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A Decade of National Trends and Outcomes Between Immediate versus Staged Autologous Free-Flap Breast Reconstruction
Andrew Hannoudi
1,Timothy C. Olsen
1, Aamirah Mccutchen
1, Margaret M. Hornick
1, Ayaka N. Deguchi
1, Kaamya Varagur
1, Robyn B. Broach
1, Joseph Serletti
1, Said Azoury
1
1. Division of Plastic Surgery, University of Pennsylvania, Philadelphia , PA, United States.
Background: Staged autologous breast reconstruction (ABR), involving tissue expander placement followed by delayed free-flap transfer, preserves reconstructive options when the need for postmastectomy radiation therapy (PMRT) is uncertain. Despite the utility of staged ABR, contemporary trends in utilization and outcomes between the two approaches remain unknown. This study uses a federated electronic health records network to evaluate national trends in immediate versus staged ABR.
Methods: The TriNetX US Collaborative Network was queried for women undergoing post-mastectomy immediate or staged free-flap ABR from 2013 to 2024. Annual utilization, baseline comorbidities, and 90-day outcomes were analyzed with binomial models and difference-in-differences. Secondary propensity score-matched analyses compared 1-year outcomes.
Results: Among 142,997 women undergoing autologous free-flap reconstruction, 110,035 underwent immediate and 32,962 staged ABR. Staged ABR increased from 19.4% to 27.0% of autologous reconstructions. Relative to immediate ABR, staged ABR increased among patients with obesity, hypertension, active smoking, and obstructive sleep apnea (all p<0.001), while PMRT rates did not differentially change over time (p=0.764). Trends in 90-day revision, infection, reoperation, fat necrosis, and thrombosis increased more with staged ABR (all p<0.001). After matching on obesity, hypertension, smoking, obstructive sleep apnea, and malignancy, staged ABR showed lower rates of flap failure (6.2% vs 8.3%), skin excision (1.9% vs 5.0%), and secondary reconstruction (6.2% vs 11.6%; all p≤0.011), but higher rates of revision (46.9% vs 36.3%) and breast disproportion (32.3% vs 28.2%; all p≤0.003).
Conclusion: Staged free-flap ABR is increasingly used both overall and in high-risk patients. Although short-term adverse outcomes increased over time in unadjusted analyses, matched analyses suggest staged ABR may reduce flap failure and skin excision at the cost of a more revision-intensive reconstructive course.
Models adjusted for BMI, tissue expander size, and axillary irradiation. OR > 1 indicates higher odds with early exchange.
Back to 2026 Abstracts
Models adjusted for BMI, tissue expander size, and axillary irradiation. OR > 1 indicates higher odds with early exchange.
