Redefining salvage in free flap breast reconstruction: Long-term breast volume symmetry after re-exploration

Little is known about long-term esthetic outcomes after re-exploration for microvascular compromise in autologous breast reconstruction. We assessed long-term breast volume symmetry and introduced a symmetry-based "true salvage rate".

We retrospectively reviewed 727 consecutive free-flap breast reconstructions between 2017 and 2022. Among them, 26 patients experienced microvascular compromise and underwent takeback surgery. Postoperative breast volume was measured using 3D surface imaging at ≥12 months. Volume symmetry was defined as salvaged/contralateral volume ratio and graded by volume reduction: Grade 0: <0%, Grade 1: 0-5%; Grade 2: 5-15%; Grade 3: 15-50%; Grade 4: >50%. The "true salvage rate" was defined as the proportion of all re-explored cases that achieved Grade 0-2 at ≥12 months.

Sixteen flaps survived (61.5%). Amongst salvaged flap cases (n=16), the median volume ratio was 0.96 (IQR 0.69-1.15); 11/16 demonstrated Grade 0-2, 3/16 Grade 3, and 2/16 Grade 4. Considering all re-explored cases, the true salvage rate was 11/26 (42.3%). Grade 0-2 asymmetry occurred in 6/7 cases when the flap was salvaged within 24 h, versus 3/5 at 24-48 h and 2/4 after 48 h. Severe asymmetry was more frequent after 48 h.

Re-exploration for microvascular compromise may be associated with favorable long-term esthetic outcomes, particularly when performed within 24 h. A symmetry-based true salvage rate can complement conventional flap survival and provide an objective, patient-centered endpoint for counseling and quality assessment.