Analysis of Breast Aesthetic Revision Procedures after Unilateral Abdominal-based Free-flap Breast Reconstruction: A Single-center Experience with 1251 Patients

Background:

Although autologous free-flap breast reconstruction is the most durable means of reconstruction, it is unclear how many additional operations are needed to optimize the aesthetic outcome of the reconstructed breast. The present study aimed to determine the average number of elective breast revision procedures performed for aesthetic reasons in patients undergoing unilateral autologous breast reconstruction and to analyze variables associated with undergoing additional procedures.

Methods:

A retrospective review of all unilateral abdominal-based free-flap breast reconstructions performed from 2000 to 2014 was undertaken at a tertiary academic center.

Results:

Overall, 1251 patients were included in the analysis. The average number of breast revision procedures was 1.1 ± 0.9, and 903 patients (72.2%) underwent at least one revision procedure. Multiple logistic regression analysis demonstrated that younger age, higher body mass index, and prior oncologic surgery on the reconstructed breast were factors associated with increased likelihood of undergoing a revision procedure. The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m²) increase in a patient’s body mass index. Multiple Poisson regression modeling demonstrated that younger age, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were significant factors associated with undergoing a greater number of revision procedures.

Conclusions:

Most patients who undergo unilateral autologous breast reconstruction require at least one additional operation to optimize their breast aesthetic results. Young age and obesity increase the likelihood of undergoing additional operations. These findings can aid reconstructive microsurgeons in counseling patients and establishing patient expectations prior to their undergoing microvascular breast reconstruction.

Takeaways

Question: How many aesthetic breast revisions do unilateral abdominal-based free-flap breast reconstruction patients undergo, and what factors are associated with undergoing an increased number of procedures?

Findings: The average number of aesthetic breast revision procedures was 1.1 ± 0.9. Younger age, higher body mass index, prior oncologic surgery on the reconstructed breast, and bipedicle reconstruction were identified as risk factors for aesthetic revisionary surgery.

Meaning: Patients with risk factors associated with undergoing an increased number of aesthetic revisions should be counseled regarding this possibility.

INTRODUCTION

Although patient satisfaction can be achieved in breast reconstruction using either a device-based approach or the patient’s own tissue, studies have demonstrated that using autologous techniques results in superior long-term outcomes, particularly in the setting of radiation therapy.^1–3 Unilateral autologous free-flap breast reconstruction aims to create a durable, aesthetic breast mound that mirrors the size, shape, and contour of the contralateral native breast. However, symmetry can be difficult to achieve, and breast asymmetry has been shown to have a significant negative impact on patient body image and patient satisfaction.^4,5 As such, additional surgical procedures on the reconstructed breast, the contralateral breast, or both may be necessary to restore maximum balance and symmetry.^6–10

Data are lacking on the variables that influence the number, type, and timing of enhancement procedures after unilateral autologous breast reconstruction. Although some studies have attempted to delineate factors that can impact the number of revision operations needed to achieve an optimal aesthetic result, their findings are difficult to interpret owing to inconsistencies in study design.^4,11–19 Limitations of prior studies include inclusion of both autologous and implant-based cohorts,^4,6,7,11,19 inclusion of both unilateral and bilateral cohorts,^6,11,19 inconsistent inclusion of donor site revisions,¹² and unclear delineation between procedures for aesthetic refinement and those needed to address complications.^12,18,19

A deeper understanding of the factors associated with additional surgery following unilateral autologous breast reconstruction may facilitate counseling and informed decision-making for patients considering microvascular breast reconstruction. To avoid the aforementioned limitations of previous studies and eliminate potential confounding variables such as bilateral reconstruction, donor site revisions, and procedures addressing complications, the present study focused on a single cohort of patients undergoing unilateral abdominal-based free-flap breast reconstruction to identify the average number of elective breast aesthetic revision procedures undertaken by patients and to analyze variables associated with undergoing additional procedures.

METHODS

Patients

After institutional review board approval, we performed a retrospective review of all patients who underwent a unilateral abdominal-based free-flap breast reconstruction performed at a tertiary academic cancer center from 2000 to 2014. Only patients with at least 12 months of follow-up after free-flap reconstruction were included. Patients who underwent autologous reconstruction with nonabdominal, pedicled abdominal, or latissimus dorsi flaps were excluded. Patients who had total flap loss were recorded but excluded from the analysis.

