A Comparative Analysis of Risk Factors for Breast Skin Necrosis following Autologous versus Device-Based Breast Reconstruction

Abstract

Background: Mastectomy skin flap necrosis often necessitates prolonged wound care, surgical re-excision, and increases the risk for infection. This study aims to compare rates of skin flap necrosis between autologous and device-based reconstructions and identify risk factors. Methods: The authors retrospectively identified patients who underwent immediate breast reconstruction using either the deep inferior epigastric perforator flap (n = 373 breasts, 41 percent) or tissue expanders (n = 529 breasts, 59 percent) by two surgeons at a single institution between 2011 and 2021. The rate of skin flap necrosis between autologous and device-based reconstructions was compared and multivariate regression analysis was performed to identify risk factors. Results: There was no significant difference in rates of skin flap necrosis between the two cohorts (26.8 percent versus 15.5 percent, p = 0.052). Across all patients, hypertension and body mass index > 30 were significant predictors of necrosis (p = 0.024 and p < 0.001, respectively). Within our DIEP cohort, mastectomy specimen weight was a significant risk factor for necrosis (p = 0.001). The DIEP flap weight itself does not confer a higher risk for necrosis (p = 0.8). Conclusions: Immediate autologous reconstruction does not place patients at higher risk of skin necrosis. Hypertension and obesity (body mass index > 30) were independent risk factors for necrosis in all patients. Mastectomy specimen weight was a significant predictor of necrosis in DIEP flap patients while the DIEP flap weight itself does not increase the risk for necrosis.

Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity

“…This finding was consistent with numerous prior studies that have correlated mastectomy skin necrosis with BMI > 30 kg/m 2 . [51][52][53][54] While perfusion of distal mastectomy flap skin is primarily dependent on native breast anatomy and extirpative technique, reconstructive surgeons can optimize outcomes by minimizing additional challenges to skin perfusion and anticipating potential wound healing problems. To this end, it has been our preference to offer immediate autologous reconstruction to almost all obese patients undergoing nipple-or skinsparing mastectomy.…”

“…It should also be mentioned that in a recent study, Lu Wang et al determined that immediate autologous reconstruction did not independently increase the risk of mastectomy skin necrosis relative to device-based methods. 54 Prior studies have reported detrimental effects of obesity on efficiency metrics in autologous breast reconstruction. 14 In two studies comparing obese to nonobese patients undergoing abdominal free flap breast reconstruction, mean operative times were found to be significantly longer among the obese cohorts.…”

“…It should also be mentioned that in a recent study, Lu Wang et al determined that immediate autologous reconstruction did not independently increase the risk of mastectomy skin necrosis relative to device-based methods. 54…”