Some high-risk women may benefit from delayed reconstruction after mastectomy
Mastectomy patients who are obese, have diabetes or smoke may benefit from delayed rather than immediate reconstruction (IR) using implants, or from the use of autologous reconstruction, results of a study suggest.
In the retrospective cohort study in 17,293 women who underwent mastectomy between 2004 and 2011, researchers found a significantly increased 90-day incidence of surgical site infection (SSI) among those undergoing IR vs delayed reconstruction (DR) using implants (8.9 vs 5.7 percent; p=0.04). [JAMA Surg 2017, DOI:10.1001/jamasurg.2017.2338]
The incidence of SSI was also significantly higher after implant IR as compared with implant secondary reconstruction (SR) after autologous tissue flap plus implant IR (1.8 percent; p<0.001), and with implant SR after autologous IR (1.7 percent; p<0.003).
Similar results were found for noninfectious wound complications (NIWCs). In women who underwent implant IR, the 90-day incidence of NIWCs was 9.4 percent, compared with 4.1 percent in women who underwent implant DR (p=0.001), 2.6 percent in women who received implant SR after autologous tissue flap plus implant IR (p<0.001), and 4.6 percent in women who received implant SR after autologous IR (p=0.03).
“Wound complications after implant IR were associated with high rates of implant failure and an increased likelihood of additional wound complications after SR procedures,” the authors reported.
Implant failure, defined as implant removal or exchange within 60 days of insertion, occurred in 7 percent of women after IR and 8.1 percent of women after DR (p=0.39). Among those with SSI, implant failure occurred in 43.8 percent of IR and 57.1 percent of DR procedures (p=0.23), respectively.
Compared with women without SSI after implant IR, those with SSI after implant IR were significantly more likely to have another SSI (11.4 vs 2.7 percent) and NIWCs (5.8 vs 2.5 percent) after SR.
Furthermore, adjuvant radiotherapy was associated with increased rates of SSI and NIWCs after implant SR (6.3 vs 2.9 percent and 5.8 vs 2.4 percent, respectively).
“In contrast, 90-day wound complication rates were similar in women who underwent autologous tissue flap reconstruction regardless of the timing of reconstruction, with rates of SSI being 9.8 percent after IR, 13.9 percent after DR and 11.6 percent after SR, respectively,” they noted.
“Our study showed higher rates of infectious and NIWCs after implant IR vs implant DR despite the higher risk profile of patients who underwent DR,” the authors concluded. “Our results suggest that some high-risk patients may benefit from delayed rather than immediate implant reconstruction or from the use of autologous reconstruction to decrease their risk of serious wound complications.”
Patients in the study were identified from a large database of commercially insured patients in the US. Women who underwent DR vs IR were more likely to live in a rural vs urban location (18.8 vs 9.7 percent; p<0.001), have tobacco use disorder (16.8 vs 12.1 percent; p=0.007), use oral corticosteroids (14.7 vs 10.1 percent; p=0.01), have anaemia (7.9 vs 5.5 percent; p=0.05), and have regional or metastatic cancer (23.5 vs 17.3 percent; p<0.001).