusted odds ratio: 2.28; 95% CI: 1.65–3.16; P<0.001),
and 2.83 times more in those who were morbidly obese (BMI 35)
(adjusted odds ratio: 2.83; 95% CI: 1.99–4.03; P<0.001). Heavy
preoperative alcohol use was associated with 2.7 times increased
likelihood of developing SSI versus not developing SSI (adjusted
odds ratio: 2.74; 95% CI: 1.35–5.57; P=0.005) and patients with an
ASA class of 3 or higher had a close to 50% increased likelihood of
developing SSI versus not developing SSI (adjusted odds ratio: 1.49;
95% CI: 1.14–1.94; P=0.003). Those whose operations lasted longer
than 6 hours had a 70% greater likelihood of developing SSI versus
not developing SSI (adjusted odds ratio: 1.67; 95% CI: 1.11–2.5;
P=0.013).
Risk Factors and Flap Failure in the Immediate
Reconstruction Patients
Of the 9315 who underwent mastectomy with immediate breast
reconstruction, 124 (1.3%) had flap failure (95% CI: 1.1–1.6). A
comparison of the demographic and clinical characteristics between
patients who had and those who did not have flap failure is shown
in Table 5. A statistically significant difference was found between
patients with and without flap failure in the following factors: age,
inpatient status, BMI, smoking status, ASA classification, amount
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328 |www.annalsofsurgery.com C
2012 Lippincott Williams & Wilkins
Annals of Surgery rVolume 256, Number 2, August 2012 SSI in Immediate Breast Reconstruction
TABLE 3. Comparison of Risk Factors for SSI in Immediate Breast Reconstruction
All Patients (n =9315) Presence of SSI (n =330) No SSI (n =8985) P
Age, mean (SD) 50.9 (10.3) 52 (10.7) 50.9 (10.3) 0.05
Race, N (%)
Non-Hispanic white 7243 (78%) 261 (79%) 6982 (78%) 0.06
African-American 611 (7%) 30 (9%) 581 (6%)
Hispanic white 410 (4%) 15 (5%) 395 (4%)
Asian/Pacific Islander 257 (3%) 2 (0.61%) 255 (3%)
Other & Unknown 794 (8%) 22 (7%) 772 (9%)
Outpatient/inpatient, N (%)
Outpatient 1721 (18%) 46 (14%) 1675 (19%)
Inpatient 7594 (82%) 284 (86%) 7310 (81%) 0.03
BMI, N (%)
Mean (SD) 26.9 (6.1) 30.1 (7) 26.8 (6) <0.001
<25 4211 (46%) 85 (26%) 4126 (46%) <0.001
25, <30 2661 (29%) 98 (30%) 2563 (29%)
30, <35 1445 (16%) 77 (23%) 1368 (15%)
35 931 (10%) 69 (21%) 862 (10%)
Diabetes mellitus, N (%)
No 8876 (95%) 299 (91%) 8577 (95%) <0.001
Yes 439 (5%) 31 (9%) 408 (5%)
Current smoker, N (%)
No 8053 (86%) 277 (84%) 7776 (87%) 0.19
Yes 1262 (14%) 53 (16%) 1209 (13%)
Alcohol
No 9203 (99%) 321 (97%) 8882 (99%) 0.02
Yes 112 (1%) 9 (3%) 103 (1%)
ASA
None/mild (<3) 7697 (83%) 235 (71%) 7462 (83%) <0.001
Severe/life threatening/moribund (3+) 1611 (17%) 94 (29%) 1517 (17%)
Wound Infection
No 9284 (100%) 328 (99%) 8956 (99.7%) 0.3
Yes 31 (0.33%) 2 (0.61%) 29 (0.3%)
Steroids
No 9229 (99%) 327 (99%) 8902 (99%) 1.0
Yes 86 (1%) 3 (1%) 83 (1%)
Chemotherapy
No 8954 (96%) 316 (96%) 8638 (96%) 0.66
Yes 361 (4%) 14 (4%) 347 (4%)
Radiotherapy
No 9279 (99.6%) 329 (99.7%) 8950 (99.6%) 1.0
Yes 36 (0.4%) 1 (0.3%) 35 (0.4%)
RBC (units)
<2 9268 (99.5%) 325 (99%) 8943 (99.5%) 0.07
2+44 (0.5) 4(1%) 40 (0.5%)
Flap failure
No 9191 (99%) 305 (92%) 8886 (99%) <0.001
Yes 124 (1%) 25 (8%) 99 (1%)
Intraoperative time (h)
3 3768 (40%) 102 (31%) 3666 (41%) <0.001
3, 6 4520 (49%) 169 (51%) 4351 (48%)
6 1027 (11%) 59 (18%) 968 (11%)
P<0.05 significant. RBC indicates red blood cell; SD, standard deviation.
of intraoperative transfusion, and operative time. No significant dif-
ferences were found between the groups for the other risk factors
studied.
