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Two-Stage, Prosthetic Breast Reconstruction Following Mastectomy: Understanding the Risk of Complications
Akhil K. Seth, MD, Elliot M. Hirsch, MD, John YS Kim, MD, Gregory A. Dumanian, MD, Thomas A. Mustoe, MD, Robert D. Galiano, MD, Neil A. Fine, MD.
Northwestern University, Chicago, IL, USA.
Two-stage, implant-based reconstruction continues to be the most common form of breast reconstruction following mastectomy. However, the data surrounding complication rates remains difficult to navigate, limited by conflicting reports and small patient populations. In an effort to clarify the current literature, this study evaluates complication risk factors for each stage of breast reconstruction: immediate tissue expander placement and secondary implant exchange.
A retrospective review of patients that underwent mastectomy with immediate tissue expander reconstruction at one institution from 4/1998-8/2008 was performed. Relevant demographic, operative, and postoperative factors, including complication rates, were recorded for both first-stage tissue expander placement and second-stage expander-to-implant exchange. Overall complication rates were calculated per breast and then categorized by end-outcome, including non-operative (no further surgery), operative (further surgery except explantation), and explantation. The complication risk associated with several different factors was evaluated (Table 1). Multiple regression was used for statistical analysis.
First-stage tissue expander reconstruction was completed by 897 consecutive patients (1202 breasts), of which 739 patients (1025 breasts) went on to second-stage implant exchange. Mean overall follow-up was 36.7 months. Regression analysis revealed several risk factors for complications following first-stage reconstruction (Table 1). In particular, advanced age, elevated body mass index, smoking, having had a modified radical mastectomy, larger tissue expander size, and pre- and post-reconstruction radiation were independent risk factors for the majority of complications evaluated (p<0.05). However, following second-stage surgery, many of these risk factors were no longer significant or only affected implant explantation (p<0.05). Complications were not influenced by the presence of a previous implant, expander/implant fill volumes, the use of acellular dermal matrix, or the time between first- and second-stage surgery.
Our extensive analysis, the largest to date, suggests that several different factors may contribute to the complication risk of prosthetic breast reconstruction, particularly those factors that are inherent to the patient. Radiation exposure also has a significant effect on complications, which persists during both stages of reconstruction. These findings reinforce the need for careful patient selection, while diminishing the importance of intraoperative variables, such as acellular dermis and expander/implant fill volumes. The impact of different risk factors should be individualized to, and discussed with, each patient throughout the reconstruction process.
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