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A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema
Marten N. Basta, B.S., John P. Fischer, MD, Suhail K. Kanchwala, MD, Liza C. Wu, MD, Joseph M. Serletti, MD, Julia C. Tchou, MD, Yun R. Li, BS, Stephen J. Kovach, MD, Joshua Fosnot, MD.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: While recent literature suggests lower incidence of lymphedema with breast reconstruction, controversy remains surrounding considerable study design limitations. We evaluated lymphedema incidence after axillary dissection in a propensity-matched cohort of patients with and without immediate breast reconstruction.
METHODS: Retrospective review of all patients undergoing mastectomy with axillary lymphadenectomy +/- immediate reconstruction from 1/2000-6/2013 was conducted. Comorbidities, neoadjuvant/adjuvant therapy, and operative characteristics, including mastectomy laterality, reconstructive modality, and tumor and axillary content characteristics, were reviewed. Lymphedema was defined by ICD-9 diagnosis. Univariate comparison of baseline factors facilitated matching of non-reconstructed and reconstructed cohorts by age, BMI, mastectomy laterality, cardiovascular disease, and hypertension. Multivariate regression of associated risk factors identified independent predictors of lymphedema.

RESULTS:
Of 4,647 patients identified, 2,296 had axillary lymphadenectomy (928-no reconstruction; 979-autologous reconstruction; 389-implant reconstruction). Propensity-scoring matched 234 non-reconstructed and 234 reconstructed patients. Only renal (p=0.03) and pulmonary disease (p=0.02) remained more common in non-reconstructed patients after matching.
Lymphedema was diagnosed in 26.1% of patients 27.7 months post-operatively. Obesity, hypertension, bilateral mastectomy, presence of multiple comorbidities, prior chemotherapy or radiation, and post-operative radiation were associated with lymphedema incidence; however, adjusted regression found only obesity (OR=2.42, p<0.0001) and post-operative radiation (OR=3.14, p<0.0001) remained predictive of lymphedema. Breast reconstruction demonstrated a similar incidence of lymphedema (OR=0.95, p=0.83).

CONCLUSION:
Overall lymphedema incidence was 26.1% post-axillary dissection. Propensity-matched regression suggests reconstruction, regardless of modality, does not alter lymphedema risk, while obesity and post-operative radiation greatly increase risk. These evidence-based findings may enhance pre-operative guidance and patient selection to mitigate complications.


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