Direct-to-implant breast reconstruction: An analysis of 1612 cases from the ACS-NSQIP surgical outcomes database

Abstract

There is continued debate about the outcomes of direct-to-implant (DTI) breast reconstruction when compared to a two-stage expander/implant approach. The purpose of this study was to examine outcomes after DTI reconstruction utilising the American College of Surgeons-National Surgical Quality Improvement (ACS-NSQIP) database. This study reviewed the 2005-2010 ACS-NSQIP databases identifying encounters with common procedural terminology codes for DTI (19340) (mastectomy and immediate implant placement). A composite variable of "major surgical complications" (deep infection, return to OR, device loss) was used as the dependent variable in the analysis. Logistic regression analysis was performed to assess for pre- and intraoperative factors associated with the occurrence of "major surgical complications". Overall, 1612 patients underwent one stage, DTI reconstruction with an average age of 50.8 ± 10.7 years with a body mass index (BMI) (kg/m2) of 26.9 ± 6.3 kg/m2. The incidence of major surgical complications was 9%. A multivariate regression analysis revealed obesity (OR = 1.54, p = 0.03), active smoking (OR = 1.60, p = 0.044), and prolonged operative time (>1 SD above average) (OR = 1.88, p = 0.002) were associated with surgical morbidity. The results of the analysis emphasize that DTI-based breast reconstruction can be an excellent option for a specific group of patients. Careful pre-operative patient selection will optimise outcomes, and caution must be used in assessing suitability of DTI in obese patients and active smokers.

Impact of Obesity on Outcomes in Breast Reconstruction: A Systematic Review and Meta-Analysis

“…Eighteen studies were specifically designed to investigate the effect BMI has on breast reconstruction, 7,13,[15][16][17][18][19]23,25,26,[30][31][32][33]38,[42][43][44] whereas 15 studies investigated general risk factors, one of which was obesity. 14,[20][21][22]24,[27][28][29][34][35][36][37][39][40][41] Numerical data for meta-analysis could be extracted from 29 papers, six of which investigated prosthetic reconstruction, 7,13,14,22,27,28 22 investigated autologous reconstruction, 15,[18][19][20][21]23,25,26,[29][30]…”

“…This outcome was reported in 30 studies. 7,[13][14][15][16][17][18][19][20][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][39][40][41][42][43] Wound infection was investigated in 25 studies, 7,13,[15][16][17][18]20,[22][23][24][25][26][27][28][29][30][31][32][33]35,[39][40]…”

“…16,18,20,[23][24][25][26][27][28]31,35,40,42,43 Ten studies included deep venous thrombosis (DVT) in their definition 16,18,20,23,24,26,27,40,42,43 and seven studies included pulmonary embolism (PE). 16,18,20,23,24,27,42 Four studies included any National Surgical Quality Improvement Program-defined endpoints such as PE, myocardial infarction, pneumonia, urinary tract infection, sepsis, stroke, and coma in their definition. 16,20,24,27…”

Embrace the Change

“…8,9 The best outcomes are achieved in thin patients with an athletic body frame, small breast size, minimal ptosis, and low body mass index; nonsmokers; nondiabetics; and patients with no radiation therapy. The ideal candidate will want to be at least the same size or slightly larger, with the average implant size used in our experience being only 367 cc on average.…”

“…Table 1 summarizes selection criteria associated with good outcomes in single-stage implant reconstruction. [8][9][10][11][12] Patients with large breasts and significant ptosis will require mastopexy techniques and at times free nipple grafts, which in the senior author's experience has led to an additional vascular insult to the mastectomy flaps, increasing the chances of wound breakdown and implant exposure. Radiation therapy is not an absolute contraindication to single-stage implant reconstruction but is associated with higher complication rates for infection (21.6 percent) and loss of prosthesis (18.75 percent).…”