Risk Factors for Complications in Immediate Expander-Implant Breast Reconstruction for Non-obese Patients: Impact of Breast Size on Complications

Limited impact of body mass index on the risk of postoperative complications after implant-based breast reconstruction: A retrospective cohort study of 1847 patients

BACKGROUND

High body mass index (BMI) has been linked to higher risk of complications following implant-based breast reconstruction. However, the impact of increasing BMI within the normal to overweight range (18.5-30 kg/m2) remains underexplored. We aimed to examine the association between BMI and complications and evaluate differences in risk of implant loss between patients undergoing immediate- and delayed reconstruction.

METHODS

Consecutive patients who underwent implant-based breast reconstruction from 2010-2023 at three plastic surgical departments were analyzed with BMI as a continuous variable. The primary outcome was implant loss stratified by immediate versus delayed reconstruction. Secondary outcomes included implant infection, seroma, hematoma, and mastectomy skin flap necrosis. All outcomes were analyzed with multivariate Cox regression.

RESULTS

We included 1847 patients (2631 breasts) with a median BMI of 23.3 kg/m2 (IQR 21.0-25.8, range 17.1-36.9). In patients undergoing immediate reconstruction, BMI was significantly associated with an increased risk of implant loss (P=0.04) but not after delayed reconstruction (P=0.22). Overall, higher BMI was significantly associated with risk of implant infection (P=0.003) and seroma (P<0.001) but not hematoma or mastectomy skin flap necrosis. The absolute risk difference for implant loss between BMI 23 kg/m² (6.2%) and 30 kg/m² (8.2%) was 2.0% (95% CI -2.9 to 6.8) for immediate reconstruction.

CONCLUSION

The small absolute risk differences for complications in patients with BMI between 23 and 30 kg/m² suggest that patients with BMI ≤30 kg/m² should not be discouraged from implant-based breast reconstruction. However, delayed reconstruction may be a safer option for patients with higher BMI.

Effects of Prostaglandin E1 on Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

BACKGROUND

Necrosis of a cutaneous flap including the nipple-areola complex is a common complication in immediate implant-based breast reconstruction following nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM). This study aimed to evaluate the efficacy of prostaglandin E1 (PGE1) in reducing such complications.

METHODS

A retrospective analysis of prospectively collected data was conducted at two centers, and the cohort consisted of patients undergoing NSM/SSM followed by immediate reconstruction with a prosthesis. Patients who were randomly allocated to the treatment group were administered daily intravenous PGE1 (10 μg/2 mL) beginning intraoperatively through postoperative day 6. Skin flap complications including nipple/skin necrosis, delayed wound healing, and postoperative wound revision were recorded. Complication rates were compared between the PGE1 and control groups.

RESULTS

A total of 276 breasts in 259 patients were included for analysis (139 breasts in the treatment group and 137 breasts in the control group). There was no difference in patient demographics between the control and treatment groups. Reconstructed breasts receiving PGE1 had significantly lower rates of overall skin complications (21.6% versus 34.3%; P = 0.022) and wound revision (2.9% versus 9.5%; P = 0.025). Among NSM cases, the PGE1 group showed a significantly lower rate of nipple necrosis (15.5% versus 29.4%; P = 0.027). In the multivariate analysis, the use of PGE1 significantly reduced the risk of overall skin flap complications (OR, 0.491; P = 0.018) and wound revision (OR, 0.213; P = 0.018) in NSM/SSM cases, and nipple necrosis (OR, 0.357; P = 0.008) in NSM cases.

CONCLUSION

PGE1 can be effective in reducing risk of mastectomy flap complications in immediate implant-based breast reconstructions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management

BACKGROUND

Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation.

PATIENTS AND METHODS

An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded.

RESULTS

Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005).