Odds ratio of flap failure versus no flap failure and its 95% CI
for each significant risk factor are presented in Table 6 together with
the adjusted odds ratios and 95% CI from the multivariate analysis.
After adjustment, the significant risk factors for flap failure are an age
of 50 years or more, inpatient status, BMI of 25 or higher, tobacco
use, and operative time longer than 6 hours. Those who were 50
years of age or older had a 57% increased likelihood of flap failure
versus no flap failure than those younger than 50 years (adjusted
odds ratio: 1.57; 95% CI: 1.08–2.30; P=0.02). Inpatients were more
than 2 times more likely to experience flap failure versus no failure
(adjusted odds ratio: 2.14; 95% CI: 1.07–4.29; P=0.03). Using
those with normal BMI (<25) as the reference group, the likelihood
of flap failure versus no failure was 1.8 times more in the overweight
group (BMI 25, <30) (adjusted odds ratio: 1.80; 95% CI: 1.11–
2.9; P=0.02), and 3.75 times more in those who were morbidly
obese (BMI 35) (adjusted odds ratio: 3.75; 95% CI: 2.21–6.36; P
<0.001). Tobacco use had more than 2 times increased likelihood of
flap failure versus no flap failure (adjusted odds ratio: 2.05; 95% CI:
1.32–3.19; P<0.001), and intraoperative time longer than 6 hours
had more than a fourfold increased likelihood of flap failure versus
no failure (adjusted odds ratio: 4.35; 95% CI: 2.61–7.27; P<0.001).
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Nguyen et al Annals of Surgery rVolume 256, Number 2, August 2012
TABLE 4. Odds Ratios (OR) of SSI by Risk factors—Univariate and Multivariate Analysis
Univariate Analysis Multivariate Analysis
% SSI in Subgroup (SSI/Cases) Unadjusted OR (95% CI) Unadjusted PAOR (95% CI) Adjusted P
Age (yrs)
<50 3.07% (135/4400) 1.00 1.00
50 3.97% (195/4915) 1.31 (1.04, 1.63) 0.0211.13 (0.89, 1.43) 0.324
Race, N (%)
Asian/Pacific Islander
No 3.62% (328/9058) 1.00 1.00
Yes 0.78% (2/257) 0.21 (0.05, 0.84) 0.0090.29 (0.07, 1.17) 0.081
BMI, N (%)
<25: 2.02% (85/4211) 1.00 1.00
25, <30: 3.68% (98/2661) 1.86 (1.38, 2.49) <0.0011.61 (1.19, 2.18) 0.002
30, <35 5.33% (77/1445) 2.73 (2.00, 3.74) 2.28 (1.65, 3.16) <0.001
35: 7.41% (69/931) 3.89 (2.80, 5.39) 2.83 (1.99, 4.03) <0.001
Diabetes mellitus, N (%)
No 3.37% (299/8876) 1.00 1.00
Yes 7.06% (31/439) 2.18 (1.49, 3.20) <0.0011.37 (0.91, 2.06) 0.134
Alcohol
No 3.49% (321/9203) 1.00 1.00
Yes 8.04% (9/112) 2.42 (1.21, 4.82) 0.0182.74 (1.35, 5.57) 0.005
ASA
<3 3.05% (235/7697) 1.00 1.00
3+5.83% (94/1611) 1.97 (1.54, 2.52) <0.0011.49 (1.14, 1.94) 0.003
Inpatient/outpatient
Outpatient 2.67% (46/1721) 1.00 1.00
Inpatient 3.74% (284/7594) 1.41 (1.03, 1.94) 0.031.23 (0.88, 1.71) 0.222
Flap failure
No 3.32% (305/9191) 1.00 1.00
Yes 20.16% (25/124) 7.36 (4.68, 11.58) <0.0015.24 (3.25, 8.46) <0.001
Intraoperative time (h)
<3 2.71% (102/3768) 1.00 1.00
3, <6 3.74% (169/4520) 1.40 (1.09, 1.79) <0.0011.27 (0.98, 1.64) 0.071
6 5.74% (59/1027) 2.19 (1.58, 3.04) 1.67 (1.11, 2.50) 0.013
P<0.05 significant.
OR indicates odds ratio; AOR, adjusted odds ratio.
DISCUSSION
The risk factors associated with SSI, such as prolonged op-
erative time, preoperative radiation, and diabetes, have been well
characterized in various surgical oncologic populations25–27 but have
not yet been studied in patients having mastectomy with or without
immediate breast reconstruction. This analysis of more than 9300
cases demonstrated a 1% increase in the incidence of SSI in the im-
mediate breast reconstruction population (P<0.001). Although the
1% difference of SSI was statistically significant, it is not a clinically
important difference. If the same number of cases had provided an
incidence rate of 5.75% of SSI in immediate breast reconstruction,
the relative risk would be 2.33 and the 95% CI would be 2.1 to 2.58,
which would be outside the zone of clinical indifference.
