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Page 4 of 10 Dengsoe et al. Plast Aesthet Res 2024;11:25 https://dx.doi.org/10.20517/2347-9264.2024.20

RESULTS
Our search identified a total of 1,077 publications. 187 duplicates were removed, some manually and some
automatically by Covidence. That left a total of 890 publications for title and abstract screening. In this
process, 757 publications were excluded, leaving a total of 133 publications for full text screening. Full text
screening led to the exclusion of 126 publications due to criteria which are specified in a PRISMA flow chart
[Supplementary Figure 1]. It is worth mentioning that a total of 20 articles had to be excluded because it was
not possible, even by a medical librarian, to access the full text version of the article or that the only version
published online was a conference abstract. Three articles were excluded because they involved only
implant-based reconstructions and 21 were excluded because they only involved reconstructions based on
pedicled flaps or did not specify how many patients received a free flap reconstruction. Four articles did
specify the proportion of patients with free flap reconstructions, but they did not distinguish between
pedicled or free flap reconstructions when evaluating complications or time from surgery to initiation of
adjuvant therapy. When screening was completed, seven articles were included in the systematic
review [15,16,22-26] . The study characteristics are presented in Supplementary Table 2. Six studies are
retrospective case-control studies and compare one group of patients receiving mastectomy immediately
followed by a free flap reconstruction (cases) to another group of patients receiving only a mastectomy
(controls). One study by Nguyen et al. is a retrospective cross-sectional study that sorely investigates 30
patients receiving DIEP reconstructions without comparing to a control group . A total of 267 patients
[26]
treated with mastectomy followed by immediate free flap reconstruction and 2,622 patients treated with
mastectomy-only were included in this systematic review. Most reconstructions were performed using a
DIEP flap, but free TRAM-flaps, S/I-GAP-flaps, SIEA-flaps, TUG-flaps and TMG-flaps were also used in
some cases.

Complications
Only four studies included data on postoperative complications, specifically on free flap reconstruction.
These data are presented in Supplementary Table 3. Lee et al. evaluated wound complications including
[23]
wound dehiscence, infection, skin necrosis, seroma, and skin flap maceration . They found that 22% with
DIEP-flap reconstructions and 2.5% with mastectomy-only had a wound complication. O’Connell et al.
differentiated between any complication and major complications requiring further surgery or hospital
readmission . They found that free flap reconstruction was strongly associated with major complications.
[24]

Kontos et al. did not compare complication rates in the two groups . Instead, they evaluated the group of
[16]
patients who had a free flap reconstruction and where chemotherapy was initiated later than six weeks after
surgery, trying to explain the reason for the delay. Most notably, six patients had complete or partial flap
necrosis and three patients experienced abdominal wound dehiscence. Nguyen et al. divided complications
[26]
into three categories based on their location: breast, donor site, and systemic . Four patients had further
surgery due to either venous congestion or total flap loss. Two patients suffered abdominal wound
dehiscence. Lastly, two patients had a pulmonary embolism and one patient developed pneumonia.

Time to adjuvant therapy
Six of the studies investigated solely adjuvant treatment with chemotherapy. Only one study by O’Connell et
al. investigated adjuvant radiotherapy as well, specifying that 55% of patients - regardless of reconstruction
or not - received chemotherapy as the first adjuvant treatment whereas 46% received radiotherapy as the
[24]
first adjuvant treatment . Five of the included studies calculated the mean time in days to initiation of
adjuvant treatment, whereas two studies recorded time to adjuvant treatment as a categorial variable,
describing the proportion of patients who had initiated treatment at a defined point in time. In one
[25]
study , it was six weeks after surgery, and in another study , it was eight weeks after surgery. These data
[22]
are presented in supplementary table 4. In the study by Wilson et al., the median time to initiation of