Background: The requirement for postmastectomy radiation therapy (PMRT) at the time of mastectomy is often unknown. Autologous reconstruction is preferred in the setting of radiotherapy by providing healthy vascularized tissue to the chest. To maximize mastectomy skin preservation, tissue expander (TE) placement maintains the breast pocket until definitive reconstruction. This study aims to compare outcomes of skin-preserving delayed versus standard delayed autologous breast reconstruction in the setting of PMRT. Methods: A retrospective review of a prospective database was performed of two patient cohorts at a single center between 2006 and 2016. Inclusion criteria were locally advanced breast cancer patients who completed PMRT and free autologous reconstruction. Primary outcomes were major intraoperative and postoperative TE and flap complications. Results: Over 10 years, 241 patients underwent mastectomy and PMRT. Standard delayed autologous breast reconstruction was performed in 131 breasts (non-TE group). Skin-preserving delayed autologous reconstruction was performed in 113 breasts (TE group). The TE group was associated with a higher incidence of intraoperative complications during flap reconstruction (P = 0.002) and had a higher venous thrombosis incidence than the non-TE cohort (P = 0.007). Other major postoperative complications were not significantly different between the two groups. TE patients had 7.5 times higher risk of intraoperative complications and an 18.6% TE loss rate. Conclusions: We identified higher intraoperative flap complications and a high rate of TE loss in patients who underwent skin-preserving delayed autologous breast reconstruction. The benefit of mastectomy skin preservation needs to be weighed against the increased risk of TE loss and higher rates of flap thrombosis.
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