No Skin Paddle, No Problem: Burying Deep Inferior Epigastric Artery Flaps in the Immediate Setting is Safe in Select Patient Populations.

BACKGROUND: In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery. METHODS: A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery. RESULTS: The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed-immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients. CONCLUSION: Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps.

Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery.

BACKGROUND: Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes. METHODS: A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation). RESULTS: A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m2, median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups. CONCLUSIONS: Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.

Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction.

BACKGROUND: Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. METHODS: We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. RESULTS: We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 1.15, p < 0.001) and operative time (ß - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. CONCLUSIONS: Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.

Treatment of multiple limb lymphedema with combined supermicrosurgical techniques.

INTRODUCTION: Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation. PATIENT AND METHODS: Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33-66 years) with an average BMI of 34.8 kg/m2 (range: 17.6-53.6 kg/m2 ). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment. RESULTS: One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four-limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow-up was 15.8 months (range: 12.6-28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis. CONCLUSION: Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.

Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation.

BACKGROUND: Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. METHODS: We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. RESULTS: We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). CONCLUSION: Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

Determinants of telemedicine adoption among financially distressed patients with cancer during the COVID-19 pandemic: insights from a nationwide study.

PURPOSE: Telemedicine use during the COVID-19 pandemic among financially distressed patients with cancer, with respect to the determinants of adoption and patterns of utilization, has yet to be delineated. We sought to systematically characterize telemedicine utilization in financially distressed patients with cancer during the COVID-19 pandemic. METHODS: We conducted a cross-sectional analysis of nationwide survey data assessing telemedicine use in patients with cancer during the COVID-19 pandemic collected by Patient Advocate Foundation (PAF) in December 2020. Patients were characterized as financially distressed by self-reporting limited financial resources to manage out-of-pocket costs, psychological distress, and/or adaptive coping behaviors. Primary study outcome was telemedicine utilization during the pandemic. Secondary outcomes were telemedicine utilization volume and modality preferences. Multivariable and Poisson regression analyses were used to identify factors associated with telemedicine use. RESULTS: A convenience sample of 627 patients with cancer responded to the PAF survey. Telemedicine adoption during the pandemic was reported by 67% of patients, with most (63%) preferring video visits. Younger age (19-35 age compared to ≥ 75 age) (OR, 6.07; 95% CI, 1.47-25.1) and more comorbidities (≥ 3 comorbidities compared to cancer only) (OR, 1.79; 95% CI, 1.13-2.65) were factors associated with telemedicine adoption. Younger age (19-35 years) (incidence rate ratios [IRR], 1.78; 95% CI, 24-115%) and higher comorbidities (≥ 3) (IRR; 1.36; 95% CI, 20-55%) were factors associated with higher utilization volume. As area deprivation index increased by 10 units, the number of visits decreased by 3% (IRR 1.03, 95% CI, 1.03-1.05). CONCLUSIONS: The rapid adoption of telemedicine may exacerbate existing inequities, particularly among vulnerable financially distressed patients with cancer. Policy-level interventions are needed for the equitable and efficient provision of this service.

Master's Degrees Among Academic Plastic Surgeons and Plastic Surgery Residents: What Are the Trends?

BACKGROUND: As more plastic surgery clinicians pursue advanced degrees and strive to become stronger physician-scientists, an objective understanding of how such degrees influence careers becomes important. We hypothesized that having a master's degree is associated with higher scholarly activity, research funding, academic progression, and leadership appointments. METHODS: Accreditation Council for Graduate Medical Education-accredited integrated plastic surgery residency program Web sites were queried to create a data set of current academic plastic surgeons (APSs) and plastic surgery residents (PSRs). Scholarly metrics such as publications, citations, and H-indices were extracted from the Scopus database. National Institutes of Health and Plastic Surgery Foundation funding information was collected through their respective Web sites. RESULTS: Our cohort comprised 799 APSs and 922 PSRs, of whom 8% and 7.4%, respectively, had at least one master's degree. Academic plastic surgeons with master's of public health degrees had a significantly higher median number of publications and citations than APSs without a master's of public health. There was no association between any master's degree and academic rank or being a department chairman or program director. Academic plastic surgeons with master of science degrees were more likely to receive National Institutes of Health grants. Among PSRs, master's of science graduates had a higher median number of publications. Other master's degrees did not significantly influence scholarly productivity or funding. CONCLUSIONS: Certain master's degrees had an impact on scholarly productivity, with no significant effect on academic rank or leadership positions. The value of master's degrees in programs focusing on healthcare management, leadership skills, and business acumen likely extends beyond the scope of this study.