Data Collection

Medical records were reviewed for patient demographic data, including their home addresses (to calculate distance to the study institution), clinical and treatment characteristics, smoking status (defined as smoking within 12 months of reconstruction), and history of chemotherapy and/or radiation therapy. Operative notes were reviewed for timing of the reconstruction relative to the mastectomy, type of free flap, type and timing of any contralateral symmetry procedures, and additional revision procedures. Surgical revision data collected included the number and type of revision procedures performed.

The primary endpoint was the total number of aesthetic breast revision procedures. An aesthetic breast revision procedure was defined as any subsequent surgical procedure performed in the operating room or clinic that manipulated the size and/or shape of either the reconstructed or the contralateral breast. Nipple reconstruction was recorded but not considered a revision procedure because it was typically performed on an outpatient basis at the study institution. Revisions to specifically address acute complications (such as flap salvage, abscess, and seroma/hematoma drainage) were not considered revision procedures, though patients who sustained complications were included in the overall data analysis. Abdominal revisions were not included because these often occurred secondary to a prior complication (infection, dehiscence, abdominal bulge) and abdominal aesthetics were not evaluated in order to focus on the desired end point of breast aesthetic revisions. The duration of follow-up from the initial free-flap procedure and overall disease status at the time of the most recent medical record encounter were recorded.

Statistical Analysis

Descriptive statistics, such as means, standard deviations, medians, interquartile ranges (IQRs), and ranges, were used to summarize age, body mass index (BMI), number of revisions, and other continuous variables. Frequencies and percentages were used to summarize the categorical clinical characteristics and outcomes. The two-sample t test or Mann-Whitney U test was used to compare the interval variables between the patients with and without revisions after breast reconstruction. The chi-squared test or Fisher exact test was used to assess the association between categorical variables and revisions versus no revisions after breast reconstruction. Univariate and multiple logistic regression models were used to identify the risk factors affecting the probability of occurrence of revisions. The Hosmer-Lemeshow test was used to check the goodness of fit for the logistic regression model. The receiver operating characteristic curve was applied to evaluate the predictive ability of the model. Univariate and multiple Poisson regression models were utilized to identify risk factors associated with the total number of revisions. Value/df for deviance close to 1 indicated no overdispersion. The goodness of fit was examined using a chi-squared test. A stepwise selection algorithm was applied to fit a multiple regression model using the Akaike information criterion. All tests were two-sided. A P value of less than 0.05 was considered significant. A senior biostatistician (J.L.) performed all analyses in SAS 9.4 (SAS Institute Inc., Cary, N.C.).

RESULTS

Patients

A total of 1433 patients underwent a unilateral autologous breast reconstruction during the study period, and 1251 met the criteria for inclusion in the study (Fig. 1). Patient characteristics are shown in Table 1. All radiation therapy was completed before the free-flap reconstruction. The mean duration of follow-up was 58.0 ± 30.9 months (median: 54.3 months). At the time of data collection, 1126 patients (90.0%) were alive with no evidence of disease, 60 patients (4.8%) were alive with locally recurrent or metastatic disease, 64 patients (5.1%) were deceased, and one patient’s (0.1%) survival status was unknown.

Fig. 1.

Visual schematic of study inclusion and exclusion criteria. After application of the inclusion and exclusion criteria, 1251 patients were analyzed in the study.

Table 1.

