by Shammas, Ronnie L.; Cason, Roger W.; Sergesketter, Amanda
R.; Glener, Adam D.; Broadwater, Gloria; Hollins, Andrew; Le, Elliot; Marks,
Caitlin; Atia, Andrew N.; Orr, Jonah P.; Hollenbeck, Scott T.
Plastic and Reconstructive Surgery: September
2021 - Volume 148 - Issue 3 - p 501-509
Background: Patients undergoing mastectomy may not be
candidates for immediate free-flap breast reconstruction because of medical
comorbidities or postmastectomy radiation therapy. In this setting, flap
reconstruction may be intentionally delayed or staged with tissue expander
placement (“delayed-immediate” reconstruction). The optimal reconstructive
choice and incidence of complications for these approaches remain unclear.
Methods: The authors retrospectively identified patients who
underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)]
abdominal free-flap breast reconstruction between 2010 and 2018 and compared
the incidence of postoperative complications.
Results: Patients undergoing staged reconstruction had a
higher overall incidence of perioperative complications, including
surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound
healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma
(11.1 percent versus 0.7 percent; p < 0.001), and return to the operating
room (27.8 percent versus 4.4 percent; p < 0.0001). These complications
occurred predominately during the expansion stage, resulting in an 18.5 percent
(n = 10) rate of tissue expander failure. Mean time from mastectomy to flap
reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p <
0.001). At the time of flap reconstruction, there was no significant difference
in the incidence of complications between the staged cohort versus the delayed
cohort, including microsurgical complications (1.9 percent versus 4.3 percent;
p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat
necrosis (5.6 percent versus 5.0 percent; p = 0.875).
Conclusions: The aesthetic and psychosocial benefits of
staged free-flap breast reconstruction should be balanced with the increased
risk of perioperative complications as compared to a delayed approach.
Complications related to definitive flap reconstruction do not appear to be
affected by the approach taken at the time of mastectomy.
Clinical Question/Level of Evidence: Therapeutic, III.