Industry Payments to Plastic Surgeons: What Has Changed Over the Last 6 Years Following Implementation of the Physician Payments Sunshine Act?

BACKGROUND: The Open Payments Program, as designated by the Physician Payments Sunshine Act, is the single largest repository of industry payments made to licensed physicians within the United States. Though sizeable in its dataset, the database and user interface are limited in their ability to permit expansive data interpretation and summarization. OBJECTIVES: The authors sought to comprehensively compare industry payments made to plastic surgeons with payments made to all surgeons and all physicians to elucidate industry relationships since implementation. METHODS: The Open Payments Database was queried between 2014 and 2019, and inclusion criteria were applied. These data were evaluated in aggregate and for yearly totals, payment type, and geographic distribution. RESULTS: A total 61,000,728 unique payments totaling $11,815,248,549 were identified over the 6-year study period; 9089 plastic surgeons, 121,151 surgeons, and 796,260 total physicians received these payments. Plastic surgeons annually received significantly less payment than all surgeons (P = 0.0005). However, plastic surgeons did not receive significantly more payment than all physicians (P = 0.0840). Cash and cash equivalents proved to be the most common form of payment; stock and stock options were least commonly transferred. Plastic surgeons in Tennessee received the most in payments between 2014 and 2019 (mean $76,420.75). California had the greatest number of plastic surgeons who received payments (1452 surgeons). CONCLUSIONS: Plastic surgeons received more in industry payments than the average of all physicians but received less than all surgeons. The most common payment was cash transactions. Over the past 6 years, geographic trends in industry payments have remained stable.

Surgical Decision Making in Autologous Fat Grafting: An Evidence-Based Review of Techniques to Maximize Fat Survival.

Autologous fat grafting is an important tool in plastic surgery and is widely used for a variety of applications, both aesthetic and reconstructive. Despite an ever-increasing list of indications and extensive research over many years into improving outcomes, fat grafting remains plagued by incomplete and often unpredictable graft survival. Decisions made at each stage of surgery can potentially contribute to ultimate success, including donor site selection and preparation, fat harvest, processing, and purification of lipoaspirate, recipient site preparation, and delivery of harvested fat to the recipient site. In this review, we examine the evidence for and against proposed techniques at each stage of fat grafting. Areas of consensus identified include use of larger harvesting and grafting cannulas and slow injection speeds to limit cell damage due to shearing forces, grafting techniques emphasizing dispersion of fat throughout the tissue with avoidance of graft pooling, and minimizing exposure of the lipoaspirate to the environment during processing. Safety considerations include use of blunt-tipped needles or cannulas to avoid inadvertent intravascular injection as well as awareness of cannula position and avoidance of danger zones such as the subgluteal venous plexus. We believe that using the evidence to guide surgical decision-making is the key to maximizing fat grafting success. Level of Evidence: 4.

The impact of co-surgeons on complication rates and healthcare cost in patients undergoing microsurgical breast reconstruction: analysis of 8680 patients.

PURPOSE: The use of two operating microsurgeons has been shown to improve the efficiency and reduce the operative duration of microsurgical breast reconstruction (MSBR). However, the impact of this practice on healthcare cost has not been previously assessed. The goal of this study is to query a national claims database to assess complication rates and overall cost in patients undergoing MSBR using co-surgeon (CS) vs. single-surgeon (SS) approach. METHODS: The study cohort, extracted from the MarketScan database, included all female patients who underwent MSBR between 2010 and 2017. Our primary outcome measure was the difference in total healthcare cost between the two operative groups while differences in complication rates were secondary outcome measures. RESULTS: We identified a total of 8680 patients, out of whom 7531 (87%) underwent MSBR with a SS and 1149 (13%) had a CS. Over the study period, the annual incidence rate of MSBR cases using CS increased from 7.2% in 2010 to 23.3% in 2017 (p < 0.001). Following propensity score matching, complications, emergency room visits, readmissions, and reoperations were all similar between the CS and SS groups. The median total healthcare cost was higher for the CS group [US $76,227 (IQR $67,879) vs. $61,340 (IQR $54,318); p < 0.0001], CONCLUSIONS: Use of the CS approach in MSBR has become increasingly prevalent over time. Analyses of a national claims database suggested that the use of CS is a safe option for patients undergoing MSBR. Further research is needed to optimize CS utilization from a costs and outcomes perspective.