According to the most recent report from the National Nosoco-
mial Infection Surveillance System,20 the 3 characteristics predictive
of infection were the following: (1) duration of operation more than
75th percentile for the specific operation, (2) ASA class, and (3)
wound class. In this study, operations lasting 6 or more hours and
those performed on patients with ASA class greater than 2 were at a
significantly increased risk of developing SSI.
Increased BMI was a significant risk factor for developing SSI,
and the risk increased in a stepwise fashion with increasing degrees
of obesity. Patients who were overweight had a 60% increased risk
of SSI compared with those who had normal BMI. Those who were
obese had a 2.3-fold increased likelihood of SSI, and patients who
were morbidly obese had 2.8-fold increased odds of SSI. Our find-
ing that obesity is an independent risk factor for SSI in immediate
breast reconstruction has previously been reported.2,4,8 The patho-
physiological processes regarding obesity and the development of
infections are not fully understood. However, one study stated that
excess adiposity predisposed to increased local tissue trauma related
to retraction and operative time, which in concert, contributed to in-
creased incidence of SSI.28 Preoperative alcohol use was also found
to be an independent risk factor for SSI. After adjusting for con-
founding risk factors, those who had documented heavy alcohol use
preoperatively were nearly 3 times more likely to develop SSI. In a
study of alcohol use in patients undergoing elective surgery, Nath et
al29 reported that those who had documented preoperative alcohol
use were at an increased risk of developing superficial and deep SSI,
but not organ space SSI. The increased rate of SSI in these patients
may be related to immunosuppression, as several studies have doc-
umented this effect from chronic alcohol exposure.30,31 ASA class
greater than 2 was another significant risk factor for SSI in this study,
which is in concordance with several other studies.11,20 ,32 ,33 Our
cutoff point of an ASA class of less than 3 and greater than 3
was based on several previous studies citing this segregation of
variables.11, 34 Examples of comorbidities that would classify a pa-
tient as ASA class 2 include well-controlled disease states includ-
ing diabetes, hypertension, or obesity. To qualify for ASA class 3,
one must have a severe systemic disease that results in functional
limitation such as diabetes with vascular complications, poorly con-
trolled hypertension, and morbid obesity, whereas more severe disease
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330 |www.annalsofsurgery.com C
2012 Lippincott Williams & Wilkins
Annals of Surgery rVolume 256, Number 2, August 2012 SSI in Immediate Breast Reconstruction
TABLE 5. Comparison of Risk Factors for Flap Failure in Immediate Breast Reconstruction
All Patients (n =9315) Presence of Flap Failure (n =124) No Flap Failure (n =9191) P
Age, mean (SD) 50.9 (10.3) 53.2 (9.8) 50.9 (10.3) 0.012
Race, N (%)
Non-Hispanic white 7243 (77.8%) 106 (85.5%) 7137 (77.7%) 0.079
African-American 611 (6.5%) 10 (8.1%) 601 (6.5%)
Hispanic white 410 (4.4%) 2 (1.6%) 408 (4.4%)
Asian/Pacific Islander 257 (2.8%) 2 (1.6%) 255 (2.8%)
Other & unknown 794 (8.5%) 4 (3.2%) 790 (8.6%)
Outpatient/inpatient, N (%)
Outpatient 1721 (18.5%) 9 (7.3%) 1712 (18.6%) 0.001
Inpatient 7594 (81.5%) 115 (92.7%) 7479 (81.4%)
BMI, N (%)
Mean (SD) 26.9 (6.1) 30.2 (6.8) 26.9 (6.1) <0.001
<25 4211 (45.5%) 30 (24.4%) 4181 (45.8%) <0.001
25, <30 2661 (28.8%) 42 (34.2%) 2.619 (28.7%)
30, <35 1445 (15.6%) 20 (16.3%) 1425 (15.6%)
35 931 (10.1%) 31 (25.2%) 900 (9.9%)
Diabetes mellitus, N (%)
No 8876 (95.3%) 116 (93.6%) 8760 (95.3%) 0.387
Yes 439 (4.7%) 8 (6.5%) 431 (4.7%)
Current smoker, N (%)
No 8053 (86.5%) 97 (78.2%) 7956 (86.6%) 0.011
Yes 1262 (13.6%) 27 (21.7%) 1235 (13.4%)
Alcohol
No 9203 (98.8%) 122 (98.4%) 9081 (98.8%) 0.662
Yes 112 (1.2%) 2 (1.6%) 110 (1.2%)
ASA
None/mild (<3) 7697 (82.7%) 93 (75.6%) 7604 (82.8%) 0.041
Severe/life threatening/moribund (3+) 1611 (17.3%) 30 (24.4%) 1581 (17.2%)
Steroids
No 9229 (99.1%) 123 (99.2%) 9106 (99.1%) 1.00
Yes 86 (0.9%) 1 (0.8%) 85 (0.9%)
Chemotherapy
No 8954 (96.1%) 120 (96.8%) 8834 (96.1%) 1.00
Yes 361 (3.9%) 4 (3.2%) 357 (3.9%)
Radiotherapy
No 9279 (99.6%) 123 (9.2%) 9156 (99.6%) 0.383
Yes 36 (0.4%) 1 (0.8%) 35 (0.4%)
RBC units transfused
<2 9268 (99.5%) 121 (97.6%) 9147 (99.6%) 0.021
2+44 (0.5%) 3 (2.4%) 41 (0.4%)
Intraoperative time (h)
3 3768 (40.5%) 28 (22.6%) 3740 (40.7%) <0.001
3, 6 4520 (48.5%) 55 (44.4%) 4465 (48.6%)
6 1027 (11.0%) 41 (33.0%) 986 (10.7%)
P<0.05 significant.
