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Beyond Nitroglycerin: Early Clinical Outcomes of Tacrolimus at Discharge for Threatened Mastectomy Skin Flaps
Michael Stigliano, Carson Gundlach, Paneed Jalili, Fiona R. Fragomen, Annie McVeigh, Daana Bajnauth
*, David Otterburn
Weill Cornell Medicine, New York, NY
Background: Conservative treatments for threatened mastectomy skin flaps remain limited. Topical nitroglycerin has been used clinically to reduce mastectomy skin flap necrosis. Following encouraging rodent flap data, topical tacrolimus was adopted clinically by the senior author in 2024 as an outpatient treatment for threatened mastectomy skin flaps.
Methods: A retrospective cohort study was performed of immediate tissue expander breast reconstructions with threatened mastectomy skin flaps. Threatened flaps were identified by SPY filling defects or inpatient clinical examination. Before 2024, threatened flaps were managed with inpatient nitroglycerin. In 2024, tacrolimus was used at discharge, with or without inpatient nitroglycerin. Outcomes were any necrosis (partial- or full-thickness) and full-thickness necrosis. The primary analysis compared flaps treated with discharge tacrolimus versus no discharge tacrolimus. A nitroglycerin-restricted sensitivity analysis compared inpatient nitroglycerin alone versus nitroglycerin followed by discharge tacrolimus.
Results: In the primary analysis, any necrosis occurred in 8/47 flaps (17.0%) treated with discharge tacrolimus versus 21/48 flaps (43.8%) without discharge tacrolimus (RR 0.39, 95% CI 0.19-0.79; p=0.007). Full-thickness necrosis occurred in 4/47 flaps (8.5%) versus 11/48 flaps (22.9%) (RR 0.37, 95% CI 0.13-1.08; p=0.089). In the sensitivity analysis, any necrosis occurred in 7/33 flaps (21.2%) treated with inpatient nitroglycerin followed by discharge tacrolimus versus 21/48 flaps (43.8%) treated with inpatient nitroglycerin alone (RR 0.48, 95% CI 0.23-1.01; p=0.056). Full-thickness necrosis occurred in 3/33 flaps (9.1%) versus 11/48 flaps (22.9%) (RR 0.40, 95% CI 0.12-1.31; p=0.140).
Conclusion: Discharge tacrolimus was associated with lower rates of any necrosis after immediate tissue expander reconstruction. Rates of full-thickness necrosis were also lower but did not reach statistical significance. These findings support further study of tacrolimus as a treatment for threatened mastectomy skin flaps.
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