Patient Characteristics (N = 1251)

Variable	N (%)
Age (y), mean ± SD	50.3 ± 8.9
BMI (kg/m2), mean ± SD	27.5 ± 4.8
Length of follow-up (mo), mean ± SD	58.0 ± 30.9
Length of follow-up (mo), median (IQR)	54.3 (31.5, 81.7)
Smoking	261 (20.9%)
Bra size
A/B/C	855 (68.3%)
D+	288 (23.0%)
Not documented	108 (8.6%)
Laterality
Left	652 (52.1%)
Right	599 (47.9%)
AJCC stage
DCIS, I, II	912 (72.9%)
III, IV	292 (23.3%)
N/A or unknown	47 (3.8%)
Estrogen receptor +	874 (69.9%)
Progesterone receptor +	725 (58%)
HER2 receptor +	272 (21.7%)
Radiation therapy, preflap	505 (40.4%)
Radiation therapy, postflap	0 (0%)
Chemotherapy	689 (54.3%)
Distance to MD Anderson
<50 miles	566 (45.2%)
50–100 miles	107 (8.6%)
>100 miles	527 (42.1%)
Texas residence
Within state	939 (75.1%)
Out of state	261 (20.9%)

AJCC, American Joint Committee on Cancer, 8th edition; DCIS, ductal carcinoma in situ.

Prior Breast Surgery

Of the 1251 patients studied, 765 patients (61.2%) had a history of prior surgery on the reconstructed breast, and 42 patients (3.4%) had a history of prior surgery on the contralateral breast. Twenty-four patients (1.9%) had a history of cosmetic surgery on the reconstructed breast before their breast cancer diagnosis, and 753 patients (60.2%) had prior surgery on the reconstructed breast for oncologic purposes. Of the 753 patients who underwent prior oncologic breast surgery, 389 (51.7%) underwent mastectomy without reconstruction, 206 (27.4%) underwent mastectomy with either a tissue expander or permanent implant placement, five (0.7%) underwent mastectomy with latissimus dorsi reconstruction, and 153 (20.3%) underwent partial mastectomy before their free-flap procedure. Of the 42 patients with prior surgery on the contralateral breast, 24 patients (1.9%) had a history of cosmetic surgery before their breast cancer diagnosis, and 18 patients (1.4%) underwent an oncologic-related symmetry procedure before their free-flap reconstruction.

Reconstruction

Of the 1251 patients included in the study, 627 patients (50.1%) underwent immediate reconstruction, 141 (11.3%) underwent staged reconstruction involving placement of a tissue expander followed by subsequent replacement with a free flap, and 483 patients (38.6%) underwent delayed reconstruction. A total of 813 (65.0%) underwent a transverse rectus abdominus myocutaneous flap or muscle-sparing transverse rectus abdominus myocutaneous (msTRAM) flap reconstruction, 383 patients (30.6%) underwent a deep inferior epigastric artery perforator flap or superficial inferior epigastric artery perforator flap reconstruction, and 55 patients (4.4%) underwent a bipedicle abdominal flap reconstruction.

Revision Procedures

Excluding patients who experienced a breast-related complication, the average number of total revision procedures performed for aesthetic reasons only was 1.1 ± 0.9 (Table 2). Patients who underwent a bipedicle flap reconstruction had an average of 1.5 ± 1.1 total revision procedures (Table 2). Among all different types of revisions, procedures to adjust the contour of the reconstructed breast were the most common, followed by flap liposuction and fat grafting. Mastopexy was the most common symmetry procedure performed on the contralateral breast (Table 3). Regarding the contralateral breast, 596 patients (47.6%) did not have a symmetry procedure, 196 patients (15.7%) underwent an immediate balancing procedure at the time of their free-flap reconstruction, and 459 patients (36.7%) underwent a balancing procedure in a staged fashion.

Table 2.

Additional Surgical Procedures for All Patients (N = 1251)

All Patients (N = 1251)		Patients without Complications (N = 824)		Patients with Bipedicle Reconstruction (N = 55)
Variable	N (%)	Variable	N (%)	Variable	N (%)
Total revision procedures on reconstructed breast		Total revision procedures on reconstructed breast		Total revision procedures on reconstructed breast
0	348 (27.8%)	0	220 (26.7%)	0	9 (16.4%)
1	586 (46.8%)	1	372 (45.1%)	1	21 (38.2%)
2	242 (19.3%)	2	176 (21.4%)	2	17 (30.9%)
3	61 (4.9%)	3	44 (5.3%)	3	4 (7.3%)
4	14 (1.1%)	4	12 (1.5%)	4	4 (7.3%)
Total procedures on contralateral breast		Total procedures on contralateral breast		Total procedures on contralateral breast
0	582 (46.5%)	0	375 (45.5%)	0	19 (34.5%)
1	526 (42%)	1	351 (42.6%)	1	24 (43.6%)
2	121 (9.7%)	2	80 (9.7%)	2	8 (14.5%)
3	21 (1.7%)	3	17 (2.1%)	3	3 (5.5%)
4	1 (0.1%)	4	1 (0.1%)	4	1 (1.8%)

Table 3.

