Secondary Procedures following Microsurgical Breast Reconstruction: An Analysis of the Nationwide Inpatient Sample

Purpose: Descriptive studies on breast reconstruction utilizing free flaps (FF) are often a review of high volume centers that may not represent the national average.¹ The goals of the current study are 1) to identify the rate of return to the operating room (ROR) during initial hospital stay in patients undergoing FF breast reconstruction and 2) to determine how FF type and ROR impacts patient care.

Methods: We identified patients in the Nationwide Inpatient Sample (NIS) database who received a single FF procedure for breast reconstruction in 2009 and 2010.  ROR was defined as a vascular repair, a surgical breast procedure, or a surgical skin procedure after their initial FF. Statistical analysis was performed to assess the impact of FF type and ROR on inpatient length of stay (LOS) and hospital costs.

Results: In 2009 and 2010, 1,888 patients underwent a single FF for breast reconstruction. Overall ROR rate was 7.8%. There was a significant relationship between FF type and any re-operative procedure (p<0.0001) where superficial inferior epigastric artery (SIEA) (24.3%) and gluteal artery perforator (GAP) (17.4%) FF were associated with greater ROR than free transverse rectus abdominis myocutaneous (fTRAM) (5.5%) and deep inferior epigastric artery perforator (DIEP) (9.0%) FF (Figure 1). Those with a ROR had a significantly longer mean LOS than those without (8.3 days vs. 4.3 days, p<0.0001). No significant difference was seen in LOS across FF types. The cost of inpatient care in those with a ROR was almost twice as high as those without ($39,581 vs. $21,215, p<0.0001). Costs ranged between $21,044 (fTRAM) and $32,859 (GAP) (p<0.0001).

Conclusion: The NIS database ROR rate during the initial inpatient stay for microvascular breast reconstruction was 7.8%. Those that received a SIEA or GAP FF were more likely to receive a subsequent surgical procedure. ROR was associated with a longer LOS and higher hospital costs. Despite no discernible difference in LOS across FF types, GAP FF were associated with a significantly higher average inpatient cost.