title: Evolution of Bilateral Free Flap Breast Reconstruction over 10 Years: Optimizing Outcomes and Comparison to Unilateral Reconstruction.
abstract: BACKGROUND
  There is an increasing trend for contralateral prophylactic mastectomy, but studies focusing on bilateral free flap breast reconstruction are lacking.
  
  
  METHODS
  A retrospective review was performed of all bilateral free flap breast reconstructions performed from 2000 to 2010.
  
  
  RESULTS
  Overall, 488 patients underwent bilateral breast reconstruction (bilateral immediate, n = 283; bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which more than doubled from the years 2000-2005 to 2006-2010 [147 versus 341 (232.0 percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a similar increase over the decade [139 versus 282 (203.9 percent)]. There was an increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17 percent)] between the first and second halves of the decade. Patients undergoing a bilateral immediate/delayed reconstruction were significantly more likely to undergo a revision (p = 0.05), particularly on the immediate reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity were significantly associated with postoperative complications. Obesity, smoking, and radiation therapy significantly increased fat necrosis rates, 2.77 (p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In comparison to unilateral reconstruction, bilateral reconstruction had significantly higher flap loss rates (p = 0.004), comparable donor-site complications, and equivalent rates of revisions.
  
  
  CONCLUSIONS
  There has been an increase in bilateral free flap breast reconstruction. Bilateral immediate/delayed reconstruction had higher revision rates of the prophylactic breast to achieve symmetry. Obesity, smoking, and radiation therapy were associated with increased complications, including fat necrosis, but successful reconstruction can be achieved with acceptable risks.
  
  
  METHODS
  Therapeutic, III.
authors.affiliation: Houston, Texas From the Department of Plastic and Reconstructive Surgery, University of Texas M. D. Anderson Cancer Center.
authors.forename: Edward I
authors.initials: EI
authors.lastname: Chang
authors.forename: Eric I
authors.initials: EI
authors.lastname: Chang
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Soto-Miranda
authors.forename: Hong
authors.initials: H
authors.lastname: Zhang
authors.forename: Naveed
authors.initials: N
authors.lastname: Nosrati
authors.forename: Shadi
authors.initials: S
authors.lastname: Ghali
authors.forename: David W
authors.initials: DW
authors.lastname: Chang
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D016015:Logistic Models; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply*; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012189:Retrospective Studies; D018570:Risk Assessment; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology