Immediate breast reconstruction postmastectomy linked to increased complication risk
Immediate breast reconstruction (IR) following a mastectomy is linked to an elevated risk of wound complications, which in turn, is linked to subsequent complications and delayed chemo- and radiotherapy initiation, according to a US study.
“[IR] is often recommended to women undergoing mastectomy because it is thought to confer psychosocial benefits and result in better cosmesis,” said the researchers. “Our results suggest that some high-risk patients may benefit from delayed rather than immediate implant reconstruction or from the use of autologous reconstruction ... our findings ... underscore the need to communicate individualized complication risk to women considering IR,” they said.
“[T]ailoring of preventive measures to patients’ unique risk factors and/or careful consideration of the best timing of reconstruction may be needed to prevent complications,” they said.
Participants in this retrospective cohort study were 17,293 women (mean age, 50.4 years) who underwent mastectomy between 2004 and 2011, 58.1 percent of whom underwent IR (autologous or implant reconstruction within 7 days of mastectomy).
Women who underwent implant IR had a higher incidence of surgical site infections (SSIs; 7.2 percent vs 3.2 percent; p<0.001) and noninfectious wound complications (NIWCs; 8.2 percent vs 2.6 percent; p<0.001) within 90 days of reconstruction procedure compared with women who underwent implant secondary reconstruction (SR [reconstruction >7 days after mastectomy which included immediate reconstruction]). [JAMA Surg 2017;doi:10.1001/jamasurg.2017.2338]
Ninety-day SSI incidence was also higher in women who underwent implant IR than implant delayed reconstruction (DR [procedure >7 days after mastectomy without immediate reconstruction]; 8.9 percent vs 5.7 percent; p=0.04), as was 90-day NIWC incidence (9.4 percent vs 4.1 percent; p=0.001).
Women who had an SSI after implant IR had a higher risk of subsequent SSI (11.4 percent vs 2.7 percent; p<0.001) or NIWC (5.8 percent vs 2.5 percent; p<0.001) following implant or autologous SR compared with women with no SSI after implant IR, a finding potentially attributed to low-level infection or a higher risk for complications following the initial procedure, the researchers said.
Timing of reconstruction procedure did not affect wound complication incidence among women who underwent autologous tissue flap reconstruction, though researchers acknowledged that this result could be due to the fewer autologous procedures performed.
“One possible explanation for increased complication rates after implant IR is the substantial dead space and hypovascular field in which the initial implant is placed, compared with the surgical field at the time of delayed or second-stage implant insertion,” said the researchers. “Another explanation ... is the longer operation times often required for IR.”
Women who had wound complications after implant IR also required more breast procedures within 2 years of the initial surgery compared with women with no complications (mean number of subsequent procedures, 1.92 vs 1.37), as did women with wound complications after autologous IR (1.11 vs 0.87; p<0.001).
Women with wound complications after IR also initiated chemotherapy and radiotherapy later than women with no IR-related complications (median chemotherapy initiation, 53 vs 39 days postmastectomy and median radiotherapy initiation, 162 vs 142 days postmastectomy; p<0.001 for each comparison), while receiving adjuvant therapy prior to reconstruction was linked to a higher incidence of wound complications following implant SR (p<0.001) but not implant DR, or autologous DR or SR.
The use of insurance claims data to identify complications may have affected the findings due to misclassification of diagnosis or undercoding of minor complications, said the researchers, who recommended a prospective study to confirm the results.