Direct-to-implant breast reconstruction: Higher complication rate vs cosmetic benefits

Abstract

Background: Since skin- and nipple-sparing mastectomies (SSM/NSM) are now considered oncologically safe options, the number of immediate implant-based breast reconstructions (IBBR) has increased. We present our experience with different techniques of immediate and delayed IBBR over a period of 5 years.

Methods: A single center, retrospective, cohort study was performed from January 2008 to January 2013. Complications, reconstructive failure, contralateral adjustment, cosmetic outcome, patient's quality of life, and the thickness of the overlying tissue were compared between different techniques of immediate and delayed IBBR.

Results: A total of 180 patients who underwent immediate (n = 148, 82.2%) or delayed (n = 32, 17.8%) IBBR after SSM (n = 62, 34.4%), NSM (n = 21, 11.7%), or total mastectomy (n = 97, 53.9%) were included. The mean follow-up was 46 months. Immediate IBBR was associated with better cosmetic outcomes (P = 0.026), fewer surgical interventions (P = 0.017), and better quality of life (P = 0.004). Patients with NSM showed the best quality of life results (P =< 0.001) and the best cosmetic outcome (P = 0.001). While immediate IBBR with direct-to-implant procedures achieved a trend toward best cosmetic outcomes (P = 0.66), it was associated with the highest complication rate (37.1%) compared to permanent expanders (10.5%) and a two-stage expander-to-implant procedure (22.9%; P = 0.013) without a significant difference in the rate of implant loss (P = 0.51).

Conclusion: Whenever oncologically feasible, immediate IBBR should be offered to the patient. The advantages of immediate IBBR with a direct-to-implant procedure such as better cosmetic outcome and fewer surgical interventions should be weighed up against the relatively high overall complication rate associated with this procedure.

Keywords: acellular dermal matrix; breast reconstruction; direct-to-implant; expander; mesh; permanent expander.