Frailty is the New Age: A Retrospective Study of Modified Frailty Index for Preoperative Risk Assessment in Autologous Breast Reconstruction

Predicting Outcomes of Breast-Conserving Surgery in Patients with Breast Cancer Using the Modified 5-Item Frailty Index: A Retrospective Cohort Study

BACKGROUND

Breast cancer is the most common malignancy among women worldwide, with breast-conserving surgery (BCS) being a key treatment. The modified 5-item frailty index (mFI-5), a well-validated tool for assessing frailty, has shown predictive utility in other surgical contexts but remains under-explored in BCS.

PATIENTS AND METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database (2008-2021), we identified adult female patients with breast cancer who underwent BCS. Frailty was assessed using the mFI-5 and scored from 0 to 5, with higher scores indicating greater frailty. Multivariable logistic regression was employed to evaluate associations between mFI-5 scores and postoperative outcomes.

RESULTS

A total of 96,586 patients were included. Higher mFI-5 scores were significantly associated with older age, higher body mass index (BMI), and increased ASA scores. Multivariate analysis showed greater frailty was linked to higher risks of any (mFI = 1: OR 1.06; mFI = 2: OR 1.26; mFI ≥ 3: OR 2.45), surgical (mFI = 1: OR 1.18; mFI = 2: OR 1.65; mFI ≥ 3: OR 3.17), and medical complications (mFI = 1: OR 1.72; mFI = 2: OR 2.56; mFI ≥ 3: OR 6.05). Similarly, frail patients had significantly higher odds of mortality (mFI = 1: OR 2.27; mFI = 2: OR 4.3; mFI ≥ 3: OR 11.05) and unplanned readmission (mFI = 1: OR 1.38; mFI = 2: OR 2.25; mFI ≥ 3: OR 6.05). Reoperation risk decreased with higher mFI-5 scores (mFI = 1: OR 0.92; mFI = 2: OR 0.73; mFI ≥ 3: OR 0.92).

CONCLUSIONS

The mFI-5 is strongly associated with postoperative outcomes after BCS and serves as a valuable tool for risk stratification. Our findings reinforce its role as a critical preoperative index to identify high-risk patients and guide surgical planning.

The Five-Item Modified Frailty Index Predicts Adverse Surgical Outcomes in Patients Undergoing Mastectomy

BACKGROUND

The 5-item modified Frailty Index (mFI-5) is a clinical tool to predict adverse outcomes in surgical patients by assessing five comorbidities: diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status. It helps to evaluate postoperative complication risks, recovery time, and overall survival, particularly in frail patients undergoing oncological and gynecological surgeries.

METHODS

This retrospective cohort study analyzed American College of Surgeons, National Surgical Quality Improvement Program data from adult female patients undergoing mastectomy procedures without reconstruction between 2017 and 2022. Patients were selected based on Current-Procedural-Terminology codes, excluding incomplete or non-breast-related cases. Preoperative, perioperative, and 30-day postoperative data were analyzed using logistic and linear regression models, with the mFI-5 cutoff set at 2.

RESULTS

Between 2017 and 2022, 860 patients underwent mastectomies at Yale Healthcare Network; 19% (n = 163) had mFI score ≥2. High-risk patients (mFI ≥2) were significantly older (66.32 ± 10.83 years) and had a higher body mass index (33.69 ± 7.73, both p < 0.001). Surgical complications occurred in 11.98% of patients, with a higher rate in the high-risk group (22.7% vs. 9.5%, p < 0.001). Adjusted multivariate logistic regression showed an increased risk of complications in frail patients (aOR 2.66; [1.60-4.43], p < 0.001). Although slight reductions in hospital stay and surgery duration were observed for high-risk patients, these differences were not significant. Sensitivity analysis confirmed higher odds of complications, including acute kidney failure (odds ratio [OR] 9.01) and pneumonia (OR 4.10).

CONCLUSIONS

The mFI-5 is a robust tool for predicting surgical complications in patients undergoing mastectomy, particularly those with multiple comorbidities.

The Five-Item Modified Frailty Index (mFI-5) Predicts Adverse Short-term Outcomes in Patients Undergoing Mastectomy: A Propensity Score-Matched Analysis of 252,054 Cases

BACKGROUND

Frailty has emerged as a critical predictor of postoperative outcomes, particularly in older surgical patients. However, its role in mastectomy patients remains underexplored. This study evaluates the utility of the 5-item Modified Frailty Index (mFI-5) in predicting 30-day postoperative complications in mastectomy patients, aiming to improve risk stratification and inform clinical decision-making.

METHODS

A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2008 to 2022. Patients were categorized into high-risk (mFI-5 ≥ 2) and low-risk (mFI-5 < 2) groups. Propensity score matching (PSM) was applied to create balanced cohorts and multivariate logistic regression was used to evaluate associations between frailty and postoperative outcomes.

