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Air Versus Saline In Initial Prepectoral Tissue Expansion: A Propensity-Matched Comparison Of Complications And Patient-Reported Outcomes
Ethan L. Plotsker, BA*1; Michelle Coriddi, MD1; Robyn N. Rubenstein, MD1; Jacqueline J. Chu, BA1; Kathryn Haglich, MS1; Joseph J. Disa, MD1; Evan Matros, MD, MPH, MMSc1; Joseph H. Dayan, MD1; Robert Allen Jr., MD1; Jonas A Nelson, MD, MPH1
1Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.

Background: One option to optimize prepectoral tissue expander fill volume while minimizing stress on mastectomy skin flaps is to use air as an initial fill medium, with subsequent exchange to saline during postoperative expansion. To date, little is known of the impact that initial air-fill with subsequent exchange to saline may have on complications or outcomes following prepectoral breast reconstruction We compared complications and early patient-reported outcomes (PROs) based on fill type in prepectoral breast reconstruction patients. We hypothesized that there would be no marked differences in complication rates and PROs.
Methods: We reviewed prepectoral breast reconstruction patients who underwent intraoperative tissue expansion with air or saline from 20182020 to assess fill-type utilization. Primary endpoint was expander loss; secondary endpoints included seroma, hematoma, infection/cellulitis, full-thickness mastectomy skin flap necrosis (MSFN) requiring revision, expander exposure, and capsular contracture. PROs were assessed with BREAST-Q Physical Well-Being of the Chest 2 weeks postoperatively. Propensity-matching was performed as a secondary analysis.
Results: Of 560 patients (928 expanders) included in our analysis, 372 had devices initially filled with air (623 expanders) and 188 with saline (305 expanders). No differences were observed for overall rates of expander loss (4.7% vs. 3.0%, p=0.290) or overall complications (22.5% vs. 17.7%, p=0.103). No difference in BREAST-Q scores was observed (p=0.142). Utilization of air-filled expanders decreased substantially over the last study year. Following propensity matching, we did not observe differences in loss or other complications across cohorts.
Conclusion: Tissue expanders initially filled with air appear to have no significant advantage over saline-filled expanders in maintaining mastectomy skin flap viability or PROs, including after propensity matching. This suggests that initial tissue expander fill with air does not confer the benefits for which it was intended. These findings can help guide choice of initial tissue expander fill-type. Further research should continue to examine outcomes contingent upon initial expander fill.


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