Single-Institution Algorithm for Prevention and Management of Complications in Direct-to-Implant Breast Reconstruction

Abstract

Complications including infection and wound dehiscence are major concerns for direct-to-implant breast reconstruction. However, the risk factors associated with severe complications and implant salvage remain unclear. This was a retrospective study of all patients undergoing unilateral direct-to-implant breast reconstruction from 2014 through 2019. The risk factors associated with complications and prosthesis explantation were identified using multivariate logistic regression modeling and interaction analyses. Among 1027 patients enrolled, 90 experienced severe complications, 41 of whom underwent prosthesis explantation; 49 were successfully salvaged. Multivariate analysis demonstrated that patients with larger implant size ( p = 0.003), use of bovine mesh ( p < 0.001), adjuvant radiotherapy ( p = 0.047), low plasma albumin ( p = 0.013), and elevated blood glucose ( p = 0.006) were significantly more likely to have complications. Adjuvant radiation therapy (OR, 7.44; 95 percent CI, 1.49 to 37.18; p = 0.014) and obesity (OR, 4.17; 95 percent CI, 1.17 to 14.88; p = 0.028) were associated with significantly lower rates of implant salvage and surgical-site infection and wound dehiscence, whereas mastectomy skin flap necrosis was not associated with device explantation. There were no differences in complication and explantation rates between nipple-sparing and skin-sparing mastectomies. However, the combined impact of surgical-site infection and wound dehiscence added a greater than 14-fold higher risk of prosthesis explantation (95 percent CI, 9.97 to 19.53). Success in direct-to-implant breast reconstruction is multifactorial. Larger implant size, adjuvant radiation therapy, diabetes, and malnutrition demonstrate increased risk of complications in the direct-to-implant approach. Surgical-site infections and wound dehiscence should be treated aggressively, but the combination of both complications portends poor salvage rates. Risk, III.