CONCLUSION

We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

Elderly and Patients with Large Breast Volume Have an Increased Risk of Seroma Formation after Mastectomy-Results of the SerMa Pilot Study

The collective of the SerMa pilot study included 100 cases of primary breast cancer or Carcinoma in situ who had undergone a mastectomy procedure with or without reconstruction of the breast using an implant or expander at Augsburg University Hospital between 12/2019 and 12/2022. The study aimed to investigate possible causes of seroma formation; reported here are the clinicopathological correlations between seroma formation and tumor biology and surgical procedures. Seroma occurred significantly more often in patients with older age (median patient age in cases with seroma was 73 years vs. 52 years without seroma; p < 0.001). In addition, patients with larger mastectomy specimen were significantly more likely to develop seroma (median ablation weight in cases with seroma 580 g vs. 330 g without seroma; p < 0.001). Other significant parameters for seroma formation were BMI (p = 0.005), grading (p = 0.015) and tumor size (p = 0.036). In addition, with insertion of implant or expander, a seroma occurred significantly less frequently (p < 0.001). In a binary logistic regression, age in particular was confirmed as a significant risk factor. In contrast, tumor biological characteristics, number of lymph nodes removed or affected showed no significant effect on seroma formation. The present study shows the need for patient education about the development of seroma in particular in older patients and patients with large breast volumes within the preoperative surgical clarification. These clinicopathological data support the previously published results hypothesizing that seroma formation is related to autoimmune/inflammatory processes and will be tested on a larger collective in the planned international multicenter SerMa study.

Impact of Body Composition on Postoperative Outcomes in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction

Nipple-areolar complex (NAC)-related complications are common during nipple-sparing mastectomy (NSM), with obesity as a risk factor. Although the incidence of NAC-related complications after robotic NSM (RNSM) with immediate breast reconstruction (IBR) is lower than that after conventional NSM, it remains one of the most unwanted complications. We aimed to evaluate body composition-based risk factors for NAC-related complications after RNSM with IBR. Data of 92 patients with breast cancer who underwent RNSM with IBR using direct-to-implant or tissue expander from November 2017 to September 2020 were analyzed retrospectively. Risk factors for NAC-related complications were identified with a focus on body composition using preoperative transverse computed tomography at the third lumbar vertebra level. Postoperative complications were assessed for 6 months. The most common complication was NAC ischemia, occurring in 15 patients (16%). Multivariate analysis revealed a low skeletal muscle index/total adipose tissue index (SMI/TATI) ratio as an independent NAC ischemia risk factor. An increase in the SMI/TATI ratio by one decreased the incidence of NAC ischemia by 0.940-fold (p = 0.030). A low SMI/TATI ratio is a risk factor for postoperative NAC ischemia in patients undergoing RNSM with IBR for breast cancer. Preoperative body composition-focused evaluation is more valuable than simple body mass index assessment.

Inframammary Fold Approach for Second-stage Operation in Expander-Implant Breast Reconstruction

BACKGROUND AND OBJECTIVES

Despite expander-based breast reconstruction being used as a reliable reconstruction method, implant removal due to wound dehiscence and infection still occurs in 0.5% to 15% of cases. This study aimed to compare the outcomes of the new inframammary fold (IMF) incision approach with previous incision in second-stage operation of expander-based 2-stage breast reconstruction.

METHODS

Patients who underwent expander-based 2-stage breast reconstruction between February 2014 and May 2019 were included. After expander inflation, patients undergoing second-stage reconstruction were divided into the previous incision and IMF incision groups and their outcomes were compared. Propensity score matching analysis was performed to compare postoperative 1-year results.

RESULTS

The previous incision and IMF incision groups comprised 79 and 31 patients, respectively. There were no intergroup differences in general demographics or intraoperative data, except for total inflation volume (426.87 ± 102.63 mL in the previous incision group and 375.48 ± 94.10 mL in the IMF incision group, P = 0.017). Wound dehiscence occurred in 12 and 0 cases in the previous and IMF incision groups, respectively (P = 0.018). Implant removal was performed due to dehiscence in 9 cases (8.18%) and 0 cases (0%) in the previous and IMF incision groups, respectively (P = 0.049). In 1-to-1 propensity score matching analysis, the IMF incision group showed better results at 1-year follow-up (odds ratio: 0, 95% confidence interval: 0-1.09; P = 0.063).

