Northeastern Society of Plastic Surgeons

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A Nationwide Database Analysis of Breast Revision Profiles in Immediate vs. Delayed Implant-Based Breast Reconstruction
Olivia Waldron*1, Andrea Hiller2, Jessica C. El-Mallah2, Junjia Zhu3, Colette Pameijer2, Dino Ravnic2
1Pennsylvania State University College of Medicine, Hershey, PA; 2Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA; 3Department of Public Health Science, Penn State College of Medicine, Hershey, PA

Background
Most patients prefer to start breast reconstruction at the time of mastectomy either as a direct-to-implant (DTI) or a staged tissue expander-to-implant approach (TE). However, skin flap quality following mastectomy often precludes any device placement, necessitating a delay. We hypothesize that DTI leads to fewer subsequent soft-tissue revisional procedures compared to TE or delayed approaches.

Methods
Using TriNetX, females with breast cancer who underwent a mastectomy and either DTI, TE or delayed reconstruction from 2003-2023 were included. Revisional procedures were analyzed using the following CPT codes 19380 (skin excision), 19370 (partial capsulectomy), 19371 (total capsulectomy), 15771 (limited fat grafting), and 15772 (extensive fat grafting). Patient demographics were analyzed using chi-square tests. Quantitative variables underwent nonparametric Kruskal-Wallis tests. A multivariable logistic regression model examined the relationship between reconstruction, revisional procedures, and potential confounders (age, BMI, irradiation, smoking, diabetes, chemotherapy) using odds ratio (OR) with a 95% confidence interval (CI).

Results
Of 2,137 patients, the majority underwent TE-based reconstruction (1,138 patients, 53.3.%) followed by DTI (889 patients, 41.6%) with fewer having delayed reconstruction (110 patients, 5.1%). DTI patients were less likely to undergo skin excision and partial capsulectomy compared to the TE group (OR (CI) 0.71 (0.57-0.89)) p=0.0024; 0.5 (0.41-0.61) p<0.0001) while the delayed group was more likely to undergo skin excision (OR (CI) 1.22 (0.72-2.16)). Overall, DTI patients underwent 2.93 fewer revisional procedures (p<0.0001) compared to TE, while delayed patients underwent 1.26 more (p=0.0152) (Table 1).

Conclusions
Poor skin flaps post-mastectomy often necessitate delayed device placement for breast reconstruction therefore increasing soft-tissue revisions. These results further suggest that skin flap quality is vital in reducing the number of requisite procedures involved in the patient's breast reconstruction journey.
Table 1: Multivariable Logistic Regression for Revisional Breast Procedures
Multivariable Logistic Regression for Revisional Procedures (Reference Group: Tissue Expander)
 Skin ExcisionsPartial CapsulectomyTotal Revisionary Procedures
Type of Breast ReconstructionOR (95%CI)p-valueOR (95%CI)p-valueOR (95%CI)p-value
Direct0.71 (0.57-0.89)0.00240.5 (0.41-0.61)<0.0001-2.93 (-3.39-2.47)<0.0001
Delayed1.22 (0.72-2.16)0.48230.6 (0.38-0.92)0.0231.26 (0.24-2.28)0.0152


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