Flap Failure in 2013: A Perfect Year for American College of Surgeons National Surgical Quality Improvement Program Microsurgeons?

Abstract

Sir: In an ongoing analysis of the predictors of flap failure in autologous breast reconstruction, our team began to integrate the recently available 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File to our database. Immediately, the incidence of flap failure in each type of reconstruction dropped. This was initially perceived as an immense improvement of microsurgical techniques, so we decided to look at the incidence of flap failure over time (Fig. 1). However, not a single flap failure was reported in any of the 2895 patients undergoing autologous breast reconstruction procedures in 2013. Backtracking, we looked at flap failure in all 651,940 surgical patients recorded in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File: not a single complication of graft, prosthesis, or flap failure was reported.Fig. 1: Incidence of flap failure in autologous breast reconstruction over time.This finding can signify one of a few things: 2013 could have been the perfect year for American College of Surgeons National Surgical Quality Improvement Program microsurgeons, with not one flap failing in any of the reported cases. Flap failure may have been dropped from the list of reported variables that the American College of Surgeons National Surgical Quality Improvement Program collects. However, this is not described in the User Guide for the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File,1 and they continue to include it as a reported variable. By chance, the systematic sampling process that the American College of Surgeons National Surgical Quality Improvement Program uses for case inclusion missed all of the flap failures and only recorded the successful microsurgical patients. The incidence of flap failure is estimated to be around 2 percent,2,3 and the American Society of Plastic Surgeons reports that there were 19,511 total autologous breast reconstructions performed in 2013,4 so it can be estimated that there were 3902 flap failures in 2013. The chance of the 2013 National Surgical Quality Improvement Program database missing all of these flap failures is less than 0.001 percent. Flap failure was reported improperly in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File. The American College of Surgeons National Surgical Quality Improvement Program Database has been validated and effectively used on countless occasions, producing important and thoughtful research. The power of this database is not to be underestimated. However, the use of this database has been criticized before, emphasizing the need for a clear statement of methods, data management, and limitations of these studies.5 The statement that the American College of Surgeons requires to be included with each National Surgical Quality Improvement Program article should not be brushed over, but should be genuinely integrated as a part of the critical reading of articles from this and similar databases: “The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.” DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Benjamin B. Massenburg, B.A. Paymon Sanati-Mehrizy, B.A. Peter J. Taub, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, N.Y.