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Free Flap Breast Reconstruction in Cancer Patients: The Effect of Reconstruction Timing on Procedural Outcomes
Madeline A. Cullins, Ronnie A. Pezeshk, MD, Samar Kayfan, Nikitha K. Reddy, Andrew Gassman, MD, Sumeet S. Teotia, MD, Nicholas T. Haddock, MD.
University of Texas Southwestern Medical Center, Dallas, TX, USA.

Deep inferior epigastric perforator (DIEP), superficial inferior epigastric artery (SIEA), and profunda artery perforator (PAP) flaps are acceptable options for autologous breast reconstruction. This study comprehensively evaluates the differences in outcomes between patients receiving immediate, delayed/immediate (staged with the use of tissue expanders), and delayed breast reconstructions (without the use of tissue expanders).
A retrospective review of an Institutional Review Board-approved prospectively collected database of 524 free flaps (DIEP, SIEA, or PAP) on 297 patients performed by two attending surgeons at The University of Texas Southwestern Medical Center University Hospitals from 2010-2015 was completed. Patients were grouped based on reconstruction timing: immediate (n=174 flaps), delayed-immediate (n=225 flaps), and delayed (n= 125 flaps). Comorbidities, preoperative radiation, neoadjuvant/postoperative chemotherapy, length of hospital stay, number of subsequent revision surgeries, and breast and donor site complications were analyzed between the three groups. The following complications at the breast and donor sites were considered: wound/necrosis, seroma, hematoma, and overall flap failure and removal.
In patients receiving 2 free flaps (bilateral or double-pedicle unilateral reconstruction), compared to delayed-immediate reconstructions, immediate reconstructions encountered higher rates of breast site infection (p<0.05), breast wound necrosis (p<0.0001), longer average hospital stays (p <0.0001, 5.2 versus 4.1 days), longer procedure times (p<0.0001), and larger numbers of subsequent revision surgeries (p<0.0001, 2.6 versus 1.8 revisions). Compared to delayed reconstructions, immediate reconstructions had higher rates of breast flap necrosis (p <0.0041), longer average hospital stays (p<0.0001, 5.2 versus 4.2 days), and longer procedure times (p<0.0001). In patients receiving a single unilateral flap, immediate reconstructions required longer procedure times (p<0.0001) in comparison to delayed-immediate reconstructions. There were no significant differences between outcomes of single flap immediate or delayed reconstructions. Lastly, there were no significant differences between any of the groups in the occurrence of overall flap failure and subsequent removal.
Immediate, delayed-immediate, and delayed reconstructions are all reasonably safe options for breast reconstruction. However, higher rates of complications among immediate reconstructions imply delayed-immediate and delayed reconstructions may be superior options to immediate reconstructions, especially in procedures involving the use of 2 free flaps. These results should be considered between the surgeon and patient when deciding an appropriate reconstruction plan based on the risks, benefits, and potential costs associated with different breast reconstruction timings. Based on this data, we have made institutional adjustments to our practice focusing on more delayed reconstructions.

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