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Determining The Optimal Timing Of Free Flap Breast Reconstruction, A Systematic Review And Pooled Analysis
Vasanth S. Kotamarti, M.D., Sairisheel Gabbireddy, B.S., Adee Heiman, M.D., Joseph A. Ricci, M.D..
Albany Medical Center, Albany, NY, USA.

Background: Post-mastectomy radiation therapy (PMRT) has decreased breast cancer recurrence and mortality. Implant-based breast reconstruction in the setting of PMRT has been associated with higher risk of reconstructive failure and capsular contracture. Free flap breast reconstruction provides well-vascularized tissue, which may be more resilient to radiation. However, the optimal timing of free tissue transfer relative to PMRT is unclear. The purpose of this study was to systematically evaluate the literature on outcomes of delayed or immediate free flap breast reconstruction in the setting of PMRT.
Methods: The PubMed database was searched in July 2019 to identify articles discussing free flap breast reconstruction and PMRT. Data from each study were grouped by reconstruction timing. Outcomes of interest included patient demographics, flap type, complications (i.e. partial and total flap loss, unplanned return to the operating room, vascular complications, need for revision surgeries, fat necrosis, seroma/hematoma, infection, wound healing complications), and subjective outcome measures. Univariate analysis was performed using Fisher's Exact Test to characterize differences in outcomes. Odds ratios were subsequently calculated to determine risk of complications for delayed and immediate groups.
Results: Thirty-two studies met inclusion criteria with 1,600 patients identified. 645 patients underwent immediate reconstruction (46.5% deep inferior epigastric artery perforator flap (DIEP), 35.4% transverse rectus abdominis myocutaneous flap (TRAM), 5.2% superficial inferior epigastric artery flap (SIEA), 0.1% superior or inferior gluteal artery perforator flap (SGAP/IGAP), 0.8% diagonal or transverse upper gracilis, 12.6% mixed/not reported) while 955 underwent delayed reconstruction (43.7% DIEP, 52.8% TRAM, 2.4% SIEA, 0.7% SGAP/IGAP, 0.4% mixed/not reported). Pooled analysis revealed that immediate reconstruction compared to delayed reconstruction had significantly lower rates of partial (1.9% versus 4.6%, p=0.0073) and total flap loss (0.9% versus 2.4%, p=0.0386). Additionally, immediate reconstruction had significantly lower rates of revisions performed (0.41% versus 0.59%, p<0.0001). However, immediate reconstruction demonstrated significantly higher rates of infection (6.6% versus 3.1%, p=0.0159) and wound healing complications (17.2% versus 7.6%, p<0.0001).
Conclusions: In the setting of PMRT, immediate free flap breast reconstruction is associated with higher flap success and fewer revisions. The surgical success of immediate free flaps may be attributed to the absence of PMRT-mediated damage around the surgical site including the internal mammary vessels, increasing flap integrity. Performing an immediate breast reconstruction after mastectomy also leads to prolonged exposure of operative site and increased dead space in the mastectomy pocket. These factors may contribute to the increased incidence of surgical area infection indicated by our data. Plastic surgeons should consider these factors in combination with the oncologic treatment plan and the individual patient's goals when developing a reconstructive plan.

ComplicationNo. of Studies (Total Patients):
Immediate
No. of Studies (Total Patients): DelayedOdds Ratio [Confidence Interval]P value (Fisher's)
Complete Flap Loss13 (582)10 (833)2.84 [1.06, 7.61]0.04
Partial Flap Loss13 (582)10 (833)2.48 [1.26, 4.90]0.01
Unplanned Reoperation5 (144)4 (377)1.44 [0.71, 2.88]0.41
Vascular Complications3 (105)6 (644)1.15 [0.48, 2.78]1.00
Revision Surgeries9 (439)3 (188)2.03 [1.43, 2.87]<0.0001
Infection10 (485)6 (483)0.45 [0.24, 0.850.02
Wound Healing Complication12 (582)6 (539)0.40 [0.27, 0.58]<0.0001
Seroma/
Hematoma
7 (497)5 (479)1.10 [0.57, 2.12]0.87
Fat Necrosis15 (708)8 (541)0.85 [0.60, 1.22]0.42
Locoregional Spread5 (190)2 (221)1.03 [0.44, 2.45]0.10
Distant Metastases5 (190)2 (221)1.20 [0.61, 2.36]0.61
Death Due to Cancer5 (190)2 (221)0.17 [0.02, 1.45]0.10



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