CONCLUSIONS

The IMF approach is a safe method for replacing the expander with an implant, with lower incidence of wound dehiscence and implant explantation.

Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery

BACKGROUND

Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS.

MATERIALS AND METHODS

Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss.

RESULTS

956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567).

CONCLUSION

In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Goldilocks Principle: Preference for Change in Breast Size in Breast Cancer Reconstruction Patients

Patients' preferences regarding changing or maintaining their breast size after mastectomy and reconstruction are important but understudied determinants of post-surgical satisfaction and quality of life. The goal of this study was to identify factors associated with preferences for changing or maintaining breast size for women undergoing breast reconstruction at The University of Texas MD Anderson Cancer Center in the United States from 2011 to 2014. The average age of participants was 45.7 ± 9.1 years. At baseline, mean average breast volumes were 755.7 ± 328.4 mL for all women (n = 48), 492.3 mL ± 209.3 for 13 women who preferred to be "bigger than now," 799.2 mL ± 320.9 for 25 women who preferred to remain "about the same," and 989.3 mL ± 253.1 for 10 women who preferred "smaller than now." Among the 23 women who preferred to change their breast size, 19 desired to shift toward the mean. Women with the smallest and largest 20% of baseline breast size were more likely to desire a change toward the mean (p = 0.006). Multinomial logistic regression models found average breast volume and satisfaction with breast size to be the most important factors associated with preferences for changing or maintaining breast size for women undergoing breast reconstruction. This study provides preliminary evidence for a "Goldilocks principle" in women's preferences for breast size change in the context of breast reconstruction, and identifies hypotheses for future studies of the associations among preference for change in breast size, preference achievement, and post-reconstruction body image.

The influence of contralateral breast augmentation on the development of complications in direct-to-implant breast reconstruction

BACKGROUND

Simultaneous contralateral augmentation in direct-to-implant (DTI) breast reconstruction may increase the risk of skin flap necrosis on the reconstruction side due to increased tension on the skin flap when implants are larger than the original breast size. The purpose of this study was to evaluate whether the contralateral augmentation procedure affects complications in unilateral DTI breast reconstruction.

METHODS

Patients who underwent immediate unilateral DTI breast reconstruction from January 2013 to July 2017 were included in this study. Data were collected through retrospective review of individual medical records. The primary outcome variable was the development of perioperative complications including skin flap necrosis. Univariable and multivariable logistic regression analyses were performed to identify risk factors for complications.

RESULTS

A total of 121 patients who underwent unilateral immediate DTI breast reconstruction were included in this study. Twenty-one patients (17.4%) underwent simultaneous contralateral augmentation mammoplasty and 100 patients (82.6%) underwent DTI without contralateral augmentation. Overall complications were not different between the contralateral augmentation and no-augmentation groups (23.8% vs. 31%, respectively, p = 0.512). The frequency of skin flap necrosis in the augmentation group (14.3%) was not significantly different from that in the no-augmentation group (18.0%, p > 0.999). In multivariable analysis, mastectomy weight was the only predictor for complications (p = 0.053) and contralateral augmentation was not associated with development of complications.

CONCLUSION

Contralateral breast augmentation in DTI breast reconstruction is not a risk factor for complications and can be safely performed in selected patients.

Trans-Vertical Mastectomy With Immediate Implant-Based Reconstruction: A Retrospective, Observational Study

Background

In women with large and ptotic breasts who require a mastectomy and immediate, implant-based reconstruction, long flaps pose a high risk for flap ischemia and necrosis. A new trans-vertical incision for skin-reducing mastectomy is described, which reduces the skin envelope and lifts the breast.

Objectives

The authors sought to describe the new mastectomy access incision and assess its efficacy and safety when followed by immediate implant-based reconstruction.

