A Systematic Review and Head-to-Head Meta-Analysis of Outcomes following Direct-to-Implant versus Conventional Two-Stage Implant Reconstruction

Basta, Marten N.; Gerety, Patrick A.; Serletti, Joseph M.; Kovach, Stephen J.; Fischer, John P.

doi:10.1097/prs.0000000000001749

Cited by 89 publications

(89 citation statements)

References 43 publications

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“…Previous investigators have analyzed outcomes for direct-to-implant and tissue expander/implant-based reconstruction, but these studies have been limited by single-center designs or relatively short lengths of follow-up. 5,17,18 By contrast, the current study is multicenter and prospective in its design, includes 2-year outcomes, and controls for site and multiple demographic and clinical variables. When controlling for these covariates, we found no statistically significant differences between the procedure types for risks of overall complication, major complication, overall infection, or major infection.…”

Section: Discussionmentioning

confidence: 99%

Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study

Srinivasa

Garvey

et al. 2017

Plastic &Amp; Reconstructive Surgery

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Background Direct-to-implant breast reconstruction offers time-saving advantages over two-stage techniques. However, use of direct-to-implant reconstruction remains limited, in part, because of concerns over complication rates.1,2 The authors’ aim was to compare 2-year complications and patient-reported outcomes for direct-to-implant versus tissue expander/implant reconstruction. Methods Patients undergoing immediate direct-to-implant or tissue expander/implant reconstruction were enrolled in the Mastectomy Reconstruction Outcomes Consortium, an 11-center prospective cohort study. Complications and patient-reported outcomes (using the BREAST-Q questionnaire) were evaluated. Outcomes were compared using mixed-effects regression models, adjusting for demographic and clinical characteristics. Results Of 1427 patients, 99 underwent direct-to-implant reconstruction and 1328 underwent tissue expander/implant reconstruction. Two years after reconstruction and controlling for covariates, direct-to-implant and tissue expander/implant reconstruction patients did not show statistically significant differences in any complications, including infection. Multivariable analyses found no significant differences between the two groups in patient-reported outcomes, with the exception of sexual well-being, where direct-to-implant patients fared better than the tissue expander/implant cohort (p = 0.047). Conclusions This prospective, multi-institutional study showed no statistically significant differences between direct-to-implant and tissue expander/implant reconstruction, in either complication rates or most patient-reported outcomes at 2 years postoperatively. Direct-to-implant reconstruction appears to be a viable alternative to expander/implant reconstruction. This analysis provides new evidence on which to base reconstructive decisions.

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Section: Discussionmentioning

confidence: 99%

Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study

Srinivasa

Garvey

et al. 2017

Plastic &Amp; Reconstructive Surgery

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“…Single-stage, DTI reconstruction has been associated with higher rates of flap necrosis, reoperation, and implant loss. 46 Theoretically, immediate implant placement in the subcutaneous plane may further increase the risk of these complications. Though statistical conclusions cannot be drawn between DTI and 2-stage cohorts in this review given the lack of comparative studies and presence of confounding factors, comparison of the 2 cohorts showed similar rates of these complications with the exception of explantation, which was higher in the DTI group, and minor infection, which was higher in the 2-stage group.…”

Section: Discussionmentioning

confidence: 99%

“…Though statistical conclusions cannot be drawn between DTI and 2-stage cohorts in this review given the lack of comparative studies and presence of confounding factors, comparison of the 2 cohorts showed similar rates of these complications with the exception of explantation, which was higher in the DTI group, and minor infection, which was higher in the 2-stage group. Several important variables, however, must be further elucidated when assessing the increased risk with DTI reconstructions, including patient comorbidities, radiation therapy, quality of mastectomy flaps, 46 and implant size. These are particularly relevant when single-stage reconstruction is combined with subcutaneous techniques.…”

Section: Discussionmentioning

confidence: 99%

Subcutaneous Implant-based Breast Reconstruction with Acellular Dermal Matrix/Mesh: A Systematic Review

Salibian

Frey

Choi

et al. 2016

Plastic and Reconstructive Surgery - Global Open

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Background:The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes.Methods:A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes.Results:Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%.Conclusions:Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.

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“…[160] performed a head-to-head meta-analysis of outcomes, comparing conventional two-stage implantation with direct-to-implant reconstruction. It emerged that even though both are successful reconstructive strategies with similar infection, seroma, hematoma, and contracture rates, the direct-to-implant approach was associated with greater risk of flap necrosis and implant failure.…”

Section: Complicationsmentioning

confidence: 99%

Tissue expansion for breast reconstruction: Methods and techniques

Bertozzi

Pesce

Santi

et al. 2017

Annals of Medicine &Amp; Surgery

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ObjectiveIn this work, the authors review recent data on the different methods and techniques of TE/implant-based reconstruction to determine the complication profiles and the advantages and disadvantages of the different techniques. This information will be valuable for surgeons performing breast reconstructions.Materials and methodsA thorough literature review was conducted by the authors concerning the current strategy of tissue expander (TE)/implant-based breast reconstruction following breast cancer surgery.ResultsLoss of the breast can strongly affect a woman's personal and social life while breast reconstruction reduces the sense of mutilation felt by women after a mastectomy, and provides psychosocial as well as aesthetic benefits. TE/implant-based reconstruction is the most common breast reconstructive strategy, constituting almost 65% of all breast reconstructions in the US. Although numerous studies have been published on various aspects of alloplastic breast reconstructions, most studies are single-center observations. No evidence-based guidelines are available as yet. Conventional TE/implant-based reconstruction can be performed as a two-stage procedure either in the immediate or delayed setting. Moreover, the adjunctive use of acellular dermal matrix further broadened the alloplastic breast reconstruction indication and also enhanced aesthetic outcomes.ConclusionsTE/implant-based reconstruction has proved to be a safe, cost-effective, and reliable technique that can be performed in women with various comorbidities. Short operative time, fast recovery, and absence of donor site morbidity are other advantages over autologous breast reconstruction.

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A Systematic Review and Head-to-Head Meta-Analysis of Outcomes following Direct-to-Implant versus Conventional Two-Stage Implant Reconstruction

Cited by 89 publications

References 43 publications

Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study

Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study

Subcutaneous Implant-based Breast Reconstruction with Acellular Dermal Matrix/Mesh: A Systematic Review

Tissue expansion for breast reconstruction: Methods and techniques

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