Financial toxicity and contralateral prophylactic mastectomy: an analysis using propensity score methods.

PURPOSE: Contralateral prophylactic mastectomy (CPM) is increasingly performed in average-risk patients despite the lack of survival benefit. In an era of heightened awareness of healthcare costs, we sought to determine the impact of CPM on financial toxicity in breast cancer. METHODS: A single-institution propensity-matched analysis of female patients who underwent unilateral mastectomy (UM) with or without CPM for breast cancer over an 18-month period. Patients with a history of genetic predisposition or bilateral cancer were excluded. The validated Comprehensive Score for financial Toxicity (COST) evaluated financial toxicity among participants. Multivariable regression analysis evaluated the relationship between CPM and financial toxicity. Relevant domains of the Breast Q and SF12 instruments were examined as secondary outcomes. Sensitivity analysis was performed using propensity-weighting to examine robustness of results and increase our sample size. RESULTS: Overall, 104 patients were identified, equally distributed across UM and CPM. CPM was not associated with financial toxicity, as evidenced by comparable COST scores (adjusted difference, 1.53 [- 3.24 to 6.29]). Minor complications were significantly lower in UM patients (UM, 8%; CPM, 31%). CPM was associated with significantly higher Breast Q psychosocial well-being score (adjusted difference, 10.58 [1.34 to 19.83]). BREAST Q surgeon satisfaction, SF12 mental and physical component scores were comparable. Similar results were noted on sensitivity analysis involving 194 patients. CONCLUSIONS: Choice for CPM was associated with higher minor complications, but led to improved psychosocial well-being without a higher degree of patient-reported financial toxicity. Prospective studies are needed to discern the influence of CPM on the incidence and trajectory of financial toxicity.

Application of Three-Dimensional Printed Vascular Modeling as a Perioperative Guide to Perforator Mapping and Pedicle Dissection during Abdominal Flap Harvest for Breast Reconstruction.

BACKGROUND: Advancements in three-dimensional (3D) printing have enabled production of patient-specific guides to aid perforator mapping and pedicle dissection during abdominal flap harvest. We present our early experience using this tool to navigate deep inferior epigastric artery (DIEA) topography and evaluate its impact on operative efficiency and clinical outcomes. PATIENTS AND METHODS: Between January 2013 and December 2018, a total of 50 women underwent computed tomographic angiography (CTA)-guided perforator mapping prior to abdominal flap breast reconstruction, with (n = 9) and without (n = 41) 3D-printed vascular modeling (3DVM). Models were assessed for their accuracy in identifying perforator location and source-vessel anatomy, as determined by operative findings from 18 hemi-abdomens. The margin of error (MOE) for perforator localization using 3DVM was calculated and compared with CTA-derived measurements for the same patients. Flap harvest times, outcomes, and complications for patients who were preoperatively mapped using 3DVM versus CTA alone were analyzed. RESULTS: Overall, complete concordance was observed between 3DVM and operative findings with regards to perforator number, source-vessel origin, and DIEA branching pattern. By comparison, CTA interpretation of these parameters inaccurately identified branching pattern and perforator source-vessel origin in 28 and 33% of hemi-abdomens, respectively (p = 0.045 and p = 0.02). Compared with operative measurements, the average MOE for perforator localization using 3DVM was significantly lower than that obtained from CTA alone (0.81 vs. 8.71 mm, p < 0.0001). Reference of 3D-printed models, intraoperatively, was associated with a mean reduction in flap harvest time by 21 minutes (60.7 vs. 81.7 minutes, p < 0.001). Although not statistically significant, rates of perforator-level injury, microvascular insufficiency, and fat necrosis were lower among patients mapped using 3DVM. CONCLUSION: The results of this study support the accuracy of 3DVM for identifying DIEA topography and perforator location. Application of this technology may translate to enhanced operative efficiency and fewer perfusion-related complications for patients undergoing abdominal free flap breast reconstruction.

Reconstruction in the Metastatic Breast Cancer Patient: Results from the National Cancer Database.