Methods

This retrospective analysis included 70 consecutive patients (101 breasts) with large and ptotic breasts who underwent a unilateral (n = 39; 55.7%) or bilateral (n = 31; 44.3%), skin-reducing mastectomy utilizing the trans-vertical approach for either breast cancer or risk reduction. All received immediate one- (n = 86; 85.5%) or two-stage (n = 15; 14.5%), implant-based reconstruction utilizing acellular dermal matrix.

Results

Mean age was 50.1 years and mean body mass index was 25.6 kg/m². After a median follow-up of 4.9 years, the number of breasts with minor and major complications was 21 (20.8%) and 26 (25.7%), respectively. The most common major complications were skin-flap necrosis (n = 12; 11.9%) and infection (n = 8; 7.9%). All occurred within 3 months postsurgically. There were 7 cases of capsular contracture (6.9%) and 5 reconstruction failures (5.0%). Higher body mass index (P < 0.01) and breast weight (P < 0.05) were associated with increased complication rates. According to BREAST-Q, 55/64 patients (85.9%) were somewhat or very satisfied with the aesthetic outcome.

Conclusions

The trans-vertical approach is an effective, reproducible, and safe alternative to conventional skin-reducing mastectomy, with favorable aesthetic outcomes, in patients with large and ptotic breasts.

Level of Evidence: 4

Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study

PURPOSE

Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions.

METHODS

A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed.

RESULTS

A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511).

CONCLUSIONS

A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.

Expander/Implant Removal After Breast Reconstruction: Analysis of Risk Factors and Timeline

INTRODUCTION

Removal of tissue expanders (TE) or implants is a dire consequence of breast reconstruction, and has the potential to halt the reconstructive efforts. Our goals were to characterize a cohort of patients with TE/implant removal, to perform a time-based analysis, and to review the bacteriology associated with explanted devices.

MATERIALS AND METHODS

Review of a prospectively maintained database was performed to identify patients who underwent TE/implant removal. Patient characteristics, surgical technique, adjuvant therapies, indications, complications, culture results were obtained. Data were analyzed according to timing of explantation.

RESULTS

A total of 55 TE and implants were removed in 43 patients. Reasons for explantation were infection (58%), patient request (22%), and wound-related complications (20%). The majority of explantations occurred after 30 days (62%), and after Stage I (81%). Median days to explantation was 62. Patients of older age (p = 0.01) and higher BMI (p = 0.02) were more likely to undergo explantation after Stage I. The most commonly cultured organisms were S. epidermidis (10.9%), S. aureus (10.9%) and P. aeruginosa (10.9%). Antibiotic resistance was commonly encountered for ampicillin, cefazolin, penicillin, and erythromycin.

CONCLUSION

Infection is the most common reason for explantation after prosthetic breast reconstruction. Patients should be carefully monitored for a prolonged period of time after Stage I, as the majority of explantations occur in this stage but beyond 30 days. For oral treatment, fluoroquinolones and trimethoprim-sulfamethoxazole and for IV treatment a combination of vancomycin or daptomycin with piperacillin-tazobactam or imipenems/carbapenems appear to be appropriate choices according to our culture results.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preoperative breast size affects reconstruction status following mastectomy

Much research has been devoted to why women choose not to be reconstructed following mastectomy. The effect of breast size has not been well explored. The authors aimed to assess the relationship between breast size and reconstructive choices. A single-center retrospective review of women undergoing mastectomy between 2011 and 2014 was performed. Demographics, surgical variables, and reconstruction decisions were analyzed using t tests, Mann-Whitney U tests, and chi-squared tests. Significant (P < .05) variables were included in a multivariable logistic regression model. About 610 patients were analyzed. The median mastectomy specimen weight was 572 g (62-5230 g), which did not correlate with BMI (P = .44). Women who underwent reconstruction had lighter mastectomy specimens, averaging 643 vs 848 g (P < .0001). A regression controlling for ethnicity, insurance status, number of comorbidities, age at mastectomy, cancer stage, BMI, specimen weight, and mastectomy laterality was constructed. Lower specimen weight (P = .005), lower cancer stage (P = .008), bilateral mastectomy (P = .042), and younger age at mastectomy (P < .0001) were significantly associated with reconstruction. Women with larger breasts were less likely to be reconstructed regardless of their BMI and comorbidities. Larger breasted women may be considered worse prosthetic reconstruction candidates due to increased complications and suboptimal aesthetic outcomes but may find the increased invasiveness and recovery of autologous reconstruction an unattractive alternative. Furthermore, it is possible that surgeons may be less supportive of breast reconstruction for larger breasted women if there are concerns about safety or the aesthetic quality of the result. In the future, qualitative research must be done to determine why more larger breasted women choose not to be reconstructed as well as develop better ways to increase their reconstructive options.

