Do 2 Free Flaps Put the Patient at More Risk?: Comparing Patient Characteristics and Complications in Unilateral and Bilateral Autologous Free Flap Breast Reconstruction
Ines C. Lin, MD1, Joshua Fosnot, MD1, Jesse C. Selber, MD, MPH2, Joseph M. Serletti, MD1.
1Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 2MD Anderson Cancer Center, Houston, TX, USA.
BACKGROUND: It has recently been reported that the rate of contralateral prophylactic mastectomy in breast cancer patients has more than doubled from 1998 to 2003. Bilateral breast reconstructions subject the patients to two free flaps and longer operations, potentially increasing their risk to surgery-related complications. This study compares unilateral and bilateral autologous free flap breast reconstruction patients for population differences and rates of peri-operative complications.
METHODS: A retrospective chart review identified 116 bilateral free flap breast reconstructions (in 58 patients) and 115 unilateral free flap breast reconstructions performed by the senior author at a single institution between March 2005 and January 2008. Only abdominal donor site flaps (TRAM, DIEP, SIEA) were investigated. Operative records, hospital charts, and office charts, were reviewed for the patient characteristics, such as age, BMI, and co-morbidities, and perioperative complications, such as vessel thrombosis, seroma, hematoma, infection, flap loss, bulge/hernia, fat necrosis, other post-operative or medical complications.
RESULTS: There was no significant difference in age, BMI, and ASA class between the unilateral and bilateral reconstruction groups. A significantly higher percentage of unilateral patients were African-American (21.1% vs. 7.5%, p<0.01) and had a diagnosis of hypertension (27.2% vs. 10.5%, p<0.01). Bilateral reconstructions were more likely to be immediate reconstructions (88.2% vs 77.4%, p=0.03) and had a higher percentage of SIEA flaps (20.7% vs. 9.6%, p=0.04) and less TRAM flaps (45.7% vs. 57.4%, p=0.04). In univariate analysis, there were a significantly higher number of intra-operative vessel thromboses in the bilateral breast reconstructions (10 vs. 1, p=0.01) although this did not translate to any significant differences in the rate of post-operative complications between the 2 study groups. Furthermore, the significant difference was lost in subsequent multivariate analysis. The difference in operative time between unilateral and bilateral reconstructions was 2 hours and 20 minutes (6 hours 34 minutes vs. 8 hours 54 minutes). Both groups had an average hospital stay of 4.1-4.2 days.
CONCLUSIONS: This comparison of unilateral and bilateral breast reconstructions shows some significant differences in patient characteristics between the two patient groups. Bilateral reconstructions are more likely to be immediate reconstructions and the less invasive SIEA flap. Despite a higher rate of intra-operative vessel thromboses and longer operative time, bilateral breast reconstruction flaps do not have a significantly higher rate of post-operative complications. These findings support the safety of bilateral free flap breast reconstructions, which may become more common as the rate of contralateral prophylactic mastectomies rises.
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