The effects of prolonged intraoperative hypothermia on patient outcomes in immediate, implant-based breast reconstruction

Published:November 19, 2022DOI:



      The importance of thermoregulation in surgical procedures has become a recent focus for anesthesiologists and surgeons to improve patient outcomes. In breast surgery, maintenance of normothermia has been shown to reduce surgical site infections. However, there is a paucity of information evaluating the relationship between intraoperative core body temperatures and reconstructive surgical outcomes.


      A retrospective review of patients that underwent immediate breast reconstruction following mastectomy from 2015 - 2020 was performed. Patients were organized into a majority normothermic (NT) group if patients spent greater than half of the operative time above or equal to 36°C or a majority hypothermic (HT) group if patients spent greater than or equal to half of the operative time below 36°C. Patient demographics, comorbidities, surgical techniques, and postoperative complications were recorded. Complications were classified according to the Clavien-Dindo classification. Univariate and multivariate statistics were utilized to assess for significant relationships.


      There were 329 total patients that met inclusion criteria with 174 in the NT group and 155 in the HT group, yielding 302 and 264 total breasts, respectively. There was no significant difference in rates of infection (p=1.0), seroma (p=0.27), hematoma (p=0.61), or wound dehiscence (p=1.0). However, patients in the HT group had significantly more overall ischemic complications (p=0.009) and specifically, grade IIIb ischemic complications (p=0.04). After controlling for tobacco use, body mass index, mastectomy pattern, radiation, operating surgeon, and mastectomy weight, multivariate analysis showed increased ischemic complications in the HT group (p=0.04).


