Influence of Triple-Negative versus Luminal A Breast Cancer Subtype on Choice of Autologous versus Implant-Based Delayed-Immediate Breast Reconstruction

Background This study aimed to assess whether the reconstructed breast volume changed postoperatively following a deep inferior epigastric artery perforator (DIEP) flap. Methods Patients were included if they had undergone unilateral breast reconstruction with a DIEP flap at the two selected centers between April 2017 and September 2019. Serial 3-D surface imaging of both breasts was taken at 1, 3, 6, and 12 months postoperatively. The primary outcome was a volume ratio of the reconstructed to the contralateral breast. A linear mixed-effect model was used to evaluate whether the DIEP flap volume changed according to the postoperative time. Results A total of 74 patients were included in the analysis. The mean volume ratio of the reconstructed side compared to the contralateral breast at 1, 3, 6, and 12 months postoperatively were 106.9 %, 105.9 %, 108.7 %, and 107.6 %, respectively. In the linear mixed effect model, the volume ratio of the reconstructed breast did not change over time for immediate reconstructions (p = 0.376). However, there was an increase over time in delayed reconstructions (p = 0.043). Adjuvant radiation, chemotherapy, and hormone therapy did not influence the volume ratio of the reconstruced breast. Correlation analysis using repeatedly measured values showed that both reconstruced and healthy breast volumes had positive correlation with the patient’s body weight (p < 0.001). On the other hand, volume ratio of the breasts was not influenced by the patient’s body weight (p = 0.493). The volume ratio of the reconstructed breast significantly decreased in the upper inner (p = 0.003) and the upper outer (p = 0.006) quadrants, while increasing in the lower outer (p = 0.002) quadrant throughout the first-year postoperative period. Conclusion The volume ratio of the reconstructed to the contralateral breast does not decrease postoperatively following DIEP flap breast reconstruction.

Section: Accepted Manuscriptsupporting

confidence: 93%

Three-dimensional Volume Changes of the Reconstructed Breast Following DIEP Flap Breast Reconstruction

Lee

Park

et al. 2022

“…Given that a free flap is a major surgery that brings in healthy, nonradiated excess abdominal tissue, these results are not surprising and are in line with a previous study by Dickey et al, which shows that patients with a higher BMI and those undergoing radiation therapy are significantly more likely to elect for autologous reconstruction. 25 Patients who ultimately had autologous reconstruction had a TE in place for 48 days longer than patients who had exchange to an implant. This longer TE duration is likely the result of several factors including waiting for the patient to recover after completing radiation and surgeon availability when scheduling a free flap.…”

Section: Discussionmentioning

confidence: 99%

Consequences and Predictors of Prolonged Tissue Expander Duration in Breast Reconstruction

Langdell

Sergesketter

Biswas

et al. 2023

Background: Tissue expanders (TEs) are temporary devices used in breast reconstruction, which are generally removed within one year. There is a paucity of data regarding the potential consequences when TE’s have longer indwelling times. Thus, we aim to determine whether prolonged TE implantation length is associated with TE-related complications. Methods: This is a single center retrospective review of patients who underwent TE placement for breast reconstruction from 2015-2021. Complications were compared between patients who had a TE for > 1 year and < 1 year. Univariate and multivariate regressions were used to evaluate predictors of TE complications. Results: A total of 582 patients underwent TE placement and 12.2% had the expander for > 1 year. Adjuvant chemoradiation, BMI, overall stage, and diabetes predicted the duration of TE placement (p ≤ 0.006). Return to the OR rate was higher in patients who had TEs in place > 1 year (22.5% vs 6.1%, p < 0.001). On multivariate regression, prolonged TE duration predicted an infection requiring antibiotics, readmission, and re-operation (p < 0.001). Reasons for longer indwelling times included need for additional chemoradiation (79.4%), TE infections (12.7%), and requesting a break from surgery (6.3%). Conclusion: Indwelling TEs for > 1 year are associated with higher rates of infection, readmission, and re-operation even when controlling for adjuvant chemoradiation. Patients with diabetes, a higher BMI, advanced cancer stage, and those requiring adjuvant chemoradiation should be advised they may require a TE for a longer time-interval prior to final reconstruction.

“…7 8 The reasons for this include (1) early reports of higher flap complication rates in immediate reconstruction followed by radiation, (2) limitations in treatment planning due to guidelines for postmastectomy radiation based on findings discovered at the time of mastectomy, and (3) potential for the flap to interfere with effective delivery of radiation to the chest wall. 9 10 11 12 22 23 24 25 26 The optimal timing of reconstruction after radiation remains an ongoing debate. Many believe that longer delays allow for recovery of acute inflammatory changes induced by radiation.…”

Section: Discussionmentioning

confidence: 99%

“…Although patient and treatment factors guide discussions and decisions for timing of reconstruction with anticipated radiation therapy (RT), delayed or delayed-immediate reconstruction remains the most common approach with anticipated radiation. 7 8 9 10 11 12 The prevailing assumption is that longer delays are needed to allow sufficient time for recovery of radiation treatment effects to tissues. This is supported by studies reporting higher complications rates when reconstruction is performed before 12 months.…”

mentioning

confidence: 99%

A Paradigm Shift: Outcomes of Early Autologous Breast Reconstruction after Radiation Therapy

Elver

Egan

Cullom

et al. 2022

Background Radiation creates significant challenges for breast reconstruction. There is no consensus regarding optimal timing for autologous reconstruction following radiation. This study explores clearly defined, shorter time intervals between completion of radiation and reconstruction than previously reported. Methods A retrospective review was performed on patients who underwent autologous reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Cohorts were selected by time elapsed between radiation and autologous reconstruction including <3 months, 3 to 6 months, 6 to 9 months, 9 to 12 months, 12 to 24 months, and >24 months. Analysis compared baseline characteristics, operative details, complications, revision rates, and BREAST-Q scores. Analysis of variance was used for continuous variables and chi-square for discrete variables. Results In total, 462 radiated patients underwent 717 flaps. There were 69 patients at <3 months (14.9%), 97 at 3 to 6 months (21%), 64 at 6 to 9 months (13.9%), 36 at 9 to 12 months (7.8%), 73 at 12 to 24 months (15.8%), and 123 at >24 months (26.6%). Age, time from mastectomy, and failure of primary reconstruction were higher at >24 months (p < 0.001). There was no difference between cohorts in intraoperative complications in radiated or nonradiated breasts. There was no difference in acute and late postoperative complications between cohorts. Wound-healing complications in radiated sides were lowest at <3 months and 3 to 6 months (5/69 [7.3%] and 11/97 [11.3%], respectively) compared with other groups (18.8–22.2%) but did not reach significance (p = 0.11). More fat graft revisions occurred at <3 months (p = 0.003). Conclusion Reconstruction can be safely performed within 3 months after radiation without increases in intraoperative, acute, or late reconstructive complications.