RBC indicates red blood cell; SD, standard deviation.
processes such as advanced pulmonary, renal, or hepatic dysfunction
are categorized as class 4. Lastly, examples of conditions found in
a moribund patient not expected to survive 24 hours without emer-
gent operation (ASA class 5) include ruptured abdominal aneurysm,
pulmonary embolus, and a head injury with increased intracranial
pressure.35 Several studies have found that those with a higher ASA
classification score have additional severe systemic comorbidities,
which place them at increased risk for complications other than
SSI.36, 37 Among the risk factors studied, flap failure, which included
mastectomy flap necrosis and full or partial failure of a transverse
rectus abdominus myocutaneous or free flap, had increased risk of
SSI. After adjusting for other risk factors, those with flap failure were
more than 5 times more likely to develop SSI. When flap failure
occurred, necrotic tissue may have served as a nidus for infection. Al-
ternatively, several rat studies have shown that local infection and/or
systemic sepsis contributed to thrombosis and flap failure.38,39 Sim-
ilarly, a retrospective review of late head and neck free-flap failures
identified a subset of patients with concomitant deep neck abscesses
and infections.40 Multivariate analysis on the risk factors for flap fail-
ure identified increased age, increased BMI, and prolonged operative
time as significant as risk factors. Those that are common to SSI and
flap failure are also increased age, increased BMI, and prolonged
operative time.
In this study, operative time of 6 or more hours was a significant
risk factor for developing SSI. This finding is consistent with those of
several other studies that have identified longer operative time as an
independent risk factor for SSI.32, 41– 43 Prolonged operative time may
correlate with prolonged exposure to microorganisms in the operating
room and additionally serve as a surrogate for case complexity, more
advanced disease, and difficulties encountered intraoperatively.42, 43 A
long operative time predisposes incisions to desiccation, which may
increase the probability of incisional contamination.32 This study
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2012 Lippincott Williams & Wilkins www.annalsofsurgery.com |331
Nguyen et al Annals of Surgery rVolume 256, Number 2, August 2012
TABLE 6. Odds Ratio (OR) of Flap Failure by Risk Factors in Univariate and Multivariate Analyses
Univariate Analysis Multivariate Analysis
Percentage SSI (SSI/Cases) Unadjusted OR (95% CI) Unadjusted PAOR (95% CI) Adjusted P
Age (yrs)
<50 1.02% (45/4400) 1.00 1.00
50 1.61% (79/4915) 1.58 (1.09, 2.28) 0.0151.57 (1.08, 2.30) 0.020
Outpatient/inpatient, N (%)
Outpatient 0.52% (9/1721) 1.00 1.00
Inpatient 1.51% (115/7594) 2.92 (1.48, 5.78) 0.0022.14 (1.07, 4.29) 0.032
BMI, N (%)
<25 0.71% (30/4211) 1.00 1.00
25, <30 1.58% (42/2661) 2.23 (1.40, 3.58) 0.0011.80 (1.11, 2.90) 0.017
30, <35 1.38% (20/1445) 1.96 (1.11, 3.46) 0.0211.55 (0.87, 2.76) 0.137
35 3.33% (31/931) 4.80 (2.89, 7.97) <0.0013.75 (2.21, 6.36) <0.001
Current Smoker, N (%)
No 1.20% (97/8053) 1.00 1.00
Yes 2.14% (27/1262) 1.79 (1.17, 2.76) 0.0082.05 (1.32, 3.19) 0.001
ASA
None/mild (<3) 1.21% (93/7697) 1.00 1.00
Severe/life threatening/moribund (3+) 1.86% (30/1611) 1.55 (1.02, 2.35) 0.0381.06 (0.69, 1.65) 0.782
RBC (units)
<2 1.31% (121/9268) 1.00 0.0051.00 0.116
2+6.82% (3/44) 5.53 (1.69, 18.11) 2.66 (0.79, 9.02)
Intraoperative time (h)
3 0.74% (28/3768) 1.00 0.0331.00 0.078
>3, 6 1.22% (55/4520) 1.65 (1.04, 2.60) <0.0011.53 (0.95, 2.44) <0.001
>6 3.99% (41/1027) 5.55 (3.42, 9.03) 4.35 (2.61, 7.27)
P<0.05 significant.
