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Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy

Seth, Akhil K. MD; Silver, Hayley R. BS; Hirsch, Elliot M. MD; Kim, John Y.S. MD; Fine, Neil A. MD

doi: 10.1097/SAP.0000000000000191
Breast Surgery

Background Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER).

Methods A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test.

Results There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P < 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts.

Conclusions This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients’ potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction.

From the Division of Plastic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Received November 6, 2013, and accepted for publication, after revision, February 3, 2014.

Akhil K. Seth and Hayley R. Silver contributed equally to this work.

Presented at the Plastic Surgery Research Council Annual Meeting, June 16, 2012, oral presentation format.

Conflicts of interest and sources of funding: John Y.S. Kim received research funding from Mentor and the Musculoskeletal Transplant Foundation. Neil A. Fine received research funding from Allergan. The remaining authors have nothing to disclose.

Reprints: Neil A. Fine, MD, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 676 N St Clair, Suite 1525A, Chicago, IL 60611. E-mail:

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