Additional OR Procedures for All Patients (N = 1251)

Category	Mean	Median (IQR)	Range	Mean (95% CI)
Total number of additional OR procedures	1.05 ± 0.88	1 (0–2)	0–4	1.05 (1–1.09)
Flap contour	0.69 ± 0.69	1 (0–1)	0–4	0.69 (0.66–0.73)
Flap liposuction	0.3 ± 0.56	0 (0–1)	0–3	0.3 (0.27–0.33)
Flap fat grafting	0.21 ± 0.54	0 (0–0)	0–4	0.21 (0.18–0.24)
Flap inframammary fold repositioning	0.05 ± 0.23	0 (0–0)	0–2	0.05 (0.04–0.06)
Flap augmentation	0.05 ± 0.25	0 (0–0)	0–3	0.05 (0.03–0.06)
Flap reduction	0.03 ± 0.18	0 (0–0)	0–2	0.03 (0.02–0.04)
Flap mastopexy	0.06 ± 0.27	0 (0–0)	0–2	0.06 (0.05–0.08)
Total procedures on contralateral breast	0.67 ± 0.73	1 (0–1)	0–4	0.67 (0.63–0.71)
Contralateral augmentation	0.17 ± 0.45	0 (0–0)	0–3	0.17 (0.15–0.2)
Contralateral reduction	0.17 ± 0.44	1 (0–1)	0–4	0.17 (0.15–0.2)
Contralateral mastopexy	0.38 ± 0.59	0 (0–1)	0–3	0.38 (0.35–0.42)

In univariate logistic regression analysis, higher BMI, advanced cancer stage, prior radiation therapy, prior chemotherapy, and prior oncologic surgery on the reconstructed breast were significantly associated with a higher probability of needing revision surgery, whereas older age and immediate reconstruction were associated with a lower probability of revision (Table 4). Multiple logistic regression analysis confirmed that younger age, higher BMI, and prior oncologic surgery on the reconstructed breast remained significant factors associated with undergoing surgical revision. Patients with a history of prior oncologic surgery on the reconstructed breast were significantly more likely to undergo at least one revision compared to patients without a history of breast surgery (odds ratio [OR]: 1.70; 95% confidence interval [CI]: 1.32–2.19; P < 0.001). The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m²) increase in patient BMI.

Table 4.

Univariate and Multiple Logistic Regression Models of Additional Surgical Procedures

								Multiple Model
Variable	OR (95% CI)			P	OR (95% CI)					P
Age	0.98 (0.97–0.99)			0.007	0.98 (0.97–0.99)					0.008
BMI	1.04 (1.01–1.07)			0.007	1.03 (1.01–1.06)					0.033
Smoking		0.78 (0.58–1.05)							0.107
Bra size (D+ versus A/B/C)		1.18 (0.87–1.60)							0.294
AJCC stage (III/IV versus DCIS/I/II)		1.79 (1.30–2.47)							<0.001
ER+		1.10 (0.83–1.48)							0.506
PR+		1.05 (0.81–1.37)							0.698
HER2+		1.08 (0.79–1.48)							0.63
Prior XRT		1.54 (1.19–2.00)							0.001
Chemotherapy		1.59 (1.24–2.04)							<0.001
Prior surgery on reconstructed breast		1.69 (1.31–2.17)							0
Cosmetic surgery		0.53 (0.23 – 1.21)							0.132
Oncologic surgery	1.76 (1.37–2.27)		<0.001				1.70 (1.32–2.19)			<0.001
Prior cosmetic surgery on contralateral breast		0.66 (0.34–1.26)							0.206
Before cancer diagnosis		0.53 (0.23–1.21)							0.132
Symmetry procedure		0.99 (0.35–2.79)							0.982
Timing of reconstruction
Delayed								Reference
Immediate		0.52 (0.40–0.68)							<0.001
Staged		0.88 (0.56–1.37)							0.563
Flap type (DIEP/SIEA versus TRAM/MSTRAM)		0.97 (0.74–1.27)							0.843
Pedicle (bipedicle versus single pedicle)		2.02 (0.98–4.18)							0.057
Distance
<50 miles to MDA								Reference
50–100 miles to MDA		0.86 (0.55–1.35)							0.516
>100 miles to MDA		0.98 (0.75–1.28)							0.861
Texas residence		1.26 (0.93–1.70)							0.13
International versus domestic	0.57 (0.31–1.03)		0.062			0.54 (0.30–0.97)				0.039