OR indicates odds ratio; AOR, adjusted odds ratio; RBC, red blood cell.
focused on risk factors for SSI in those having immediate recon-
struction after mastectomy. These findings may be a manifestation of
selection bias, because out of the 9315 patients who had immediate
breast reconstruction, only 4.2% were smokers (1262/9315), 3.49%
were on corticosteroid therapy (86/9315), 3.88% were on neoadju-
vant chemotherapy (361/9315), and 2.78% received preoperative ra-
diation (36/9315). It is a common belief that these factors predispose
to poor outcomes in immediate breast reconstruction,21,44–47 and the
low percentage of patients with these factors in this study group is
consistent with careful patient selection for immediate reconstruction
after mastectomy.48
To our knowledge, this is an analysis of the largest cohort of
patients (n =9315) to date identifying the incidence of SSI in pa-
tients undergoing mastectomy and immediate breast reconstruction.
The data included operations performed by multiple surgeons from
more than 200 institutions nationwide. Using the American College
of Surgeons’ National Surgical Quality Improvement database, we
found that the 1% difference in incidence of SSI between the imme-
diate breast reconstruction and the mastectomy alone populations was
statistically significant (P<0.001). Overall, the incidence of SSI in
all mastectomy patients, including those who underwent immediate
reconstruction, was 2.7% (95% CI: 2.5%–2.8%). Significant risk fac-
tors for SSI in patients undergoing immediate breast reconstruction
were also identified and included the following: obesity, ASA class
greater than 2, occurrence of flap failure, and operative time of 6 hours
or longer. In addition, we demonstrated the national trend for type
of immediate breast reconstruction, showing that prosthetic-based
reconstruction is the type of reconstruction most often performed.
This finding is congruent with current estimates of breast reconstruc-
tion trends49 and further validated the data. Further studies need to
be conducted to evaluate whether the type of breast reconstruction
(ie, prosthetic vs autologous flap) may affect risk of SSI in patients
undergoing immediate reconstruction.
Limitations
One of the limitations of our study is the retrospective design
in which secondary data analysis was performed using an existing
database. Therefore, some potential risk factors that we queried were
either not available or were not sufficient. Despite the 240 variables
captured in the database, factors such as surgeon experience, pro-
phylactic antibiotic use, triple antibiotic breast irrigation, intraoper-
ative soaking of acellular dermal matrices, duration of drain place-
ment, type and duration of postoperative antibiotic use, postoperative
hematoma and/or seroma were not available for analysis. Further-
more, among the factors that were captured, several had more than
20% missing data and were excluded from analysis.
CONCLUSIONS
This study demonstrated that patients who had immediate
breast reconstruction after mastectomy were more likely to expe-
rience SSI than those who did not have immediate reconstruction
(3.5% vs 2.5%; P<0.001). Increased BMI, alcohol use, ASA class
greater than 2, flap failure, and an operative time of 6 hours or longer
were significant risk factors for developing SSI in patients under-
going mastectomy with immediate breast reconstruction. Significant
risk factors for flap failure were an age of 50 years or more, BMI 25
or higher, and an operative time of 6 hours or longer.
ACKNOWLEDGMENTS
The authors would like to thank Dr. Mark Urata for his constant
mentorship and support.
REFERENCES
1. Watanabe A, Kohnoe S, Shimabukuro R, et al. Risk factors associated with
surgical site infection in upper and lower gastrointestinal surgery. Surg Today.
2008;38:404–412.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
332 |www.annalsofsurgery.com C
2012 Lippincott Williams & Wilkins
Annals of Surgery rVolume 256, Number 2, August 2012 SSI in Immediate Breast Reconstruction
2. Reichman DE, Greenberg JA. Reducing surgical site infections: a review. Rev
Obstet Gynecol. 2009;2:212–221.
3. Olsen MA, Chu-Ongsakul S, Brandt KE, et al. Hospital-associated costs due
to surgical site infection after breast surgery. Arch Surg. 2008;143:53–60;
discussion 61.
