Comparing Blood Loss in Immediate and Delayed Autologous Breast Reconstruction

Authors: DeVito RG, Harlan D, Ke BG, Isaula DM, Park RH, Hollenbeck ST, Campbell CA, Stranix JT

Affiliation: Department of Plastic Surgery, University of Virginia Health System; School of Medicine, University of Virginia, Charlottesville, Virginia

Journal: Journal of Reconstructive Microsurgery, November 2025

PMID: 41197981

Key takeaways

• Immediate autologous reconstruction was associated with more blood loss and more transfusions than delayed reconstruction (unilateral and bilateral).

• Bilateral immediate cases had a 14.3% transfusion rate versus 2.0% for bilateral delayed; unilateral immediate cases had a 12.1% rate versus 0% for unilateral delayed.

• Postmastectomy radiation therapy requirement and vascular disease were the strongest independent predictors of transfusion; unilateral reconstruction and higher BMI were protective.

• Transfusion correlated with hematoma, but not with flap thrombosis or flap loss.

• Most useful for preoperative counseling and blood-management planning, not as proof that delayed reconstruction is universally better.

Background

Autologous breast reconstruction is a durable mainstay of modern breast reconstruction with good patient satisfaction rates. There is limited data on whether reconstructive timing (immediate vs. delayed) meaningfully affects perioperative blood loss and transfusion risk from autologous breast reconstruction.

Objective

To determine whether immediate versus delayed autologous breast reconstruction is associated with differences in postoperative hemoglobin drop and perioperative transfusion incidence, while also identifying predictors of transfusion.

Methods

• Retrospective single-institution cohort study.

• 264 consecutive patients undergoing free-flap breast reconstruction from July 2017 through June 2022 divided into 4 groups:

  • Bilateral immediate autologous reconstruction: n = 77

  • Bilateral delayed autologous reconstruction: n = 50

  • Unilateral immediate autologous reconstruction: n = 99

  • Unilateral delayed autologous reconstruction: n = 38

• Primary outcomes: Postoperative hemoglobin (Hgb), hemoglobin change, estimated blood loss (EBL), need for transfusion, and presence of hematoma

• Secondary outcomes: Flap thrombosis or loss, wound complications, infection, seroma, fat necrosis, hernia or bulge, deep venous thrombosis, and pulmonary embolism.

• Statistical analysis used unpaired t tests (for continuous variables) and Fisher exact tests (for categorical variables) to compare immediate and delayed populations, and multivariable regression to identify predictors of transfusion.

Results

• Primary outcomes

  • Preoperative Hgb similar across groups ~12.6 g/dL

• Bilateral reconstruction

  • Lower postoperative Hgb (p=0.00001), larger Hgb drop (p=0.0015), higher EBL (p=0.00004), more transfusions (p=0.0206), greater introp crystalloid (p=0.002) and total fluid volume (p=0.0019) given in immediate compared to delayed bilateral breast reconstruction

  • No difference in hematoma incidence (p=0.55)

  • Mean follow-up 17.5 mo (bilateral immediate), 13.3 mo (bilateral delayed)

• Unilateral reconstruction

  • Lower postoperative Hgb (p=0.0015), larger Hgb drop (p=0.0001), higher EBL (p=0.013), more transfusions (p=0.0246) given in immediate compared to delayed bilateral breast reconstruction

  • No difference in hematoma incidence (p=0.07)

  • Mean follow-up 14.7 mo (unilateral immediate), 14.6 mo (unilateral delayed)

• Predictors of transfusion

  • Increased risk of transfusion associated with:

    • Postmastectomy radiation – OR 10.3 (p=0.008)

    • Vascular disease – OR 14.5 (p=0.02)

  • Decreased risk of transfusion associated with:

    • Unilateral reconstruction – OR 0.20 (p=0.04)

    • By 12.3% by unit of BMI – (p=0.04)

• Secondary outcomes

  • Bilateral immediate cases had more mastectomy flap necrosis (16.9% vs. 4.0%, p=0.02801), while bilateral delayed cases had more donor site infections (26% vs. 9.1%, p=0.0103)

  • Unilateral immediate cases had more minor breast wounds (30.3% vs. 13.2, p=0.04), while unilateral delayed cases had more major breast wounds (21.0% vs. 6.1%, p=0.03), minor donor site wounds (39.5% vs. 19.2%, p=0.0137), donor site infections (44.7% vs. 6.1%, p<0.001)

  • Transfusion was associated with hematoma (OR 7.2, p=0.01) but not with flap thrombosis or loss

Conclusion

Immediate autologous breast reconstruction was associated with greater blood loss and higher transfusion rates than delayed reconstruction in both unilateral and bilateral cases. Timing should be considered part of perioperative blood loss/transfusion risk stratification, especially in patients with plans for bilateral surgery, history of vascular disease, or anticipated radiation.

Strengths

• Consecutive real-world cohort with clinically relevant outcomes.

• Separates unilateral and bilateral cases.

• Multivariable analysis.

Limitations

• Retrospective, single-center design.

• Groups were not fully matched, with meaningful differences in prior treatment history and operative factors.

• No standard deviations reported for data, just means (incomplete picture and makes it difficult to repeat/confirm statistics).

• Multiple comparisons made without discussion of appropriate correction factor (i.e. Holm-Bonferonni).

• Immediate case EBL/transfusion data captures effects of the combination of mastectomy and reconstruction, while delayed case EBL data captures only reconstruction.

• Limited number of flap thrombosis/loss events limits power to predict correlation between transfusions and these rare flap outcomes.

• Transfusion threshold and detailed flap-type breakdown not clearly provided.

Clinical relevance

This paper supports more explicit counseling about transfusion risk when planning immediate free-flap breast reconstruction, especially for bilateral cases and patients likely to undergo radiation. This is not a definitive statement on ideal reconstructive timing, so this data should not be used to argue that delayed autologous reconstruction is universally preferable.

Editorial Notes

• The study likely captures the bleeding burden of the whole operative episode rather than isolated flap reconstruction alone.

• The null finding for flap thrombosis and loss should be interpreted in context.of limited power given small number of flap thrombosis/loss events.

• Need additional info about institution’s transfusion thresholds, use of tranexamic acid, anemia-management pathway, and whether mastectomy type or axillary surgery differed between groups.

• Consider further focused analysis of immediate cases to identify transfusion predictors.