ORIGINAL ARTICLE – RECONSTRUCTIVE ONCOLOGY Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction Utku C. Dolen, MD 1 , Alexandra C. Schmidt, MD 1 , Grace T. Um, MD 1 , Ketan Sharma, MD 1 , Michael Naughton, MD 2 , Imran Zoberi, MD 3 , Julie M. Margenthaler, MD, FACS 4 , and Terence M. Myckatyn, MD, FACS, FRCSC 1 1 Division of Plastic and Reconstructive Surgery, Alvin J Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO; 2 Department of Medicine, Washington University School of Medicine, St. Louis, MO; 3 Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO; 4 Department of Surgery, Washington University School of Medicine, St. Louis, MO ABSTRACT Background. Delayed wound healing or infection leads to premature tissue expander (TE) explantation after imme- diate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking. Methods. A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan–Meier curves were plotted to study the timing of premature TE removal. Results. Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adju- vant CT (p = 0.035). Discussion. Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2–3 months after placement—well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients. The majority of postmastectomy breast reconstructions begin with placement of a TE that is later exchanged for a breast implant (TE/I), or in some cases an autologous flap. 1,2 TE complications, which occur more commonly in the pres- ence of risk factors like elevated body mass index (BMI) and radiation, and to a lesser extent, smoking and age, include infection, explantation, and reconstructive failure. 1,3,4 Adjuvant chemotherapy (ACT), when indicated, offers up to a one-third reduction in 10-year breast cancer mor- tality. 5,6 Neoadjuvant chemotherapy (NACT) can be used to control locally advanced breast cancer, reduce tumor size to facilitate lumpectomy in some cases, and assess, in real time, tumor responsiveness to the chemotherapeutic agent. 7 Patients receiving NACT have similar rates of recurrence and of disease-free and overall survival relative to ACT. 8 The mechanisms of action of chemotherapeutic agents that lead to tumor suppression have the theoretical potential of complicating surgical wound healing. 9–12 Despite long-standing concerns with the concurrent use of chemotherapy (CT) either before or after mastectomy, the majority of studies suggest that this is not problematic. 13–21 However, there are no large series that examine the dif- ferential impact of various chemotherapeutic agents or regimens on complication rates after TE reconstruction specifically. Ó Society of Surgical Oncology 2016 First Received: 3 September 2015 T. M. Myckatyn, MD, FACS, FRCSC e-mail: myckatynt@wudosis.wustl.edu; Myckatyn@wudosis.wustl.edu Ann Surg Oncol DOI 10.1245/s10434-016-5162-y