AJCC, American Joint Committee on Cancer, 8th edition; DIEP, deep inferior epigastric artery perforator flap; ER, estrogen receptor; HER2, human epidermal growth factor receptor 2; MDA, MD Anderson Cancer Center; msTRAM, muscle-sparing transverse rectus abdominus myocutaneous flap; PR, progesterone receptor; SIEA, superficial inferior epigastric artery perforator flap; TRAM, transverse rectus abdominus myocutaneous flap; XRT, radiation therapy.

Univariate Poisson regression modeling demonstrated that advanced cancer stage, prior radiation therapy, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were also associated with a greater number of revisions, whereas smoking and immediate reconstruction were associated with fewer revisions (Table 5). Multiple Poisson regression modeling confirmed that younger age, prior oncologic surgery on the reconstructed breast, and undergoing a bipedicle flap reconstruction were factors significantly associated with undergoing a greater number of revision procedures. Patients who received a bipedicle flap reconstruction had significantly more revisions compared with patients who received a single-pedicle flap reconstruction (incidence rate ratio [IRR]: 1.40; 95% CI: 1.12–1.75; P = 0.003). Further, patients with prior oncologic surgery on the reconstructed breast underwent significantly more revisions (IRR: 1.22; 95% CI: 1.09–1.37; P < 0.001).

Table 5.

Univariate and Multiple Poisson Regression Models of Number of Additional Surgical Procedures

Univariate Model				Multiple Model
Variables	IRR (95% CI)		P		IRR (95% CI)		P
Age	0.99 (0.98–1.00)		0.002		0.99 (0.98–1)		0.003
BMI		1.01 (1.00–1.02)				0.07
Smoking		0.83 (0.72–0.96)				0.012
Bra size (D+ versus A/B/C)		1.07 (0.94–1.22)				0.297
AJCC stage (III/IV versus DCIS/I/II)		1.17 (1.03–1.32)				0.014
ER+		1.03 (0.9–1.17)				0.676
PR+		1.01 (0.9–1.13)				0.882
HER2+		1.05 (0.92–1.2)				0.507
Prior XRT		1.16 (1.04–1.29)				0.009
Chemotherapy		1.00 (0.86-1.18)				0.954
Prior surgery on reconstructed breast		1.23 (1.1–1.38)				<0.001
Cosmetic surgery		0.75 (0.48–1.18)				0.219
Oncologic surgery	1.25 (1.12–1.40)		<0.001		1.22 (1.09–1.37)		<0.001
Prior cosmetic surgery on contralateral breast		0.86 (0.62 – 1.19)				0.36
Before cancer diagnosis		0.87 (0.57–1.33)				0.524
Symmetry procedure		0.85 (0.52–1.38)				0.505
Timing of reconstruction
Delayed				Reference
Immediate		0.78 (0.69–0.87)				<0.001
Staged		0.99 (0.84–1.18)				0.94
Flap type (DIEP/SIEA versus TRAM/MSTRAM)		0.95 (0.84–1.07)				0.371
Pedicle (bipedicle versus single pedicle)	1.47 (1.18–1.84)		0.001		1.4 (1.12–1.75)		0.004
Distance
<50 miles to MDA				Reference
50–100 miles to MDA		0.86 (0.69–1.06)				0.165
>100 miles to MDA		1.01 (0.90–1.13)				0.89
Texas residence		1.03 (0.90–1.18)				0.654
International versus domestic	0.77 (0.57–1.06)		0.107		0.74 (0.54–1.00)		0.049

AJCC, American Joint Committee on Cancer, 8th edition; DIEP, deep inferior epigastric artery perforator flap; ER, estrogen receptor; HER2, human epidermal growth factor receptor 2; MDA, MD Anderson Cancer Center; msTRAM, muscle-sparing transverse rectus abdominus myocutaneous flap; PR, progesterone receptor; SIEA, superficial inferior epigastric artery perforator flap; TRAM, transverse rectus abdominus myocutaneous flap; XRT, radiation therapy.

