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American Association of Plastic Surgeons

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A Comparison Of Surgical Complications In Patients Undergoing Delayed Free-flap Versus Staged Tissue-expander And Free-flap Breast Reconstruction
Ronnie L. Shammas, Jr., M.D.1, Roger Cason, M.D.1, Adam D. Glener, M.D.1, Andrew Hollins, M.D.1, Gloria Broadwater, M.S.2, Scott T. Hollenbeck, M.D.1.
1Duke University Medical Center, Durham, NC, USA, 2Duke University Department of Biostatistics, Durham, NC, USA.

PURPOSE
Patients who are not candidates for immediate free-flap reconstruction may be eligible for delayed or staged free-flap reconstruction after tissue-expander placement; however, the optimal choice and incidence of complications remains unclear.
METHODS
We retrospectively identified patients who underwent delayed (n=140, 72%) or staged (n=54, 28%) abdominal free-flap breast reconstruction after tissue expander placement between 2010-2018. The incidence of post-operative complications was compared, and predictors of complications were assessed using logistic regression models.
RESULTS
Overall, staged reconstruction patients more frequently underwent bilateral reconstruction and were less likely to receive adjuvant radiation therapy. Patients undergoing staged reconstruction developed complications predominately during the tissue-expander stage, and had a higher overall incidence of surgical site infections (40.7% vs. 6.5%;p<.001), wound healing complications (29.6% vs. 12.3%;p=0.004), hematoma (11.1% vs. 0.7%;p=<.001), and return to the operating room (27.8% vs. 4.4%;p<.0001). In addition, 11.1% (n=6) of staged patients suffered from tissue-expander extrusion. After definitive free-flap reconstruction, there was no significant difference in the incidence of complications between the staged versus delayed cohorts, including microsurgical complications (1.9% vs. 4.3%;p=0.415), total flap loss (0% vs. 2.1%;p=0.278) or fat necrosis (5.6% vs. 5%;p=0.875). Bilateral breast reconstruction patients were more likely to develop post-operative complications (OR:2.8 95% CI:1.2-6.6, p=0.017).
CONCLUSION
Patients undergoing staged free-flap breast reconstruction after tissue expansion experienced a higher overall incidence of complications that predominately occurred in the first reconstructive stage. The aesthetic and psychosocial benefits of this approach should be balanced with the risk of complications in patients who may otherwise be suited for delayed reconstruction.


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