Microsurgery on Steroids: The Impact of Chronic Immunosuppressive Therapy on Outcomes Following Free Flap Breast Reconstruction.

[BACKGROUND] Free flap breast reconstruction (FFBR) is a well-established technique for postmastectomy rehabilitation. However, chronic immunosuppressive therapy may compromise wound healing, increase infection susceptibility, and adversely affect surgical results. However, evidence regarding the impact of chronic immunosuppression on FFBR outcomes remains sparse.

[METHODS] We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2023), identifying female breast cancer patients who underwent immediate FFBR. Chronic immunosuppression was defined as continuous systemic administration of corticosteroids or other immunosuppressants for ≥ 30 days preoperatively. Multivariable logistic regression and propensity score matching were applied to assess the impact of immunosuppression on surgical outcomes.

[RESULTS] Of 5473 patients (mean age 52 ± 9.4 years; mean BMI 30 ± 5.6 kg/m²), 139 (2.5%) were chronically immunosuppressed. In confounder-adjusted multivariable analysis, chronic immunosuppression was independently associated with an increased risk of any complication (OR 1.5; 95% CI, 1.0-2.2; P = .048) and surgical complications (OR 2.0; 95% CI, 1.3-3.0; P = .0011), particularly postoperative bleeding (23% vs. 10%; P < .001). No significant associations were observed with medical complications (P = .73), reoperations (P = .11), or readmissions (P = .45). Propensity score matching validated these correlations, revealing elevated odds of any complications (OR 1.7; P = .044) and surgical complications (OR 2.4; P = .0026) in chronically immunosuppressed patients.

[CONCLUSION] Chronic immunosuppression doubles the risk of surgical complications following FFBR, with postoperative bleeding representing the predominant concern. These findings mandate enhanced perioperative surveillance and bleeding prevention protocols for immunosuppressed patients while supporting the continued feasibility of FFBR in this population when appropriate precautions are implemented.