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Delayed or Immediate Autologous Breast Reconstruction? A Matched Analysis of Clinical Outcomes in 884 Flaps
Martin P. Morris, MBE1, Adrienne N/ Christopher, MD1,2, Viren Patel, BS1, Cutler B. Whitely, BS1, Jessica Cunning, MD, MBA1, Arturo J/ Rios-Diaz, MD2, Robyn B Broach, PhD1, Joseph M. Serletti, MD1
1University of Pennsylvania, Philadelphia, PA; 2Thomas Jefferson University, Philadelphia, PA

BACKGROUND: Breast reconstruction after mastectomy has become a fundamental element of cancer treatment with well-established psychosocial benefits and body image gains. Optimal timing of autologous breast reconstruction (ABR) after mastectomy remains a clinical debate and current literature lacks detailed analysis of highly comparable cohorts, preventing generalizable conclusions of short and long-term complications. We compare longitudinal postoperative complications, reoperations, and nipple-areolar reconstruction (NAR) between matched cohorts that underwent immediate (IBR) or delayed ABR (DBR).
Methods: Adult patients who underwent abdominally-based ABR between 2005-2018 were identified by retrospective review. Patients were matched into two cohorts (DBR vs. IBR) via propensity-score by age, body mass index, diabetes, hypertension, smoking history, and preoperative and postoperative radiation therapy. The primary outcomes of the study were a composite of short-term postoperative clinical outcomes including surgical site occurrences of the breast and patient-level complications. The secondary outcomes include long-term clinical outcomes such as readmissions, reoperations, and revision procedures. Univariate analyses were completed between cohorts using Pearsonís Chi-square tests and Fisherís Exact tests, as appropriate for categorical variables, and t-tests for continuous variables. Multivariate logistic regression included variables that were significant (p<0.05) on univariate analysis, and odds ratio (OR) and 95% confidence intervals (CI) were reported.
Results: 884 flaps were matched (442 per cohort). 626 patients were included with mean age as 52 years and mean BMI was 30.7 kg/m2. There were no significant differences in terms of demographics, history of preoperative and postoperative radiation therapy, or flap type (all p>0.05). Analysis of flap-level complications demonstrated increased rates of delayed healing, fat necrosis, and skin necrosis after IBR (all p<0.01). No significant differences were seen in terms of other flap-level complications or patient-level complications (all p>0.05). Multivariate analysis demonstrated that DBR was independently associated with decreased incidence of delayed healing (OR 0.36, CI [0.24,0.55], p<0.001), fat necrosis (OR 0.49, CI [0.31,0.79], p=0.003), and skin necrosis (OR 0.30, CI [0.17,0.53], p<0.001). Rates of NAR and revision procedures were equivalent (p=0.606 and 0.198, respectively).
Conclusion: In a well-matched cohort, DBR demonstrates short-term benefits in terms of delayed healing, fat necrosis, and flap skin necrosis regardless of PMRT status, with equivalent patient-level and long-term clinical outcomes, including reoperations, and revisions. Proper perioperative counseling is essential for patients choosing to undergo ABR, and the decision of when to undergo autologous breast reconstruction is multifactorial, and should be made by patients and providers together.


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