4. Mangram AJ. A brief overview of the 1999 CDC Guideline for the Preven-
tion of Surgical Site Infection. Centers for Disease Control and Prevention. J
Chemother. 2001;13:35–39.
5. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the
incidence of surgical-wound infection and shorten hospitalization. Study of
Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209–
1215.
6. Vilar-Compte D, Alvarez de Iturbe I, Martin-Onraet A, et al. Hyperglycemia
as a risk factor for surgical site infections in patients undergoing mastectomy.
Am J Infect Control. 2008;36:192–198.
7. Vilar-Compte D, Jacquemin B, Robles-Vidal C, et al. Surgical site infections
in breast surgery: case-control study. World J Surg. 2004;28:242–246.
8. Vilar-Compte D, Roldan-Marin R, Robles-Vidal C, et al. Surgical site infec-
tion (SSI) rates among patients who underwent mastectomy after the intro-
duction of SSI prevention policies. Infect Control Hosp Epidemiol. 2006;27:
829–834.
9. Vilar-Compte D, Rosales S, Hernandez-Mello N, et al. Surveillance, control,
and prevention of surgical site infections in breast cancer surgery: a 5-year
experience. Am J Infect Control. 2009;37:674–679.
10. Felippe WA, Werneck GL, Santoro-Lopes G. Surgical site infection among
women discharged with a drain in situ after breast cancer surgery. Wor l d J
Surg. 2007;31:2293–2299; discussion 2300–2301.
11. Olsen MA, Lefta M, Dietz JR, et al. Risk factors for surgical site infection after
major breast operation. J Am Coll Surg. 2008;207:326–335.
12. Lefebvre D, Penel N, Deberles MF, et al. Incidence and surgical wound infec-
tion risk factors in breast cancer surgery. Presse Med. 2000;29:1927–1932.
13. Alderman AK, Wilkins EG, Kim HM, et al. Complications in postmastectomy
breast reconstruction: two-year results of the Michigan Breast Reconstruction
Outcome Study. Plast Reconstr Surg. 2002;109:2265–2274.
14. Sullivan SR, Fletcher DR, Isom CD, et al. True incidence of all complications
following immediate and delayed breast reconstruction. Plast Reconstr Surg.
2008;122:19–28.
15. Patani N, Devalia H, Anderson A, et al. Oncological safety and patient sat-
isfaction with skin-sparing mastectomy and immediate breast reconstruction.
Surg Oncol. 2008;17:97–105.
16. Gerber B, Krause A, Dieterich M, et al. The oncological safety of skin sparing
mastectomy with conservation of the nipple-areola complex and autologous
reconstruction: an extended follow-up study. Ann Surg. 2009;249:461–468.
17. Giacalone PL, Rathat G, Daures JP, et al. New concept for immediate breast
reconstruction for invasive cancers: feasibility, oncological safety and esthetic
outcome of post-neoadjuvant therapy immediate breast reconstruction versus
delayed breast reconstruction: a prospective pilot study. Breast Cancer Res
Trea t. 2010;122:439–451.
18. Kim HJ, Park EH, Lim WS, et al. Nipple areola skin-sparing mastectomy
with immediate transverse rectus abdominis musculocutaneous flap recon-
struction is an oncologically safe procedure: a single center study. Ann Surg.
2010;251:493–498.
19. Ueda S, Tamaki Y, Yano K, et al. Cosmetic outcome and patient satisfaction
after skin-sparing mastectomy for breast cancer with immediate reconstruction
of the breast. Surgery. 2008;143:414–425.
20. National Nosocomial Infections Surveillance System. National Nosocomial In-
fections Surveillance (NNIS) System Report, data summary from January 1992
through June 2004, issued October 2004. Am J Infect Control. 2004;32:470–
485.
21. Vandeweyer E, Deraemaecker R, Nogaret JM, et al. Immediate breast recon-
struction with implants and adjuvant chemotherapy: a good option? Acta Chir
Belg. 2003;103:98–101.
22. Ingraham AM, Richards KE, Hall BL, et al. Quality improvement in surgery:
the American College of Surgeons National Surgical Quality Improvement
Program approach. Adv Surg. 2010;44:251–267.
23. Wolters U, Wolf T, Stutzer H, et al. ASA classification and perioperative
variables as predictors of postoperative outcome. Br J Anaesth. 1996;77:217–
222.
24. American College of Surgeons’ National Surgical Quality Improvement Pro-
gram. Chapter 4: Surgical Case Reviewer’s variables and definitions. Avail-
able at: http://nsqip.healthsoftonline.com/lib/Documents/Ch_4_Variables_
Definitions_062810.pdf. Accessed June 28, 2012.
