Late Surgical-Site Infection in Immediate Implant-Based Breast Reconstruction

Abstract

Background: Surgical-site infection causes devastating reconstructive failure in implant-based breast reconstructions. Large national database studies offer insights into complication rates, but only capture outcomes within 30 days postoperatively. This study evaluates both early and late surgical-site infection in immediate implant-based reconstruction and identifies predictors.

Methods: As part of the Mastectomy Reconstruction Outcomes Consortium Study, 1662 implant-based breast reconstructions in 1024 patients were evaluated for early versus late surgical-site infection. Early surgical-site infection was defined as infection occurring within 30 days postoperatively; late surgical-site infection was defined as infection occurring 31 days to 1 year postoperatively. Minor infection required oral antibiotics only, and major infection required hospitalization and/or surgical treatment. Direct-to-implant patients had 1-year follow-up, and tissue expander patients had 1-year post-exchange follow-up.

Results: Among 1491 tissue expander and 171 direct-to-implant reconstructions, overall surgical-site infection rate for tissue expander was 5.7 percent (85 of 1491) after first-stage, 2.5 percent (31 of 1266) after second-stage, and 9.9 percent (17 of 171) for direct-to-implant reconstruction. Over 47 to 71 percent of surgical-site infection complications were late surgical-site infection. Multivariate analysis identified radiotherapy and increasing body mass index as significant predictors of late surgical-site infection. No significant difference between the direct-to-implant and tissue expander groups in the occurrence of early, late, or overall surgical-site infection was found.

Conclusions: The majority of surgical-site infection complications in immediate implant-based breast reconstructions occur more than 30 days after both first-stage and second-stage procedures. Radiotherapy and obesity are significantly associated with late-onset surgical-site infection. Current studies limited to early complications do not present a complete assessment of infection associated with implant-based breast reconstructions or their long-term clinical outcomes.

Clinical question/level of evidence: Risk, II.

Figure 1

Among 1491 TE and 171 DTI reconstructions, overall SSI rate for TE was 5.7% for first-stage, 2.5% for second-stage, and 9.9% for DTI. 47–71% of all SSI complications occurred as late SSI.

Figure 2

Patient is a 39 year-old female who was diagnosed with left breast cancer. Patient is seen following bilateral mastectomy with ADM and TE reconstruction, followed by post-mastectomy radiation therapy of the left chest during expansion. Patient is seen 2 months following TE exchange to implant (A). At 10 months post-operative from a TE to implant exchange procedure, mild cellulitis can be visualized overlying the left chest (B). Following IV antibiotic treatment and resolution of cellulitis, the patient now has capsular contracture and obvious asymmetry (C).