Impact of Surgeon and Surgical Team on Outcomes in Immediate Implant Based Breast Reconstruction

Purpose

This study aims to answer two questions. First, whether outcomes in immediate implant breast reconstruction (IBR) can be correlated to surgical oncologist, plastic surgeon, or both. And second, if procedure volume per team matters.

Summary background data

Outcome studies examining IBR have failed to include oncologic resections and surgical team alongside reconstruction endpoints. A complete evidence-based approach to best practices must consider the collaboration of the two surgeons. Further, there is evidence that high-volume teams in surgery achieve reduced rates of adverse events. It is hypothesized that skin flap viability is a function of the mastectomy rather than reconstructive techniques and that low- volume teams have higher complication rates.

Methods

A retrospective review of 3,142 consecutive mastectomy procedures counted by breast from 4/2004 to 9/2013 at one institution was performed. This study takes advantage of the fact that a large volume patient population is treated by small groups of collaborating surgical oncologists (4) and plastic surgeons (5), where outcome can be assessed with reasonable denominator of patients.  Experienced high-volume (>200 procedures) surgeons were evaluated and compared to colleagues in their respective cohorts individually and in teams. Rates of infection, skin necrosis, and local recurrence were measured. Multiple logistic regressions were performed to identify independent predictive factors of outcome differences.

Results

Four mastectomy surgeons and five plastic surgeons formed 20 surgical teams, sharing a patient population of equal characteristics. Total complication rate due to infection or skin necrosis was 5.98%.  Significant differences in rate of skin necrosis could be seen between mastectomy surgeons (OR= 0.90-1.93, p<0.01), but not plastic surgeons (OR= .60-1.20, p>0.05). Higher rates of necrosis did not correlate with lower rates of local recurrence. Teams that worked together on less than 150 procedures had a higher rate of complications (OR=1.92, p<0.01) and infection (OR= 2.24, p<0.01).

Conclusion

This study shows that skin necrosis following mastectomy with immediate prosthetic reconstruction is associated with the mastectomy surgeon, likely due to thinner mastectomy flaps, yet a concomitant decrease in local cancer recurrence was not seen. It is important to find a consensus on achieving both viable skin flaps and oncologic safety to guarantee successful results. High-volume teams were shown to achieve lower rates of adverse events, highlighting the need to further investigate team behavior in IBR.