25. Schwartz SR, Yueh B, Maynard C, et al. Predictors of wound complications
after laryngectomy: a study of over 2000 patients. Otolaryngol Head Neck
Surg. 2004;131:61–68.
26. Milet PR, Mallet Y, El Bedoui S, et al. Head and neck cancer surgery
in the elderly—does age influence the postoperative course? Oral Oncol.
2010;46:92–95.
27. Capone A, Valle M, Proietti F, et al. Postoperative infections in cytoreduc-
tive surgery with hyperthermic intraperitoneal intraoperative chemotherapy
for peritoneal carcinomatosis. J Surg Oncol. 2007;96:507–513.
28. Canturk Z, Canturk NZ, Cetinarslan B, et al. Nosocomial infections and obesity
in surgical patients. Obes Res. 2003;11:769–775.
29. Nath B, Li Y, Carroll JE, et al. Alcohol exposure as a risk factor for
adverse outcomes in elective surgery. J Gastrointest Surg. 2010;14:1732–
1741.
30. Nath B, Szabo G. Alcohol-induced modulation of signaling pathways in liver
parenchymal and nonparenchymal cells: implications for immunity. Semin
Liver Dis. 2009;29:166–177.
31. Szabo G, Mandrekar P. A recent perspective on alcohol, immunity, and host
defense. Alcohol Clin Exp Res. 2009;33:220–232.
32. Haridas M, Malangoni MA. Predictive factors for surgical site infection in
general surgery. Surgery. 2008;144:496–501; discussion 501–503.
33. Malone DL, Genuit T, Tracy JK, et al. Surgical site infections: reanalysis of
risk factors. J Surg Res. 2002;103:89–95.
34. Batista R, Kaye K, Yokoe DS. Admission-specific chronic disease scores as
alternative predictors of surgical site infection for patients undergoing coronary
artery bypass graft surgery. Infect Control Hosp Epidemiol. 2006;27:802–
808.
35. Cohen MM, Duncan PG, Tate RB. Does anesthesia contribute to operative
mortality? JAMA . 1988;260:2859–2863.
36. Fu KM, Smith JS, Polly DW, et al. Correlation of higher preoperative American
Society of Anesthesiology grade and increased morbidity and mortality rates
in patients undergoing spine surgery. J Neurosurg Spine. 2011;14:470–474.
37. Lomazzi C, Mariscalco G, Piffaretti G, et al. Endovasculartreatment of elective
abdominal aortic aneurysms: independent predictors of early and late mortality.
Ann Vasc Surg. 2010;25:299–305.
38. McLean NR, Ellis H. How does sepsis promote thrombosis in microvascular
anastomoses? Br J Plast Surg. 1989;42:314–317.
39. Luk KD, Zhou LR, Chow SP. The effect of established infection on microvas-
cular surgery. Plast Reconstr Surg. 1987;80:423–427.
40. WaxMK, Rosenthal E. Etiology of late free flap failures occurring after hospital
discharge. Laryngoscope. 2007;117:1961–1963.
41. Leong G, Wilson J, Charlett A. Duration of operation as a risk factor for
surgical site infection: comparison of English and US data. J Hosp Infect.
2006;63:255–262.
42. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by
wound class, operative procedure, and patient risk index. National Nosocomial
Infections Surveillance System. Am J Med. 1991;91:152S–157S.
43. Garibaldi RA, Cushing D, Lerer T. Risk factors for postoperative infection.
Am J Med. 1991;91:158S–163S.
44. Cowen D, Gross E, Rouannet P, et al. Immediate post-mastectomy breast
reconstruction followed by radiotherapy: risk factors for complications. Breast
Cancer Res Treat. 2010;121:627–634.
45. Neumayer L, Hosokawa P, Itani K, et al. Multivariable predictors of post-
operative surgical site infection after general and vascular surgery: results
from the patient safety in surgery study. J Am Coll Surg. 2007;204:1178–
1187.
46. Vandeweyer E, Deraemaecker R. Radiation therapy after immediate breast
reconstruction with implants. Plast Reconstr Surg. 2000;106:56–58; discussion
59–60.
47. Christante D, Pommier SJ, Diggs BS, et al. Using complications as-
sociated with postmastectomy radiation and immediate breast recon-
struction to improve surgical decision making. Arch Surg. 2010;145:
873–878.
48. Hu YY, Weeks CM, In H, et al. Impact of neoadjuvant chemotherapy on breast
reconstruction. Cancer. 2011;117:2833–2841.