PURPOSE: Modern treatments are prolonging life for metastatic breast cancer patients. Reconstruction in these patients is controversial. The purpose of this study was to characterize de novo metastatic breast cancer patients who undergo mastectomy and reconstruction and to report complication and survival rates. METHODS: We queried the National Cancer Database for de novo metastatic breast cancer patients, who underwent systemic therapy and mastectomy with reconstruction (R) or without reconstruction (NR) between 2004 and 2013. Patient-tumor characteristics, mortality, and readmissions were compared. Propensity score matched analysis was performed, and survival was calculated using the Kaplan-Meier method. RESULTS: A total of 8554 patients fulfilled study criteria (n = 980/11.5% R vs. n = 7574/88.5% NR). There was a significant increase in reconstruction rates by year: 5.2% in 2004, 14.3% in 2013 (p < 0.0001). Compared with the NR patients, R patients were younger (mean age 49 vs. 58 years, p < 0.0001), more hormone receptor-positive (76.1% vs. 70.5%, p = 0.0004), had lower grade disease (p = 0.0082), and fewer sites of metastases (85.7% had 1 metastasis; 14.3% had ≥ 2 R vs. 79% had 1; 21% had ≥ 2 NR, p = 0.0002). R patients received more hormonal and chemotherapy than NR but equally received radiation. Median overall survival of the total cohort was 45 months, and median overall survivals of R and NR groups by matched analysis were 56.7 and 55.3 months respectively (p = 0.86). Thirty-day mortality (0.2%-R, 0.3%-NR, p = 0.56) and readmissions (5.9%-R, 5.8%-NR, p = 0.81) were similar; 90-day mortality also was similar (1.1%-R vs. 1.6%-NR, p = 0.796). CONCLUSIONS: There is an increasing trend to reconstruct metastatic breast cancer patients with low complication rates, without survival compromise. Impact on quality of life warrants further assessment.

Advancements in imaging technology for microvascular free tissue transfer.

The use of preoperative imaging has become routine for many reconstructive microsurgeons to help localize perforators for planning of microvascular free flaps. However, with advancements in imaging technology, perforator mapping represents only one potential benefit as virtual planning and medical modeling, and flap tissue perfusion are also rapidly becoming commonplace and the standard of care for many surgeons who perform high-volume free flap reconstruction for the breast, head and neck, torso, and the extremities.

The Impact of Diabetes Mellitus on Wound Healing in Breast Reconstruction.

BACKGROUND: Although diabetes mellitus (DM) is a known risk factor for surgical complications in general, there is little published evidence to establish such an effect among patients undergoing breast reconstruction (BR). The purpose of this study was to assess the impact of DM on complications in patients undergoing postmastectomy BR. METHODS: Patients who underwent BR at our institution from November 2002 to November 2012 were identified. Clinical and demographic data of patients with type 1 or type 2 DM were reviewed. Complications occurring within 60 days of surgery were compared between diabetic and nondiabetic patients for both autologous and nonautologous reconstruction types. RESULTS: A total of 1371 BR were performed in 1035 patients. There were 877 (64.0%) autologous reconstructions and 494 (36.0%) implant-based reconstructions. Patients with DM (n = 64) had significantly higher preoperative blood glucose levels (137.5 vs 100.1, P < 0.05). Postoperatively, DM patients reconstructed with implants had a significantly higher incidence of delayed wound healing (22.2% vs 9.7%; P = 0.04). This was not observed in patients with DM reconstructed with autologous tissue (7.4% vs 6.6%; P = 0.70). Diabetic patients had a significantly higher incidence of hypertension and were older than nondiabetic patients. To control for these variables and other potential confounders, multiple logistic regression analysis was performed. Again, diabetic patients had a significantly higher incidence of delayed wound healing following implant-based reconstruction (odds ratio, 2.52, 95% confidence interval = 1.2-6.2) but not autologous reconstruction (odds ratio, 0.97; 95% confidence interval = 0.2-4.6). CONCLUSIONS: Diabetes heightens the risk of wound healing complications among patients undergoing implant-based reconstruction.

Antibiotic Prophylaxis and Resistance in Surgical Site Infection After Immediate Tissue Expander Reconstruction of the Breast.

BACKGROUND: A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI. METHODS: An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed. RESULTS: In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin). CONCLUSIONS: Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.