Geographic Location

For patients living within the United States, having a revision operation was not associated with the patients’ state of residence. International patients were found to be less likely to undergo revision surgery (OR: 0.54; 95% CI: 0.30–0.97; P = 0.039) and underwent significantly fewer revision procedures (IRR: 0.74; 95% CI: 0.54–1.00; P = 0.049) compared with domestic patients. There were no significant differences in likelihood to undergo revision or revision rate between domestic patients who lived less than 50, 50–100, or more than 100 miles from the treatment center (Tables 4 and 5).

DISCUSSION

Numerous studies have demonstrated the clear psychological and quality-of-life benefits of breast reconstruction following treatment for breast cancer. However, revision procedures required to restore an aesthetic, symmetric breast also have ramifications, such as additional exposure to general anesthesia, time off from work, and costs to the healthcare system.^4,20–22 The present study demonstrates that in 1251 unilateral autologous free-flap breast reconstructions, the majority of patients underwent at least one additional operation to optimize the final cosmetic result. This finding is consistent with the numbers reported in the literature.^{7,11–14,16–18} While other studies have demonstrated an increased number of revisions in the setting of complications, the present study suggests that patients are willing to undergo additional procedures to optimize symmetry and cosmesis regardless of complications.^11,17 In particular, younger patients, patients with higher BMI, and patients who have had prior oncologic breast resections were significantly more likely to have additional surgery to improve the aesthetic appearance and symmetry of their breasts.

Although prior research has sought to determine the average number of procedures needed to complete breast reconstruction, the findings vary tremendously^4,11–19 One potential explanation for the variability of results is the inconsistencies in defining a revision operation, particularly with regard to varied inclusion of revisions to the breast versus the abdominal donor site in the reported statistics and corresponding analysis.¹² Further, prior studies may have included revisions to address complications, such as fat necrosis, partial flap loss, or mastectomy skin flap necrosis^{4,11,16,23,24} In order to control for or eliminate potential confounding factors, the present study specifically focused on unilateral reconstruction performed using an abdominal free flap and did not include revisions on the donor site or nipple reconstruction. There is no question that the decision to pursue additional surgery is multifactorial and includes both the patient’s desire to achieve satisfaction as well as the surgeon’s agreement that an additional surgery is warranted. This underscores the need for patient-reported outcomes, which is the greatest limitation of the present study.

In our cohort, over half (52.4%) of the patients underwent an additional procedure to improve the symmetry of the contralateral breast. It was more common for these procedures to be performed in a delayed fashion rather than simultaneously with the free-flap reconstruction, although previous studies from our group have confirmed the reliability of performing a simultaneous contralateral procedure.^9,10 Because revisions were defined as any return to the operating room to address aesthetic concerns in either breast, it was unfortunately not possible to evaluate the timing of the symmetry procedure as an independent factor for additional surgery, as each delayed symmetry procedure would be considered a revision. Ultimately, the decision to have a contralateral procedure performed simultaneously or in a staged fashion is very patient and surgeon dependent, and reliable, safe results have been achieved with either approach.^{6,7,9,10,25–28}

The impact of age on aesthetic revisions remains an area that requires further study, with a particular focus on patient-reported outcomes.^29,30 The current study confirms that younger patients were significantly more likely to undergo additional operations. This finding may be due to greater cosmetic concerns and demands compared with older patients; however, further studies are needed to confirm this hypothesis. This again highlights the need for patient-reported outcomes metrics to ascertain whether patient satisfaction varies between age groups. Regardless, counseling patients on the need for additional operations should ideally occur at the time of the initial consultation, where expectations for additional operations to optimize the final aesthetic result can be established, particularly for the younger patient cohort.