49. American Society of Plastic Surgeons. 2009 Reconstructive Surgery Trends.
Arlington Heights, IL: Department of Public Relations; 2010.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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    • "These factors also influence the prognosis of the disease[7]. Because IBR is an additional surgical procedure, it may increase postoperative complications (such as flap necrosis, infection, hematoma)[8,9] and delay the initial time to adjuvant chemotherapy in some patients[10,11]. Adjuvant chemotherapy, an important component of systemic therapy for patients with breast cancer, decreases disease recurrence and improves survival. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: An increasing number of patients with breast cancer are being offered immediate breast reconstruction (IBR). The aim of this study was to analyze the impact of IBR on the prognosis of patients with breast cancer. Methods: We searched the electronic databases of Medline (Pubmed), ISI Web of Knowledge, Embase, and Google Scholar databases for studies reporting the overall recurrence, disease-free survival (DFS), and overall survival (OS) of patients after mastectomy only and mastectomy with IBR. With these data, we conducted a meta-analysis of the clinical outcomes. Results: Fourteen studies, including 3641 cases and 9462 controls, matched our criteria. Relevant information was extracted from these 14 studies. There was no significant heterogeneity (P for Q-statistic > 0.10 and I2 < 25%). Patients who underwent IBR showed no increased risk of overall recurrence of breast cancer (RR = 0.89; 95% confidence interval [CI]: 0.75, 1.04; P = 0.14). Furthermore, patients receiving IBR had similar DFS (RR = 1.04; 95%CI: 0.99, 1.08); P = 0.10) and OS (RR = 1.02; 95%CI: 0.99, 1.05; P = 0.24)) as those of control patients. Conclusion: This meta-analysis provides evidence that IBR does not have an adverse effect on prognosis. These data suggest that IBR is an appropriate and safe choice for patients with breast cancer.
    Full-text · Article · May 2015
  • [Show abstract] [Hide abstract] ABSTRACT: To date, few large-scale studies have reported the incidence of surgical-site infection in women undergoing mastectomy with respect to the various methods of immediate breast reconstruction. This study assessed whether the reconstruction method was associated with the risk of surgical-site infection in these patients. Using the National Surgical Quality Improvement Program database, 9230 female patients undergoing mastectomy with immediate reconstruction from 2005 to 2009 were identified. Reconstruction was classified as autologous, prosthetic, or hybrid. The primary outcome was the incidence of surgical-site infection within 30 days of operation. Univariate and multivariate analyses were performed to derive the unadjusted and adjusted risk of surgical-site infection according to reconstruction method. The overall rate of surgical-site infection was 3.53 percent (95 percent CI, 3.15 to 3.94 percent), with individual rates of 3.33 percent (95 percent CI, 2.93 to 3.76 percent) for prosthetic reconstruction, 4.88 percent (95 percent CI, 3.48 to 6.11 percent) for autologous reconstruction, and 2.19 percent (95 percent CI, 0.88 to 4.45 percent) for hybrid reconstruction. The adjusted odds ratio of surgical-site infection was 1.14 (95 percent CI, 0.83 to 1.58; p = 0.42) for autologous versus prosthetic methods and 0.59 (95 percent CI, 0.27 to 1.27; p = 0.18) for hybrid versus prosthetic methods. Although the risk of surgical-site infection in patients undergoing immediate reconstruction is highest with autologous and lowest with hybrid methods of reconstruction, the difference in infection risk was not statistically significant after adjustment for confounding factors. Thus, all methods of reconstruction are viable options with regard to risk for surgical-site infection. Risk, III.
    Full-text · Article · Jul 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Alcohol abuse appears to increase postoperative complications, but clinical trials have reported conflicting results. The objective of this systematic review and meta-analysis is to clarify how alcohol drinking affects postoperative surgical site infection and anastomotic leakage and to determine the impact of perioperative alcohol intervention. The databases MEDLINE, EMBASE, and CENTRAL were searched. Observational studies assessing surgical site infection and anastomotic leakage for alcohol drinkers and randomized controlled trials (RCTs) studying perioperative alcohol interventions were included. Meta-analyses were performed with random effects models. Methodological quality was assessed by the Newcastle-Ottawa Scale and Cochrane methodology. Fifteen observational studies and 2 RCTs were identified. Meta-analyses were performed for alcohol drinkers vs nondrinkers and moderate drinkers (≤2 U/day), respectively. No difference between alcohol drinkers and nondrinkers was found. When drinkers and moderate drinkers were compared, a significantly higher incidence of surgical site infection and anastomotic leakage was found in unadjusted studies. In the meta-analysis of studies adjusting for smoking and age, alcohol drinking did not significantly affect surgical site infection and anastomotic leakage. The RCTs did not show any effect of perioperative alcohol abstinence or pharmacological withdrawal treatment on outcome. Alcohol drinking is not an independent risk factor for surgical site infection and anastomotic leakage. Interventions which aim to make patients quit alcohol or treat withdrawal symptoms do not seem to affect the surgical outcomes of interest.
    Full-text · Article · Jul 2013
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