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Kim DK, Rohde CH. Five-item modified frailty index does not outperform diabetes and hypertension alone in prediction of complications after breast reconstruction. J Plast Reconstr Aesthet Surg 2024; 98:255-257. [PMID: 39303341 DOI: 10.1016/j.bjps.2024.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 09/11/2024] [Accepted: 09/13/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE Existing literature has emphasized the utility of the five-item modified frailty index (mFI-5) in predicting postoperative outcomes after surgical procedures. However, in breast reconstruction, a primarily elective post-oncologic procedure for otherwise relatively healthy patients, several components of the index may be sparse and not strongly contribute to predictive value. METHODS Breast reconstruction cases were identified in the 2012-2022 National Surgical Quality Improvement Program. Three metrics were compared in this cohort: 1) the mFI-5, 2) a simplified two-item index comprising diabetes and/or hypertension, and 3) American Society of Anesthesiologists (ASA) class. Each metric was incorporated into three multivariate logistic regression models for occurrence of at least one postoperative complication. Predictive performance among metrics was compared over fifty iterations (p < 0.05). Performance was compared between autologous and implant-based modalities in a supplementary analysis. RESULTS 134,983 breast reconstruction cases were identified in the final cohort. In multivariate regression, both MFI and the two-item index of diabetes and hypertension were significant predictors of postoperative complications (p < 0.001). The mFI-5 (average AUC: 0.6106) and two-item index (average AUC: 0.6105) performed without significant difference (p = 0.93). Discriminatory performance of ASA class (average AUC: 0.6115), was not significantly different from the other metrics (p > 0.05). CONCLUSIONS In the context of a population of mainly elective breast reconstruction procedures, the five-item modified frailty index does not outperform an index of diabetes and hypertension alone. Such findings may motivate the selection of other variables that may be more useful for prediction of postoperative outcomes.
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Affiliation(s)
- Dylan K Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia, University Irving Medical Center, New York, NY, USA
| | - Christine H Rohde
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia, University Irving Medical Center, New York, NY, USA.
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Othman S, Robinson E, Kamdar D, Pereira L, Miles B, Kasabian A, Ricci JA, Knobel D. Microvascular Free-Flap Head and Neck Reconstruction: The Utility of the Modified Frailty Five-Item Index. J Reconstr Microsurg 2024. [PMID: 39038462 DOI: 10.1055/s-0044-1788540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate preoperative assessment can aid in appropriate risk stratification and peri-operative optimization. The modified five-item frailty index (mFI-5) is a validated risk-assessment scale; however, its utility in head and neck free-flap reconstruction is unknown when compared with other common risk factors. METHODS A retrospective, single-institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A high mFI-5 score was defined as greater than 2. The total score, as well as other patient factors, was correlated to postoperative flap complications. RESULTS A total of 214 patients were deemed appropriate for conclusion. The mean age was 63.9 ± 12.8 years. There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent preoperative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any postoperative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p < 0.019) and total flap loss (16.7% vs. 6.6%, p < 0.033). Preoperative radiation was found to be associated with an increased complication rate (p < 0.003). CONCLUSION The mFI-5 score may be a potentially significant tool in the risk stratification of patients undergoing head and neck free-flap reconstruction as opposed to commonly utilized risk factors. Preoperative radiotherapy is significantly associated with postoperative complications. Appropriate preoperative assessment may help tailor patient care preoperatively.
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Affiliation(s)
- Sammy Othman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
| | - Emma Robinson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, New York, New York
| | - Dev Kamdar
- Department of Otolaryngology, Northwell Health, New Hyde Park, New York, New York
| | - Lucio Pereira
- Department of Otolaryngology, Northwell Health, New Hyde Park, New York, New York
| | - Brett Miles
- Department of Otolaryngology, Northwell Health, New Hyde Park, New York, New York
| | - Armen Kasabian
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
| | - Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
| | - Denis Knobel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
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Honig SE, Habarth-Morales TE, Davis HD, Niu EF, Amro C, Broach RB, Serletti JM, Azoury SC. Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases. J Reconstr Microsurg 2024. [PMID: 38866038 DOI: 10.1055/s-0044-1787728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Autologous breast reconstruction (ABR) after mastectomy is increasing due to benefits over implant-based reconstruction. However, free flap reconstruction is not universally offered to patients of advanced age due to perceived increased perioperative risk. METHODS Patients undergoing free flap breast reconstruction at our institution from 2005 to 2018 were included. Risk-adjusted logistic regression models were fit while controlling for demographic and comorbid characteristics to determine the association of age with the probability of venous thromboembolism (VTE), delayed healing, skin necrosis, surgical site infection (SSI), seroma, hematoma, hernia, and flap loss. Linear predictions from risk-adjusted logistic regression models were used to create spline curves and determine the risk of outcomes associated with age. RESULTS A cohort of 2,598 patients underwent free flap breast reconstruction in the period examined. The median age was 51 with approximately 9% of patients being 65 or older. Increased age was associated with a greater risk of delayed healing, skin necrosis, and hematoma after surgery. There was no increased risk of medical complications such as VTE or complications such as flap loss, seroma, or SSI. CONCLUSION A set age cutoff for patients undergoing free flap breast reconstruction does not appear warranted. There is no difference in major surgical complications such as flap loss with increasing age. However, older age does predispose patients to specific wound complications such as hematoma, skin necrosis, and delayed wound healing, which should guide preoperative counseling. Further, medical complications do not increase with advanced age. Overall, however, the safety of ABR in older patients appears uncompromised.
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Affiliation(s)
- Stephanie E Honig
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Theodore E Habarth-Morales
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Harrison D Davis
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Ellen F Niu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Chris Amro
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Jia E, Garvey SR, Chen A, Bustos VP, Morgenstern M, Friedman R, Lee BT, Dowlatshahi AS, Cauley RP. Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database. J Reconstr Microsurg 2024; 40:163-170. [PMID: 37236241 DOI: 10.1055/a-2102-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed. RESULTS In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05). CONCLUSION While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.
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Affiliation(s)
- Emmeline Jia
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R Garvey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Monica Morgenstern
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan S Dowlatshahi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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