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BACKGROUND:Alloplastic breast reconstruction with the use of tissue expanders is currently the most commonly used method for post mastectomy breast reconstruction. While this operation is fairly simple in terms of technical approach, there are a number of postoperative complications that lead to poor cosmetic results and patient morbidity. The purpose of this study was to describe the rates of post-operative complications and to identify the patient-specific and breast-specific characteristics associated with presence of at least one complication.
METHODS:Approved by our institutional review board as a retrospective cohort study, the patient medical records associated with all alloplastic breast reconstructions performed from February of 2009 till April 2013 were reviewed. Both patient-specific and breast-specific specimen characteristics were extracted including: medical comorbidities, cancer stage, pre- and post-surgery radiation and/or chemotherapy treatments, and presence of post-operative complications (including cellulitis, surgical infection, wound dehiscence, seroma formation, skin necrosis, and premature tissue expander removal). Univariate logistic regression was used to screen each patient or breast-related variables for multivariable regression modeling; with a generalized linear mixed effect model fitted using breast-level variables along with a subject-specific random effect used with statistical significance set at p = 0.05.
RESULTS:All 275 patient medical records (pathology reports for 434 breast specimens) were extracted. A total of 89 patients (32.4%) had one or more post-operative complications; 17.5% cellutis, 10.9% wound dehiscence, 1.8% hematoma, 6.2% seroma formation, 8.7% skin necrosis, and 18.2% premature tissue expander removal.
Interestingly, complication rates decreased dramatically over time from 39.6% (2010) to 5.0% (2013). Statistically significant associations were identified between key patient-specific and breast-specific factors related to the presence/absence of the complications studied. Specifically, post-operative radiation therapy, sentinel or axillary node dissection, and a history of prior breast surgery were strongly correlated with the risk of suffering at least one post-operative complication. In addition to aforementioned risk factors, cellulitis was correlated with history of diabetes and obesity. Seroma was associated with a history of prior breast surgery. Skin necrosis was linked with axillary/sentinel lymph node biopsy. Formation of an open wound postoperatively was correlated with autoimmune disease and axillary/sentinel node dissection. Removal of tissue expander was found to be associated with the advanced stage tumors, obesity, and hypertension. Importantly, the alloplastic breast reconstruction patients that had axillary/sentinel node dissections were more than 9 times more likely to have at least one complication as compared to patients without an axillary/sentinel node dissection (odds ratio = 9.17, 95% CI: 1.99 - 26.03, p<0.0001).
CONCLUSIONS:Building upon the well-established literature-based associations between radiation, obesity, diabetes, and chemotherapy with complications after tissue expander-based breast reconstruction, our study identified that a history of a previous breast surgery and axillary/sentinel node biopsy were additional factors associated with increased rate of post-operative complications. As the exact mechanisms can only be speculated, further research appears warranted to identify how to minimize the future occurrence of post-operative complications as well as to improve the overall quality of care for plastic surgeons performing alloplastic breast reconstruction using tissue expanders.