Is Tissue Expansion Worth It? Comparative Outcomes of Skin-preserving versus Delayed Autologous Breast Reconstruction

Abstract

Background: The requirement for postmastectomy radiation therapy (PMRT) at the time of mastectomy is often unknown. Autologous reconstruction is preferred in the setting of radiotherapy by providing healthy vascularized tissue to the chest. To maximize mastectomy skin preservation, tissue expander (TE) placement maintains the breast pocket until definitive reconstruction. This study aims to compare outcomes of skin-preserving delayed versus standard delayed autologous breast reconstruction in the setting of PMRT. Methods: A retrospective review of a prospective database was performed of two patient cohorts at a single center between 2006 and 2016. Inclusion criteria were locally advanced breast cancer patients who completed PMRT and free autologous reconstruction. Primary outcomes were major intraoperative and postoperative TE and flap complications. Results: Over 10 years, 241 patients underwent mastectomy and PMRT. Standard delayed autologous breast reconstruction was performed in 131 breasts (non-TE group). Skin-preserving delayed autologous reconstruction was performed in 113 breasts (TE group). The TE group was associated with a higher incidence of intraoperative complications during flap reconstruction ( P = 0.002) and had a higher venous thrombosis incidence than the non-TE cohort ( P = 0.007). Other major postoperative complications were not significantly different between the two groups. TE patients had 7.5 times higher risk of intraoperative complications and an 18.6% TE loss rate. Conclusions: We identified higher intraoperative flap complications and a high rate of TE loss in patients who underwent skin-preserving delayed autologous breast reconstruction. The benefit of mastectomy skin preservation needs to be weighed against the increased risk of TE loss and higher rates of flap thrombosis.

Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen

“…This is an important consideration for delayed reconstruction patients who often require replacement of the majority of the breast skin envelope. 20 However, if the PAP and DIEP flaps provide similarly adequate amounts of soft tissue volume and skin surface area, surgeons should consider physical activity preferences and counsel patients on the morbidity of flap harvest from each donor site. Our selection criteria for PAP flaps over DIEP flaps are the following: (1) paucity of abdominal tissue unavailable due to prior surgery (ie, abdominoplasty or lack of suitable abdominal perforators); (2) greater volume of available tissue in thighs compared with the abdomen; (3) strong patient preference to avoid the abdomen as a donor site.…”

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

“…TEs in DI-ABR furthermore keep the mastectomy skin pocket intact to facilitate final reconstruction. 13 These can be deflated prior to PMRT to optimize radiation delivery and reinflated following therapy. 24 However, TEs are subject to their own unique set of complications, including skin necrosis, infection, and exposure, with explantation prior to reconstruction reported to be required in up to 18% of cases.…”

“…9 Several other groups have since reported their experiences with DI-ABR, either in isolation or in comparison to delayed reconstruction, with varying results. 10 11 12 13…”

“…9 Several other groups have since reported their experiences with DI-ABR, either in isolation or in comparison to delayed reconstruction, with varying results. [10][11][12][13] Patients undergoing immediate autologous breast reconstruction (I-ABR) have been shown to experience less psychosocial morbidity than those who have delayed reconstruction due to elimination of the experience of a mastectomy defect. [14][15][16][17] In a previous study by our group, I-ABR had higher rates of volume loss and fat necrosis, but comparable rates of serious complications and the need for revision surgeries when compared with delayed breast reconstruction in patients undergoing PMRT.…”

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis

“…Complications following staged reconstruction are reported to approach 30–40%, especially in the setting of radiation therapy. 10 – 13 However, there remains a lack of consensus detailing the optimal timing of free-flap breast reconstruction when considering an immediate, delayed, or staged approach. Thus, to inform high-quality treatment decisions, this study aimed to compare costs, complications, and healthcare utilization across patients undergoing immediate, delayed, or staged free-flap breast reconstruction.…”