Preoperative and Intraoperative Predictors of Prolonged Length of Stay in Autologous Breast Reconstruction: A Stratified Analysis Using 2011-2023 ACS-NSQIP Datasets.

INTRODUCTION

Length of stay (LOS) following postmastectomy breast reconstruction varies based on patient characteristics, surgical technique, and perioperative factors. Identifying independent predictors of prolonged LOS can improve preoperative planning and optimize resource utilization. Although multiple studies have evaluated outcomes following breast reconstruction, factors independently associated with LOS across different autologous reconstruction techniques remain incompletely characterized.

METHODS

A retrospective cohort study was conducted using American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2023. Patients were stratified by reconstruction type: free flap, pedicled transverse rectus abdominis myocutaneous (PTRAM), and latissimus dorsi (LD) flap reconstruction. Descriptive analyses evaluated LOS across demographic, clinical, and operative variables. Multivariable linear regression models were constructed separately for each reconstruction type to identify independent predictors of LOS.

RESULTS

A total of 28,658 autologous breast reconstruction cases were included. The mean operative time differed substantially across the reconstruction types, with free flap averaging 470.54 min, PTRAM 350.44 min, and LD flaps 257.27 min (P < 0.0001). Corresponding mean LOS was 3.71 d for free flaps, 3.97 d for PTRAM, and 2.29 d for LD flaps. In multivariable analyses, operative time was the strongest predictor of LOS across all reconstruction types. Among free-flap patients, increasing age (β = 0.0094 per year, P < 0.0001), black race (β = 0.2356, P < 0.0001), higher body mass index (β = 0.0176 per kg/m2, P < 0.0001), insulin-dependent diabetes, and longer operative time were associated with increased LOS. Concurrent procedures and later surgical eras were associated with shorter LOS. In PTRAM reconstruction, operative time remained the only significant predictor of LOS. In LD reconstruction, operative time, smoking status, and surgical era were associated with LOS.

CONCLUSIONS

Across autologous breast reconstruction techniques, operative time emerged as the most consistent predictor of hospital LOS. Although demographic and comorbidity factors influenced LOS in select cohorts, procedural efficiency and evolving perioperative care pathways appear to play a greater role in determining hospitalization duration following reconstruction.