Air Versus Saline: The Effect of Tissue Expander Fill Prepectoral Breast Reconstruction Postoperative Complications

Abstract

BACKGROUND: A common practice in breast reconstruction is 2-stage implant reconstruction with initial tissue expander placement. Traditionally, saline is added to the tissue expander intraoperatively, followed by continued expansion with saline postoperatively. Recently, intraoperative expansion with air rather than saline has been proposed to reduce the pressure applied to the mastectomy skin flap and incisions in the immediate postoperative setting. The aim of our study was to determine if tissue expansion fill (air versus saline) affects postoperative complications in the setting of prepectoral delayed immediate reconstruction. METHODS: A retrospective cohort study of 144 breasts (86 patients) who underwent immediate prepectoral breast reconstruction with full anterior coverage with ADM over a 2-year period was performed. Patient demographics, intraoperative tissue expander fill medium, and the occurrence of postsurgical complications were analyzed. Crude and multivariable-adjusted logistic regression estimated odds ratios were used to identify predictors of postsurgical complications. To account for the potential clustering of 144 breast interventions from 86 women, regressions used robust variances. Statistical analyses were performed using SAS software v9.4. RESULTS: The demographic and clinical data were well matched between study cohorts. The mean follow-up time is 196 days (range, 85–633 days), and the average age is 46.7 years old. Initial tissue expander fill volume was similar (P = 0.2). ASA III+, body mass index, diabetes, and smoking status were added in a step-wise fashion as potential confounding variables in the model. The crude association between air and saline fill on overall complication suggests a protective effect when the tissue expander is filled with air (odds ratio [OR], 0.5; P = 0.04), and the suggested protective effect is maintained as potential confounding variables are added to the model (OR, 0.4; P = 0.05). Fewer complications requiring salvage reoperation were observed when tissue expanders were filled with air (OR, 0.3; P = 0.02). Additionally, there is a suggested protective effect regarding skin flap necrosis if the tissue expander is air-filled (OR, 0.7; P = 0.6). CONCLUSION: The medium used in immediate intraoperative tissue expansion affects postoperative outcomes of patients undergoing delayed immediate prepectoral breast reconstruction. Here, we demonstrate that air-filled tissue expanders were associated with significantly less postoperative complications following breast reconstruction relative to saline-filled tissue expanders.