      Prolonged intraoperative hypothermia can increase the risk for the development of ischemic wounds such as tissue necrosis or eschar formation that require operative intervention. This presents reconstructive complications that increase both patient and health system burdens that could be addressed through maintenance of normothermia. Further studies utilizing real-time flap temperature would provide more accurate insight into relationship between temperature and implant-based breast reconstruction.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jonczyk MM
        • Jean J
        • Graham R
        • Chatterjee A.
        Surgical trends in breast cancer: a rise in novel operative treatment options over a 12 year analysis.
        Breast Cancer Res Treat. 2019; 173: 267-274
        • Alkabban FM
        • Ferguson T.
        Breast Cancer.
        StatPearls. 2021;
        • Albornoz CR
        • Bach PB
        • Mehrara BJ
        • et al.
        A paradigm shift in U.S. Breast reconstruction: increasing implant rates.
        Plast Reconstr Surg. 2013; 131: 15-23
        • Panchal H
        • Matros E.
        Current Trends in Post-Mastectomy Breast Reconstruction.
        Plast Reconstr Surg. 2017; 140: 7S-13S
        • Dassoulas KR
        • Wang J
        • Thuman J
        • et al.
        Reducing Infection Rates in Implant-Based Breast Reconstruction: Impact of an Evidence-based Protocol.
        Ann Plast Surg. 2018; 80: 493-499
        • Sessler DI.
        Complications and treatment of mild hypothermia.
        Anesthesiology. 2001; 95: 531-543
        • Melling AC
        • Ali B
        • Scott EM
        • Leaper DJ.
        Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial.
        Lancet Lond Engl. 2001; 358: 876-880
        • Kurz A
        • Sessler DI
        • Lenhardt R.
        Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
        N Engl J Med. 1996; 334: 1209-1215
        • Sessler DI.
        Temperature monitoring and perioperative thermoregulation.
        Anesthesiology. 2008; 109: 318-338
        • Kankam HKN
        • Mehta S
        • Jain A.
        Thermal Preconditioning for Surgery: A Systematic Review.
        J Plast Reconstr Aesthetic Surg JPRAS. 2020; 73: 1645-1664
        • Fischer JP
        • Wes AM
        • Nelson JA
        • et al.
        Propensity-matched, longitudinal outcomes analysis of complications and cost: comparing abdominal free flaps and implant-based breast reconstruction.
        J Am Coll Surg. 2014; 219: 303-312
        • Madrid E
        • Urrútia G
        • Roqué i Figuls M
        • et al.
        Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults.
        Cochrane Database Syst Rev. 2016; 4CD009016
        • Kurz A.
        Physiology of thermoregulation.
        Best Pract Res Clin Anaesthesiol. 2008; 22: 627-644
        • Hypothermia
        Prevention and Management in Adults Having Surgery.
        National Institute for Health and Care Excellence (NICE), 2016
        • Azouz V
        • Mirhaidari S
        • Wagner DS.
        Defining Infection in Breast Reconstruction: A Literature Review.
        Ann Plast Surg. 2018; 80: 587-591
        • Dindo D
        • Demartines N
        • Clavien PA.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Weber F
        • Knapp G
        • Ickstadt K
        • Kundt G
        • Glass Ä.
        Zero-cell corrections in random-effects meta-analyses.
        Res Synth Methods. 2020; 11: 913-919
        • Galimberti V
        • Vicini E
        • Corso G
        • et al.
        Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications.
        Breast Edinb Scotl. 2017; 34 (Suppl): S82-S84
        • Chun YS
        • Verma K
        • Rosen H
        • et al.
        Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction.
        Am J Surg. 2011; 201: 160-165
        • Mlodinow AS
        • Fine NA
        • Khavanin N
        • Kim JYS.
        Risk factors for mastectomy flap necrosis following immediate tissue expander breast reconstruction.
        J Plast Surg Hand Surg. 2014; 48: 322-326
        • Abedi N
        • Ho AL
        • Knox A
        • et al.
        Predictors of Mastectomy Flap Necrosis in Patients Undergoing Immediate Breast Reconstruction: A Review of 718 Patients.
        Ann Plast Surg. 2016; 76: 629-634
        • Rudolph M
        • Moore C
        • Pestana IA.
        Operative risk stratification in the obese female undergoing implant-based breast reconstruction.
        Breast J. 2019; 25: 1182-1186
        • Frey JD
        • Salibian AA
        • Karp NS
        • Choi M.
        The Impact of Mastectomy Weight on Reconstructive Trends and Outcomes in Nipple-Sparing Mastectomy: Progressively Greater Complications with Larger Breast Size.
        Plast Reconstr Surg. 2018; 141: 795e-804e
        • Poveda V de B
        • Oliveira RA
        • Galvão CM.
        Perioperative body temperature maintenance and occurrence of surgical site infection: A systematic review with meta-analysis.
        Am J Infect Control. 2020; 48: 1248-1254
        • Li Y
        • Liang H
        • Feng Y.
        Prevalence and multivariable factors associated with inadvertent intraoperative hypothermia in video-assisted thoracoscopic surgery: a single-center retrospective study.
        BMC Anesthesiol. 2020; 20: 25
        • Ziolkowski N
        • Rogers AD
        • Xiong W
        • et al.
        The impact of operative time and hypothermia in acute burn surgery.
        Burns J Int Soc Burn Inj. 2017; 43: 1673-1681
        • Savastano DM
        • Gorbach AM
        • Eden HS
        • Brady SM
        • Reynolds JC
        • Yanovski JA.
        Adiposity and human regional body temperature.
        Am J Clin Nutr. 2009; 90: 1124-1131
        • Jeon FHK
        • Varghese J
        • Griffin M
        • Butler PE
        • Ghosh D
        • Mosahebi A.
        Systematic review of methodologies used to assess mastectomy flap viability.
        BJS Open. 2018; 2: 175-184
        • Chubb DP
        • Taylor GI
        • Ashton MW.
        True and “choke” anastomoses between perforator angiosomes: part II. dynamic thermographic identification.
        Plast Reconstr Surg. 2013; 132: 1457-1464
        • Muntean MV
        • Ardelean F
        • Strilciuc S
        • Pestean C
        • Georgescu AV
        • Muntean V.
        Flap warming improves intraoperative indocyanine green angiography (ICGA) assessment of perfusion. An experimental study.
        J Plast Reconstr Aesthetic Surg JPRAS. 2019; 72: 1150-1156
        • Jeyaraj SC
        • Chotani MA
        • Mitra S
        • Gregg HE
        • Flavahan NA
        • Morrison KJ
        Cooling evokes redistribution of alpha2C-adrenoceptors from Golgi to plasma membrane in transfected human embryonic kidney 293 cells.
        Mol Pharmacol. 2001; 60: 1195-1200
        • Zaproudina N
        • Varmavuo V
        • Airaksinen O
        • Närhi M.
        Reproducibility of infrared thermography measurements in healthy individuals.
        Physiol Meas. 2008; 29: 515-524
        • Kurz A
        • Xiong J
        • Sessler DI
        • et al.
        Isoflurane produces marked and nonlinear decreases in the vasoconstriction and shivering thresholds.
        Ann N Y Acad Sci. 1997; 813: 778-785
        • Sharif-Askary B
        • Vernon R
        • Broadwater G
        • Lane WO
        • Pomann GM
        • Hollenbeck ST.
        Subjective and objective evaluation of breast temperature following post-mastectomy reconstruction.
        Breast J. 2020; 26: 571-573
        • Sun Z
        • Honar H
        • Sessler DI
        • et al.
        Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air.
        Anesthesiology. 2015; 122: 276-285
        • Weirich TL.
        Hypothermia/warming protocols: why are they not widely used in the OR?.
        AORN J. 2008; 87: 333-344
        • Santa Maria PL
        • Santa Maria C
        • Eisenried A
        • et al.
        A novel thermal compression device for perioperative warming: a randomized trial for feasibility and efficacy.
        BMC Anesthesiol. 2017; 17: 102