Surgeon\u2019s preference of subcutaneous tissue resection: most important factor for short-term complications in subcutaneous implant placement after mastectomy\u2014results of a cohort study

André Pfob,Vivian Koelbel,Michael Golatta,Maria Blumenstein,Florian Schuetz,Joerg Heil,Manuel Feißt,André Hennigs

doi:10.1007/s00404-020-05481-x

André Pfob, Vivian Koelbel + Show 6 more

Open Access

https://doi.org/10.1007/s00404-020-05481-x

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Abstract

PurposeLittle is known about the reason of high short-term complication rates after the subcutaneous placement of breast implants or expanders after mastectomy without biological matrices or synthetic meshes. This study aims to evaluate complications and their risk factors to develop guidelines for decreasing complication rates.MethodsWe included all cases of mastectomy followed by subcutaneous implant or expander placement between 06/2017 and 05/2018 (n = 92). Mean follow-up time was 12 months.ResultsExplantation occurred in 15 cases (16.3%). The surgeon’s preference for moderate vs. radical subcutaneous tissue resection had a significant influence on explantation rates (p = 0.026), impaired wound healing or infection (requiring surgery) (p = 0.029, p = 0.003 respectively) and major complications (p = 0.018).Multivariate analysis revealed significant influence on complication rates for radical subcutaneous tissue resection (p up to 0.003), higher implant volume (p up to 0.023), higher drain volume during the last 24 h (p = 0.049), higher resection weight (p = 0.035) and incision type (p = 0.011).ConclusionBased on the significant risk factors we suggest the following guidelines to decrease complication rates: favoring thicker skin envelopes after surgical preparation, using smaller implants, removing drains based on a low output volume during the last 24 h and no use of periareolar incision with extension medial or lateral. We should consider ADMs for subcutaneous one-stage reconstructions.The individual surgeon’s preference of subcutaneous tissue resection is of highest relevance for short-term complications—this has to be part of internal team discussions and should be considered in future trials for comparable results.

Highlights

During past decades subcutaneous implant placement has been considered to be inferior to a subpectoral approach due to high complication rates [1, 2]
Wound drains remained for a mean of 5.9 days (SD 3.1), producing a mean cumulative volume of 458.3 ml (SD 521.9); the mean volume during the last 24 h was 16.7 ml (SD 11.5)—drain management seemed to be highly variable, illustrated by the high standard deviations
This study shows for the first time that radical subcutaneous tissue resection results in ischemic complications but promotes other major complications, too

Summary

Introduction

During past decades subcutaneous implant placement has been considered to be inferior to a subpectoral approach due to high complication rates (especially capsular fibrosis, infection, and skin necrosis) [1, 2]. The introduction of new surgery techniques (skin- and nipple-sparing mastectomy), new indications and additional devices like meshes require a reevaluation of complication rates in subcutaneous implant or expander placement. Several small studies investigated the complication rates in subcutaneous placement. Data are not conclusive as complication rates largely vary (explantation ranges from 0 to 18%, seroma 2–23%, nipple or skin necrosis 1–28%) [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18]. There are three main reasons for this big variance: Single-shot prophylactic antibiosis was routinely used— based on the physician’s evaluation antibiosis could be extended for several days (see Table 1).

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