Comparison of Postoperative Outcomes of Rib-Sparing Versus Rib-Sacrificing in Free Flap Breast Reconstruction Using the US Collaborative Network in TriNetX.

BACKGROUND: The "rib-sparing" method of autologous breast reconstruction has gained popularity alongside the historically used "rib-sacrificing" technique. Literature has endorsed benefits of the "rib-sparing" technique, including reduced contour irregularities, postoperative morphine use, and operative time. However, higher rates of fat necrosis and thromboembolic complications have been reported with this method. This study aims to compare postoperative complications in those undergoing rib-sparing and rib-sacrificing free flap breast reconstruction using a large-scale database. METHODS: A retrospective cohort study was conducted using the US Collaborative Network in TriNetX. Two cohorts were identified: those who underwent a free flap breast reconstruction (CPT 16634) and those who underwent a free flap breast reconstruction and a partial rib excision (CPT 21600). Propensity score matching for age and type of previous mastectomy was performed. Complications tabulated within 3 months of reconstruction were fat necrosis, hematoma/seroma, infection, dehiscence/necrosis, and venous thromboembolism. Mastodynia and deformity/disproportion within 8-18 months and reconstruction within 6-10 years of reconstruction were also tabulated. RESULTS: Propensity score matching yielded 992 subjects with a mean age of 50 ± 9.7 in each group. No difference was found between the rib-sparing and rib-sacrificing cohorts within the perioperative window for the included complications: hematoma/seroma (8.1% vs. 8.1%; p = 1.00), infection (p = 14.4% vs. 12.3%; 0.166), dehiscence/necrosis (9.2% vs. 7.6%; p = 0.195), and VTE (5.1% vs. 5.3%; p = 0.857). The rib sacrificing cohort were at 1.28 times increase risk for experiencing fat necrosis (12.9% vs. 10.1%; 95% CI: 1.00-1.64; p = 0.049). No difference was found in incidence of mastodynia (4.8% vs. 3.5%; p = 0.145) or dehiscence/necrosis (24.8% vs. 26.8%; p = 0.305) within 8-18 months. Subjects in the rib-sacrificing cohort were found to be at 1.21 (35.9% vs. 32.2%; 95% CI: 1.08-1.35;p < 0.001) times increased risk to undergo a revision within 6-10 years following initial reconstruction. CONCLUSIONS: Those who underwent rib-sacrificing reconstruction have a mild increased risk of experiencing fat necrosis and a revision in the 3 months and 6-10 years following initial reconstruction, respectively. Surgeons should consider the nuanced risks and benefits of both techniques and prioritize patient-centered decision-making.