ABSTRACT
Background: Immediate tissue expander (TE) breast reconstruction is reported to have the highest rate of postoperative infection among reconstructive modalities. The risk of infection is higher among patients treated at safety-net hospitals. Objectives: The goal of this study was to identify significant contributing factors to the elevated infection risk at our major safety-net institution. Methods: A retrospective chart review was conducted on all TE-based reconstruction patients with a diagnosis of postoperative infection between 2015 and 2019. Preoperative, perioperative, and postoperative risk factors for infection were determined and compared across patient and procedure demographics. Results: Two hundred forty-three patients, for a total of 412 breast reconstructions, were included in our study. Significant preoperative selection factors were identified to contribute to the elevated risk of infection, including the following: older age, higher BMI, and diabetes. Significant intraoperative and postoperative contributing factors included greater mastectomy weight, larger TE's and intraoperative fill volume, and longer drain duration. Doxycycline treatment for infected patients resulted in a significantly higher rate of resolution. Conclusions: Safety-net hospital population patients undergoing TE breast reconstruction are at higher risk for postoperative infection. Personal and procedural risk factors are identified. Balancing the benefits of immediate breast reconstruction with TEs with the elevated risk of postoperative infection remains challenging. Implementation of more stringent eligibility criteria may help mitigate the risk of infection.
ABSTRACT
BACKGROUND: The practice of tracking and analyzing surgical outcomes is essential to becoming better surgeons. However, this feedback system is largely absent in residency training programs. Thus, we developed a Surgery Report Card (SRC) for residents performing tissue expander (TE)-based breast reconstruction and report our initial experience with its implementation. METHODS: We performed a systematic review and meta-analysis for TE-based breast reconstructions and compared outcomes to our retrospective cohort. The primary outcome was overall complications. The SRC compares patient and complication statistics for resident-led teams to the meta-analysis. RESULTS: The meta-analysis included 12 studies, with 2093 patients (2982 breasts) that underwent TE-based reconstruction. The pooled complication rate was 26.9%; infection was most common (8.3%); failure rate was 5.9%. Our cohort included 144 patients (245 breasts) among 13 resident-led teams. Overall complication rate was 31.8%; infections were most frequent (17.6%) and failure rate was 7.3%. Our cohort had significantly higher BMIs (29.7 vs 25.4, p<0.0001) more diabetics (6.9% vs. 3.2%, p = 0.02), and more patients receiving adjuvant radiation therapy (41.4 vs 26.3%, p<0.0001). Every 3 months, residents receive a customized SRC of their cases, with the meta-analysis used as a benchmark. A survey demonstrated the SRC made residents reconsider surgical technique and more conscientious surgeons, and would like it implemented for other procedures during residency. CONCLUSIONS: The implementation of our SRC for TE-based breast reconstruction establishes a baseline for surgical performance comparison for residents, demonstrates that residents can safely perform the procedure, and allows for critiquing of surgical techniques to improve patient care.
