Assessing Complication Profile of Perioperative Versus Prophylactic Postoperative Antibiotics for Prepectoral Tissue Expanders in Immediate Breast Reconstruction: A Pilot Study

Abstract

PURPOSE: Tissue expanders (TEs) are frequently placed after mastectomy to preserve the native breast skin envelope; however, one notable risk associated with TEs is implant-associated infection. Within plastic surgery literature, there remains debate regarding the appropriate duration of antibiotics for TE-based immediate breast reconstruction (TE-IBR). Based on prospective studies reporting no significant difference between perioperative antibiotics (POA) versus prophylactic postoperative antibiotics (PPA),1 our plastic surgery division transitioned from PPA until surgical drain removal to POA alone for patients after TE-IBR. This study evaluated POA effectiveness compared to PPA with particular interest in postoperative complications at 30 and 90 days. METHODS: A retrospective chart review was undertaken to analyze patients 18 years of age or older undergoing prepectoral TE-IBR at a single, large-volume institution by 5 oncologic breast surgeons and 5 plastic surgeons. All patients who met inclusion criteria over a 6-month total time period (February to August 2019) were evaluated. Three months of which included the pilot cohort with POA alone and the preceding 3 months when patients received PPA until drain removal. Preoperative patient characteristics, intraoperative details, and postoperative complications were recorded. RESULTS: Forty patients underwent immediate, prepectoral TE-IBR for total placement of 60 TEs when considering bilateral cases. Twelve patients (16 TE) received POA and 28 patients (44 TE) received PPA. Eight (66.6%) POA patients developed complications of any type within 30 days, compared with 8 (28.6%) PPA patients (P = 0.04). These 30-day complications included surgical site infection (SSI) (25% POA versus 0% PPA), flap skin necrosis with implant exposure (8.3% POA versus 0% PPA), seroma requiring aspiration (25% POA versus 25% PPA), and superficial wound dehiscence (8.3% POA versus 3.6% PPA). In reviewing the 90-day complications, the POA group did not have a higher complication profile (P = 0.17). Of the 5 POA patients who experienced an SSI postoperatively, all received additional antibiotics, Ultimately, 33.3% of POA patients required TE explant compared with 3.6% explant rate in the PPA group (P = 0.02). There was no difference in number of emergency department visits (P = 1.00) or unplanned hospital admissions (P = 0.07). CONCLUSIONS: During a trial period of perioperative-only antibiotics, we noticed an increase in SSIs in patients undergoing immediate prepectoral TE-IBR compared with patients who received antibiotic prophylaxis until drain removal. The patients in the POA group required additional antibiotic prescriptions and underwent increased expander explant rates. The data suggests that immediate TE placement into a prepectoral tissue plane may have a different risk profile than defined in prior studies which involved submuscular or dual plane expander placement. Future work at our institution will focus on conducting a prospective randomized control trial to further analyze whether prophylactic antibiotics until drain removal is needed in this patient population. REFERENCE: 1. Phillips BT, Fourman MS, Bishawi M, et al. Are prophylactic postoperative antibiotics necessary for immediate breast reconstruction? Results of a prospective randomized clinical trial. J Am Coll Surg. 2013;22:1116–1124.