Prior studies from the authors’ institution have confirmed the safety of performing autologous breast reconstruction in patients with obesity (BMI > 30 kg/m²) and have also demonstrated better patient satisfaction and outcomes compared to device-based reconstruction in this patient population.^31–34 Despite the success of autologous reconstruction in patients with obesity, these patients should be counseled on not only the risks of complications but also the greater likelihood of needing additional revision surgery to achieve the optimal outcome. Previous studies have shown that patients with obesity were able to achieve satisfaction scores comparable to those of patients who are not obese following reconstruction, which suggests that despite the need for more revisions, patients with obesity can achieve high satisfaction with their reconstructions.³⁵

Conversely, in patients with low BMI (<25 kg/m²), the need for additional volume has increased the popularity of bipedicle and “stacked” flaps to match the size and volume of the contralateral breast. The safety of this reconstructive modality is well described, but its impact on additional revision surgery still remains unclear.^36–43 While others found no difference or a decreased incidence of revision when comparing patients undergoing bipedicle versus unipedicle reconstruction, the present study demonstrates an association between bipedicle reconstruction and more revision procedures.^43–45 Salibian et al demonstrated that the revision rate was higher in unipedicle reconstruction patients secondary to an increased rate of contralateral reduction.⁴³ Of note, the average patient BMI of the unipedicle cohort in that study was significantly higher than that of the bipedicle cohort, which may be a confounding factor.⁴³ However, the underlying rationale for using a bipedicle flap is difficult to ascertain in a retrospective study. In some circumstances, a bipedicle flap provides more breast volume, while in other cases it is needed for skin replacement. The need for additional skin to resurface the chest often occurs in the setting of delayed reconstruction following radiation therapy, which may be confounding factors. The aforementioned confounding factors may potentially explain the contradictory findings regarding secondary revision between Salibian et al. and the current study. Regardless, patients who are likely to require a bipedicle flap reconstruction should be counseled regarding the potential need for additional surgery.

Finally, this study demonstrates that prior oncologic breast surgery is also strongly predictive for undergoing additional revisions to optimize the final reconstruction. Although one may speculate that prior breast cosmetic surgery is a surrogate indicator for a more cosmetically oriented patient, this variable was not found to be significantly associated with undergoing additional revision procedures. The majority of prior operations on the reconstructed breast were for oncologic reasons, which may have distorted the breast or been associated with radiation therapy, predisposing patients to requiring more surgery to achieve the most optimal outcome.

As with all retrospective studies, there are multiple notable limitations to the present study. The study may reflect surgeons’ preferences and/or institutional practices and training, so the findings may not be applicable to other institutions. Furthermore, the data reflect the work of several different surgeons over a 15-year time frame, which adds potential confounding factors. The retrospective design of the study complicates the ability to determine whether the impetus to pursue revision was initiated by the patient or the physician and what the specific underlying aesthetic concerns prompting the desire for additional surgery were. This information was beyond the intended scope of the current study, and a prospective study would be needed to obtain it. However, the decision to pursue additional operations reflects the desires of the patient, who was willing to undergo additional surgery, and the assessment of a board-certified plastic surgeon, who agreed further surgery was warranted. If patients opted to have additional surgery at another institution, the revision rates would be underestimated. Aside from these limitations, as noted previously, the greatest limitation of the study is the lack of validated patient-reported outcomes data such as those obtained with the BREAST-Q questionnaire, which was not available at the authors’ institution during the time of the study. Nonetheless, the study provides insights into factors that may predict the need for additional surgery in patients undergoing unilateral microvascular breast reconstruction and can help reconstructive surgeons guide and establish expectations in this patient population.

CONCLUSIONS

The majority of patients undergoing unilateral abdominal-based free-flap breast reconstruction will require an additional revision operation to the reconstructed and/or contralateral breast. Our findings can assist reconstructive microsurgeons in counseling patients and establishing expectations, particularly for younger and overweight patients, who are significantly more likely to undergo further revisions.

ACKNOWLEDGEMENT

The earlier draft of this article was edited by Dawn Chalaire of the Research Medical Library at The University of Texas MD Anderson Cancer Center.