RESULTS

Of the 252,054 adult female patients who underwent mastectomy, 1.2 % were identified as high-risk frail. High-risk patients were older (70 ± 9.9 vs. 60 ± 14 years, P < .001) and had a higher BMI (35 ± 9.1 vs. 29 ± 7.1 kg/m², P < .001) compared to low-risk patients. After PSM, high-risk patients had significantly higher odds of any complication (OR: 2.05, 95 % CI: 1.70-2.47, P < .001), surgical complications (OR: 1.70, 95 % CI: 1.38-2.10, P < .001), and medical complications (OR: 3.81, 95 % CI: 2.64-5.50, P < .001). Key complications included infections, bleeding requiring transfusion, and unplanned readmissions.

CONCLUSION

The mFI-5 effectively identifies mastectomy patients at higher risk of postoperative complications, including medical complications and unplanned reoperation or readmission, underscoring its value in preoperative risk stratification. Incorporating frailty assessments into clinical practice could enhance surgical decision-making, optimize resource allocation, and improve patient outcomes.

Microvascular Free-Flap Head and Neck Reconstruction: The Utility of the Modified Frailty Five-Item Index

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.

Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases

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.

Applying the Modified Five-Item Frailty Index to Predict Complications following Lower Extremity Free Flap Reconstruction in Trauma Patients

BACKGROUND

 Free flap reconstruction in the setting of lower extremity trauma continues to be a challenging clinical problem fraught with a high risk of complications including flap compromise. Although studies have described certain risk factors that predispose these patients to poor outcomes, there remains a paucity of literature detailing frailty as a risk factor. As such, the aim of our study was to examine the application of the 5-item modified frailty index (mFI-5) in trauma patients undergoing lower extremity free flap reconstruction.

METHODS

 The 2012 to 2020 American College of Surgeons-National Surgical Quality Improvement Program database was queried for lower extremity free flap reconstructive procedures. After excluding nontrauma etiologies, patients were stratified into three cohorts by their respective mFI-5 score (0, 1, and ≥2). Univariate and multivariate logistic regressions were performed to assess the effect of mFI-5 scores on postoperative complications.

RESULTS

 A total of 219 patients were included (64.8% male) with an average age of 47.6 ± 16 years. A total of 22.4% (n = 49) of patients had at least one complication. An increased mFI-5 score was associated with an increase in any complication (p < 0.001), hematological complication (p = 0.023), and reoperation (p = 0.004) rates. A high mFI-5 score was found to be an isolated risk factor for having at least one complication (mFI-5 ≥ 2: odds ratio [OR]: 3.829; p < 0.007; 95% confidence interval [CI]: 1.445-10.145) and reoperation (mFI-5 ≥ 2: OR: 5.385; p < 0.002; 95% CI: 1.826-15.877).

CONCLUSION

 Our results indicate that the mFI-5 can be a helpful assessment tool for lower extremity trauma patients undergoing free flap reconstruction to predict the risk of surgical complications and reoperation rates. Patients with an mFI-5 score > 2 should be counseled preoperatively of their increased risk of complications.

Evaluation of Modified Frailty Index for Predicting Postoperative Outcomes after Upper Extremity Replantation and Revascularization Procedures

BACKGROUND

 Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50 to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid conditions face increased complications. This study assesses the predictive value of the modified 5-item frailty index (5-mFI) for postoperative complications in these procedures.

METHODS

 A retrospective study was done using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2021) for UE replantation/revascularization. The 5-mFI score assigned points for comorbidities including pulmonary disease, heart failure, diabetes, hypertension, and functional status (0-5 scale; 1 point to each). 5-mFI scores stratified patients into <2 (low-risk) or ≥2 (high-risk) categories.

RESULTS

 Of 2,305 patients, the mean age and body mass index (BMI) were 53.13 years and 28.53 kg/m2, respectively. The 5-mFI ≥2 cohort experienced higher rates of all-cause complications, systemic complications, unplanned readmissions, and return to the operating room on univariate analysis. There was no significant difference in wound complication rates. Multivariable logistic regression showed that a higher 5-mFI was significantly associated with increased risks of all-cause mild and severe systemic complications. Wound complications, length of stay over 30 days, unplanned readmission, and return to the operating room were higher in high-risk patients, however not statistically significant.

CONCLUSION

 5-mFI is an effective tool for evaluating risk in UE replantation and revascularization, correlating high scores with significantly increased postoperative complications. High-risk patients with 5-mFI ≥2 also had more reoperations and readmissions. The use of 5-mFI in preoperative assessments can help personalize management, enhancing patient selection and care quality in these complex reconstructions.

Five-item modified frailty index does not outperform diabetes and hypertension alone in prediction of complications after breast reconstruction

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.

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

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.