Are Large Intraoperative Fill Volumes Associated With Increased Complications After Tissue Expander Placement?

With the increased adoption of skin-sparing mastectomies, immediate 2-stage breast reconstruction is a common option for breast cancer patients. During the first stage of the procedure with tissue expander placement, higher intraoperative percent fill has been identified as a risk factor for complications. However, the postoperative outcomes of higher intraoperative fill volumes are not well established. The authors sought to evaluate if a higher initial intraoperative tissue expander fill volume is associated with higher complication rates in patients undergoing immediate breast reconstruction with tissue expander placement.

A retrospective review of patients who underwent immediate breast reconstruction with a tissue expander placement from 2016 to 2018 was conducted. Patient demographics and perioperative data were recorded. Large intraoperative fill was defined as saline fill volume greater than 350 mL. The primary outcome evaluated was skin and nipple necrosis. Secondary outcomes were major infections, minor infections, seroma, and hematoma.

A total of 147 breasts in 86 patients were included. Mean intraoperative fill volume was 246.4 ± 106.6 mL. Thirty-five tissue expanders were filled with greater than 350 mL of saline intraoperatively. Patients with large intraoperative fill volume were older (mean age, 52.6 vs 47.9 years; P = .04), had a higher mean body mass index (BMI; 33.2 vs 25.9 kg/m²; P < .0001), and had larger preoperative breast anthropometrics (P < .0001). During a mean follow-up period of 20.1 months (range, 3-55 months), 9 breasts were noted to have skin/nipple necrosis. After multivariate analysis, large tissue expander fill volume was not a significant predictor of skin or nipple necrosis (P = .62). Hypertension and anticoagulant use were associated with increased skin and nipple necrosis (P = .04 and P = .03, respectively). Large fill volume was not associated with statistically significant increases in rates of other complications like major infections, minor infections, seroma, or hematoma.

Larger fill volumes are often required and benefit patients with higher BMI or bra sizes. This also reduces the number of postoperative fills required. In this patient population, larger intraoperative tissue expander saline fill volume (greater than 350 mL) was not associated with increased postoperative complications. After careful patient selection and perfusion evaluation, larger fill volumes may be considered a safe option to improve the aesthetic outcomes in patients with high BMI.