Northeastern Society of Plastic Surgeons

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Identifying Risk Factors of Donor and Recipient Site Complications in 380 Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions After Nipple-Sparing Mastectomy
Ashley Zhang*, Matthew Wright, Sophia Salingaros, Isaiah J. Rhodes, Sophia Arbuiso, Chase Alston, David Otterburn
Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY

Background
Nipple-sparing mastectomies (NSMs), the newest evolution of conservative breast surgery, allow for immediate reconstruction without the need for additional nipple reconstruction or tattooing. Additionally, nipple-sparing approaches are associated with quality-of-life benefits. The deep inferior epigastric perforator (DIEP) flap—the gold standard flap for autologous breast reconstruction today—is favored for its minimal donor site morbidity and resemblance to the aesthetics and feel of the natural breast. Despite clinical adoption of these advances, current literature of autologous reconstruction after NSM remains limited. In this study, we classify the incidence and predictors for the most common complications in patients undergoing NSM and DIEP flap reconstruction over a 10-year period.

Methods
This was a retrospective review of all patients receiving uni- or bilateral nipple-sparing mastectomies (NSMs) with deep inferior epigastric perforator (DIEP) flap breast reconstruction by the senior author between July 2013 to November 2022. Complications included flap issues, infection, hematoma, and wound healing problems within 90 days.

Results
From 2013 to 2022, 214 patients had post-NSM DIEP reconstruction for 380 breasts. The average age at reconstruction was 49.98 (SD 10.0). 16 (4.2%) flaps required a reoperation during the same admission: 13 were due to a hematoma, 2 were due to flap thrombosis, and 1 was due to venous congestion. No flaps were lost. On multivariate analysis, BMI>25 kg/m2 and tobacco user were associated with complications of both breast and abdomen. Delayed-immediate reconstruction was protective against skin healing issues, with a rate of 3.0%, compared to 19.7% in immediate reconstruction (p<0.001).

Conclusion
In our series of 380 DIEP flaps after NSM, the largest to-date, we present a major donor site complication rate of 5.9% and a major recipient site complication rate of 16.3%. BMI and tobacco use are associated with breast and abdominal complications. Delayed-immediate reconstruction has a protective effect on breast complications.
Table 1: Multivariate analysis for factors associated with breast- and abdominal-related complications
 All breast complications (n=104)Major breast complications (n = 62)
VariableOR (95% CI)p-valueOR (95% CI)p-value
Age, y1.02 (0.99, 1.05)0.131.03 (0.99, 1.06)0.12
BMI, kg/m2    
18.5-24.9RefRefRefRef
25-29.91.18 (0.66, 2.12)0.582.58 (1.25, 5.55)0.01
>302.02 (1.04, 3.94)0.043.01 (1.32, 7.07)0.01
History of DM0.68 (0.24, 1.81)0.450.59 (0.17, 1.74)0.36
History of HTN1.09 (0.52, 2.21)0.821.10 (0.48, 2.44)0.82
History of tobacco use2.22 (1.34, 3.70)0.0021.88 (1.03, 3.42)0.04
Prior breast surgery0.89 (0.51, 1.55)0.691.17 (0.61, 2.19)0.63
Neoadjuvant radiotherapy1.47 (0.44, 4.57)0.512.57 (0.74, 8.37)0.12
Adjuvant radiotherapy1.58 (0.82, 2.99)0.170.93 (0.39, 2.06)0.87
Stacked flap0.46 (0.13, 1.33)0.190.46 (0.07, 1.77)0.33
Recon Sequence    
ImmediateRefRefRefRef
Delayed-immediate0.16 (0.05, 0.43)0.0010.30 (0.07, 0.89)0.06
Other0.33 (0.08, 1.05)0.090.58 (0.09, 2.19)0.48
     
 All abdominal complications (n = 86)Major abdominal complications (n = 17)
VariableOR (95% CI)p-valueOR (95% CI)p-value
Age, y1.03 (0.99, 1.07)0.131.02 (0.93, 1.11)0.69
BMI, kg/m2    
18.5-24.9RefRefRefRef
25-29.92.63 (1.16, 6.27)0.026.84 (1.11, 132.47)0.08
>302.87 (1.11, 7.64)0.032.27 (0.18, 54.65)0.54
History of DM1.32 (0.36, 4.62)0.671.63 (0.19, 9.99)0.62
History of HTN0.70 (0.23, 1.89)0.491.15 (0.13, 7.38)0.89
History of tobacco use2.40 (1.19, 4.84)0.013.79 (0.93, 19.1)0.07
Prior abdominal surgery1.12 (0.56, 2.23)0.741.92 (0.5, 8.16)0.34


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