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Air v. Saline: The Effect of Tissue Expander Fill on Complications in Two-Stage Prepectoral Breast Reconstruction
Pooja S. Yesantharao, MS1, Nada M. Rizk, MS2, Shanique Martin, MD2, Ruth Tevlin, MD2, Gordon K. Lee, MD2, Rahim S. Nazerali, MD MHS2.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Stanford University School of Medicine, Stanford, CA, USA.

Background A common practice in breast reconstruction is two-stage implant reconstruction with initial tissue expander placement. Traditionally, saline is added to the tissue expander intraoperatively, followed by continued expansion with saline postoperatively. Recently, intraoperative expansion with air rather than saline has been proposed to reduce the pressure applied to the mastectomy skin flap and incisions in the immediate postoperative setting. The aim of our study was to determine if the medium of tissue expansion (air versus saline) affects postoperative complications in the setting of pre-pectoral delayed immediate reconstruction.
Methods A retrospective cohort study of 144 breasts (86 patients) who underwent immediate prepectoral breast reconstruction with full anterior coverage with ADM over a 2-year period was performed. Patient demographics, intraoperative tissue expander fill medium, and the occurrence of postsurgical complications were analyzed. Crude and multivariable-adjusted logistic regression estimated odds ratios were used to identify predictors of postsurgical complications. To account for the potential clustering of 144 breast interventions from 86 women, regressions used robust variances. Statistical analyses were performed using SAS software v9.4.
ResultsThe demographic and clinical data were well matched between study cohorts. The mean follow-up time is 196 days (range: 85 to 633 days) and the average age is 46.7 years old. Initial tissue expander fill volume was similar (p=0.2). ASA III+, BMI, diabetes, and smoking status were added in a step-wise fashion as potential confounding variables in the model. The crude association between air versus saline fill on overall complication suggests a protective effect when the tissue expander is filled with air, OR=0.5 (p=0.04) and the suggested protective effect is maintained as the potential confounding variables are added to the model OR=0.4 (p=0.05). Fewer complications requiring salvage reoperation were observed when tissue expanders were filled with air, OR=0.3 (p=0.02). Additionally, there is a suggested protective effect regarding skin flap necrosis if the tissue expander is air-filled, OR=0.7 (p=0.6).
ConclusionThe medium used in immediate intra-operative tissue expansion affects post-operative outcomes of patients undergoing delayed immediate pre-pectoral breast reconstruction. Here, we demonstrate that air-filled tissue expanders were associated with significantly
less post-operative complications following breast reconstruction relative to saline-filled tissue expanders.

OverallORa95%CIp-valueORb95% CIp-value
Overall Complications
No %63.880.40.50.2-
Yes %36.219.6
No %80.992.80.90.8-0.9p<
Yes %19.27.2

Table 1: Crude and adjusted associations for overall complications and reoperationaCrude associationbAdjusted for ASA III+, BMI, diabetes, and smoking status

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