Reconstructive Surgery

Preoperative Risk Assessment: Applying the BRA Score Risk Calculator to Define Patients at a Higher Risk for Developing Breast Reconstruction Surgical Complications

The Breast Reconstruction Risk Assessment (BRA Score) is a calculator found online¹ that has been proposed to assess the preoperative risk of different breast reconstruction techniques.²⁻³ The BRA Score uses patient information such as age, body mass index, presence of comorbidities, smoking status, type of cancer treatment, and type of reconstruction to estimate the risk of surgical complications. This study aimed to validate the BRA Score as a preoperative risk calculator for its practical use in a review of 941 patients who underwent 1390 breast reconstructions of various types from 2009–2011.

Using the BRA score, institute researchers calculated a patient’s risk of overall surgical complication risk (comp-risk) and surgical site infection risk (SSI-risk) for 30 days and 1 year postsurgery, in addition to a 30-day reoperation risk (reop-risk). The statistical test receiver operating characteristics (ROC) curve was used to evaluate the calculated risk from the BRA Score as a test to predict which patients would encounter certain complications. The larger the area under the curve (AUC), the better a specific test is as a predictor.

The BRA Score was calculated for direct to implant technique in 23 breasts, free-flaps in 287 breasts, latissimus in 108 breasts, pedicled transverse rectus abdominus myocutaneous (TRAM) in 70 breasts, and tissue expander in 902 breasts. Compared with patients who did not develop the expected complication (group 2), patients who did develop the expected complication (group 1) had a significantly higher 30-day comp-risk, 1-year comp-risk, 30-day SSI-risk, and reop-risk. The predicted risk and the actual complications that were observed demonstrate that the complications observed were on the predicted range most of the time.

In this patient population, the BRA Score was a helpful tool to predict 30-day comp-risk and 30-day SSI-risk. The smaller the predicted risk of complications, the lower the chance of developing a surgical complication. The risk that a patient is willing to take is still to be defined in a case-by-case basis after thorough discussion between the patient and the surgeon.

BRA Score Predicted Risk (N = 941)

2009 - 2011

Type of Complication Developed Complication (BRA Score ± SD) Did Not Develop Complication (BRA Score ± SD) P value
Overall surgical complications (30 days) 22.06 ± 9.69 17.16 ± 7.94 < 0.001
Overall surgical complications (1 year ) 21.99 ± 13.66 18.73 ± 10.78 < 0.001
Surgical site infection (30 days) 6.86 ± 4.21 4.73 ± 4.43 < 0.001
Surgical site infection (1 year) 7.03 ± 7.96 7.89 ± 6.85 0.937
Overall clinical complications (30 days) 6.69 ± 7.19 4.94 ± 7.34 0.170
30-day reoperation 7.26 ± 3.18 6.48 ± 3.49 0.015
Predicted/Developed Complications Per Breast Reconstruction Technique (N = 941)

2009 - 2011

BRA Score Risk Overall Postoperative Complications 30 Days Reoperations 30 Days Surgical Site Infection Risk 30 Days Medical Complication Risk 30 Days
Predicted Developed Predicted Developed Predicted Developed Predicted Developed
Tissue Expander (N = 902) 14.44 ± 4.70% 14.63% 5.57 ± 2.90% 7.09% 4.14 ± 2.52% 2.32% 2.03 ± 1.01% 2.32%
Free flaps (N = 287) 23.73 ± 5.85% 33.79% 9.67 ± 3.15% 14% 6.43 ± 3.20% 5.9% 13.55 ± 6.11% 2.4%
Latissimus dorsi (N = 108) 25.15 ± 9.70% 26.85% 4.59 ± 2.05% 11.11% 4.22 ± 4.87% 5.55% 5.08 ± 16.76% 2.77%
Pedicled TRAM (N = 70) 32.70 ± 8.65% 37.14% 9.46 ± 3.48% 12.85% 7.60 ± 7.40% 11.42% 7.42 ± 5.03% 5.71%
All combined (N = 1390) 18.17 ± 8.56% 20.64% 6.5 5 ±3.46% 4.60% 4.81 ± 4.43% 1.51% 4.97 ± 7.36% 1.51%

TRAM = transverse rectus abdominus myocutaneous

References
  1. Breast Reconstruction Risk Assessment (BRA Score) available at: http://www.brascore.org/

  2. Kim JYS, Khavanin N, Jordan SW, ver Halen JP, Mlodino AS, Bethke KP, Khan SA, Hansen NM, Losken A, Fine NA. Individualized Risk of Surgical-Site Infection: An application of the Breast Reconstruction Risk Assessment Score. Plast & Reconst Surg 2014; 134(3):351e-362e.

  3. Kim JY, Mlodinow AS, Khavanin N, et al. Individualized risk of surgical complications: An application of the breast reconstruction risk assessment score. Plast & Reconstr Surg Glob Open. 2015; 3(5):e405.