Analysis of factors influencing drain amount, time to drain removal, and seroma formation in patients undergoing immediate expander-implant breast reconstruction

BACKGROUND

Placement of a closed suction drain is a common cause of patient complaints, such as postoperative pain or discomfort following immediate expander-implant breast reconstruction. This study aims to identify factors that affect drainage volume, time to drain removal, and seroma formation.

METHODS

A retrospective chart review of prospectively collected data was conducted on patients who underwent immediate expander-implant breast reconstructions following nipple-sparing or skin-sparing mastectomy without skin excision (nipple areolar complex excision only) between February 2010 and April 2015. Daily drainage volume was measured until the drain was removed. Eight independent variables, including acellular dermal matrix (ADM) usage and inflation ratio (the rate of initial inflation volume to mastectomy weight) were analysed by univariable and multivariable analyses.

RESULTS

A total of 162 breasts in 148 patients were included in this study. The inflation ratio did not influence the drain amount or days to drain removal. Although the use of ADM was significantly associated with increased drainage during the first 5 postoperative days (p = 0.015), it was not significant when adjusted for time. Old age, larger expander size, and larger drain amount on the first postoperative day were predictors for longer days to drain removal (p < 0.001). Old age had a trend toward higher risk of seroma formation that approached statistical significance (p = 0.057).

CONCLUSIONS

The use of ADM and initial inflation ratio do not influence days to drain removal or seroma formation. A longer period of drain placement is expected when a larger expander is used or in elderly patients.

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

Becker Expander-Based Breast Reconstruction Following Wise Pattern Skin-Reducing Mastectomy: Complication Rates and Risk Factors

Our aim is to analyze the results of immediate breast reconstruction in women with macromastia after skin-reducing mastectomy (SRM), with an emphasis on complications and risk factors. Between 2008 and 2013, fifty women with hypertrophic breasts, aged 21-74 years, underwent immediate expander-based breast reconstruction after Wise pattern SRM. An inferiorly based de-epithelialized skin flap was sutured to the inferolateral border of the pectoralis major muscle and covered the expander. Thirty-five women had a unilateral and fifteen a bilateral procedure (total 65 breasts). In all cases, Becker-35 expanders of volume ranging from 365 to 685 cc were used. Risk factors (BMI, smoking, expander's size, preoperative irradiation, chemotherapy) and complications were recorded. Follow-up up to 60 months was compiled. In all cases, the myodermal pouch provided safe coverage and support of the expander. Postoperative complications occurred in 18 out of 65 breasts (27.6%) and included skin ischemia in 11 breasts (16.9%), late infection in two (3%), seroma and expander rotation in four and one, respectively (6.1 and 1.5%), and severe peri-prosthetical contraction in five breasts (7.6%). Statistical analysis showed that complications were significantly related to preoperative radiotherapy and smoking; no significant correlation was documented between complication rates and chemotherapy, BMI, age or expander's size. We suggest that the inverted-T SRM, creating a combined "myodermal" flap for the coverage of a Becker expander, is a useful single-stage reconstructive option for patients with macromastia. Preoperative radiotherapy is significantly related to higher postoperative complication rates, and may result in a less optimal reconstructive outcome. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.