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Evaluation Of Aesthetic Revisions After Autologous Breast Reconstruction: An Analysis Of 3,780 Free Flaps
Said Azoury, MD, Arturo J. Rios-Diaz, MD, Jessica R. Cunning, MBA, Cutler Whitely, BS, Robyn B. Broach, PhD, Joseph M. Serletti, MD, Joshua Fosnot, MD.
University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Data on aesthetic revisions after free flap autologous breast reconstruction (FFABR) are lacking. We sought to ascertain aesthetic revision rates after FFABR, as well as patient-level and operative characteristics associated with revisions.
Methods: Patients who underwent FFABR between 2008-2017 were identified in a prospectively-maintained health system-wide registry. Patients with incomplete data were excluded. The primary outcome of breast aesthetic revision included scar revisions, fat grafting, liposuction, dog ear excision and implant-related revisions. Secondary outcomes included time to first revision, number of procedures per type of revision, and factors associated with increased aesthetic revisions. Revision rates and mean number of revisions were calculated. Chi-square tests and Cox regression controlling for potential confounders were used to determine the association of patient-level and operative factors associated with aesthetic revisions. The unit of analysis was at the flap-level.
Results: We identified 2,352 patients undergoing 3,780 flaps; 75.4% were bilateral. Characteristics that were more likely to be present in flaps that required aesthetic revisions included White race (79.5% vs. 73%, p<0.01), lower ASA (class I/II: 76.6 vs. 71.1%, p<0.01), diagnosis of cancer (90.7% vs. 88.4%, p=0.03), and lymphedema (11.3% vs. 9%, p=0.02). Type of flap, chemotherapy and radiation therapy also differed between cohorts (p<0.05). There were no differences in age, obesity (BMI>30), comorbidities, reconstruction timing, or prior BCT (p>0.05).The rate of aesthetic revisions was 36%. The Table shows the breakdown by type. The median time to first revision was 218 days after discharge (IQR 148-341), and 80.5% occurred within two years (Figure). While the majority of flaps that underwent revision required only one revision (66.2%), 12.6% underwent three or more revisions. Liposuction was the most common aesthetic revision with a rate of 17.4%.Risk-adjusted analysis showed that White race relative to Black (Hazard Ratio [HR] 1.42 [95% confidence interval [95% CI]: 1.13-1.78], p<0.01); delayed reconstruction relative to immediate (HR 1.16 [95%CI: 1.02-1.32], p<0.01); DIEP (HR 1.11 [95% CI: 1.05-1.18], p<0.01), SIEA (HR 1.5 [95% CI: 1.13-2], p<0.01), and other flap (GAP, TUG, PAP; HR 3.1 [95% CI: 2.34.-4.11], p<0.01) relative to muscle-sparing free TRAM flap; surgical site occurrences (HR 1.31 [95% CI: 1.16-1.48], p<0.01); and any surgical/non-surgical complication composite (HR 1.49 [95% CI: 1.32-1.68], p<0.01) were independently associated with increased aesthetic revisions.
Conclusions: A fourth of flaps require at least one revision after FFABR and most occur within two years. White race, type of flap, delayed reconstruction and complications are factors associated with increased aesthetic revisions. These data should be used to set appropriate expectations preoperatively and to illustrate the timeline of reconstruction in patients seeking FFABR.


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