Management of complications following implant-based breast reconstruction: a narrative review

Abstract

Background and objective: Complications associated with implant-based reconstruction have a spectrum of severity with sequelae ranging from mild aesthetic deformities to additional surgery, reconstructive failure and systemic illness. The purpose of this narrative review of the literature is to provide updated evidence-based information on the management of complications in implant-based reconstruction.

Methods: A systematic search of PubMed, OVID MEDLINE and the Cochrane Library databases was performed to identify common complications associated with implant-based breast reconstruction, incidences of occurrence as well as preventative and management strategies.

Key content and findings: Pertinent short and long-term complications of implant-based breast reconstruction include hematoma, implant infection, seroma, skin envelope necrosis, capsular contracture, rupture, malposition, animation and contour deformities, implant-associated anaplastic large cell lymphoma, and breast implant illness. Important preventative measures for short term complications include meticulous sterile technique and antibiotic irrigation, adequate drainage and critical evaluation of mastectomy flaps. Management of short-term complications requires early recognition and aggressive treatment to prevent reconstructive failure as well as long-term complications such as capsular contracture. Important technological advances include dual-port expanders for seroma drainage, indocyanine green angiography for mastectomy flap perfusion evaluation, cohesive form-stable implants for treatment of rippling, and various biologic and synthetic mesh products for pocket control and correction.

Conclusions: Important principles in management of short-term complications in implant-based reconstruction include aggressive and early intervention to maximize the chance of reconstructive salvage. Contemporary technological advances have played an important role in both prevention and treatment of complications. Over-arching principles in management of implant-based reconstruction complications focus on preventative techniques and preoperative patient counseling on potential risks, their likelihood, and necessary treatments to allow for informed and shared decision-making.

Keywords: Breast reconstruction; breast implants; complications.

Figure 1

Dual-port tissue expanders allow for aspiration of seroma fluid in the implant pocket through a second aspiration port. (A) Placement of a dual-port tissue expander in the prepectoral plane without ADM. (B) In-office aspiration of seroma after drain removal. ADM, acellular dermal matrix.

Figure 2

Skin-sparing mastectomy and immediate prepectoral reconstruction without ADM demonstrating preservation of the subcutaneous tissue superficial to the breast pseudocapsule. ADM, acellular dermal matrix.

Figure 3

Total submuscular reconstruction using pectoralis major and serratus fascia due to concern for compromised mastectomy flaps intraoperatively.

Figure 4

Well-vascularized tissue between the prosthesis and the skin can help prevent significant complications after mastectomy flap ischemia. (A) Evidence of marginal mastectomy flap incisional ischemia in an immediate total submuscular two-stage reconstruction after skin-sparing mastectomy. (B) Resultant small full-thickness dehiscence of incision to underlying muscle amenable to in-office debridement and closure (C) with subsequent healing (D).

Figure 5

Implant exposure after nipple-sparing mastectomy and prepectoral immediate implant reconstruction at an outside hospital requiring explantation and planned future autologous reconstruction.

Figure 6

Autologous fat grafting is a useful adjunctive tool to address contour deformities. Prepectoral implant-based breast reconstruction in a low body mass index patient (A) before and (B) after autologous fat grafting to improve upper pole fullness.