Background: Breast reconstruction remains a major component of the plastic surgeon’s repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes. Methods: All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed. Results: In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model. Conclusions: Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

proportion hazard model stratified by time enabled time to recurrence analysis comparing groups.RESULTS: While unsurprising, 52 patients recurred locally (10.3%) with implant-based reconstruction compared to 66 (15.8%) with autologous reconstruction (p=0.02). Average time to detection was 63.5±47.0 months after implant versus 86.5±61.5 after autologous reconstruction (p=0.02). At the time of recurrence, tumor was larger (p=0.01) and of higher stage (p=0.02) in the autologous cohort. Recurrence free survival was initially similar between groups for the first 13 years. Interestingly, it became significantly higher during years 13-18 for the autologous compared to the implant group (82.7% versus 72.8%, p=0.03), but after 18 years, trended lower than implant reconstruction. CONCLUSION:Our findings highlight an interesting but often neglected consideration when selecting breast reconstructive modality. Implant reconstruction may allow for earlier cancer recurrence detection. While there are significant premiums in autologous reconstruction, those patients may warrant increased long-term recurrence surveillance.