J Breast Cancer.  2013 Dec;16(4):426-431. 10.4048/jbc.2013.16.4.426.

Synergistic Interactions with a High Intraoperative Expander Fill Volume Increase the Risk for Mastectomy Flap Necrosis

• Khavanin N
• Jordan S
• Lovecchio
• Fine NA
• Kim J

• KMID: 1976381
• DOI: http://doi.org/10.4048/jbc.2013.16.4.426

Abstract

PURPOSE
Prosthetic-based breast reconstruction is performed with increasing frequency in the United States. Major mastectomy skin flap necrosis is a significant complication with outcomes ranging from poor aesthetic appearance to reconstructive failure. The present study aimed to explore the interactions between intraoperative fill and other risk factors on the incidence of flap necrosis in patients undergoing mastectomy with immediate expander/implant-based reconstruction.
METHODS
A retrospective review of 966 consecutive patients (1,409 breasts) who underwent skin or nipple sparing mastectomy with immediate tissue expander reconstruction at a single institution was conducted. Age, body mass index, hypertension, smoking status, premastectomy and postmastectomy radiation, acellular dermal matrix use, and application of the tumescent mastectomy technique were analyzed as potential predictors of flap necrosis both independently and as synergistic variables with high intraoperative fill. The following three measures of interaction were calculated: relative excess risk due to interaction, attributable proportion of risk due to interaction, and synergy index (SI).
RESULTS
Intraoperative tissue expander fill volume was high (> or =66.7% of the maximum volume) in 40.9% (576 of 1,409 breasts) of cases. The unadjusted flap necrosis rate was greater in the high intraoperative fill cohort than in the low fill cohort (10.4% vs. 7.1%, p=0.027). Multivariate logistic regression did not identify high intraoperative fill volume as an independent risk factor for flap necrosis (odds ratio 1.442, 95% confidence interval 0.973-2.137, p=0.068). However, four risk factors were identified that interacted significantly with intraoperative fill volume, namely tumescence, age, hypertension, and obesity. The SI, or the departure from additive risks, was largest for tumescence (SI, 25.3), followed by hypertension (SI, 2.39), obesity (SI, 2.28), and age older than 50 years (SI, 1.17).
CONCLUSION
In the postmastectomy, hypovascular milieu, multiple risk factors decreasing flap perfusion interact with high intraoperative fill volume to cross a threshold and synergistically increase the risk of flap necrosis.

Keyword

Complications; Mammaplasty; Mastectomy; Necrosis; Tissue expansion devices

MeSH Terms

Acellular Dermis
Body Mass Index
Cohort Studies
Female
Humans
Hypertension
Incidence
Logistic Models
Mammaplasty
Mastectomy*
Necrosis*
Nipples
Obesity
Perfusion
Retrospective Studies
Risk Factors
Skin
Smoke
Smoking
Tissue Expansion Devices
United States
Smoke

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