Implant-based Breast Reconstruction Following Infected Device Explantation

Is a Second Attempt Worth It?

Malke Asaad, M.D.; Cedar Slovacek, B.S.; David Mitchell, B.S.; Jun Liu, Ph.D.; Jesse C. Selber, M.D., M.P.H., M.H.C.M.; Mark W. Clemens, M.D.; Carrie K. Chu, M.D., M.S.C.R.; Alexander F. Mericli, M.D.; Charles E. Butler, M.D.

Disclosures

Plast Reconstr Surg. 2022;150(2):247e-259e. 

In This Article

Abstract and Introduction

Abstract

Background: Infection is a dreaded complication of implant-based breast reconstruction. There is a paucity of literature on the outcomes of a secondary reconstruction after infected implant-based breast reconstruction explantation.

Methods: The authors conducted a retrospective study of patients who underwent a second implant-based breast reconstruction following a failed infected device between January of 2006 and December of 2019. Surgical and patient-reported outcomes (BREAST-Q) were collected and analyzed.

Results: A total of 6093 implant-based breast reconstructions were performed during the study period, 298 (5 percent) of which involved device removal because of infection. Eighty-three patients ultimately received 92 second-attempt breast implants. Thirty-six percent of cases developed at least one postoperative complication, with infection [23 breasts (25 percent)] being the most common. Compared with first-attempt implant-based breast reconstruction, we found significantly higher infection rates among second-attempt cases (9 percent and 21 percent, respectively; p = 0.0008). Patient-reported satisfaction with the breast and sexual well-being were lower after second-attempt than after first-attempt implant-based breast reconstruction (p = 0.018 and p = 0.002, respectively) reported in the literature. Mean follow-up was 41 ± 35 months. If we exclude patients with prior radiation therapy and those who received device exchange, the success rate is 88 percent.

Conclusions: It is reasonable to offer women second-attempt implant-based breast reconstruction after explantation because of infection. However, this patient population has a higher infection and explantation rate and lower patient-reported satisfaction than patients undergoing first-attempt implant-based breast reconstruction. Because of these increased surgical risks and elevated complication rates, patients must be given reasonable expectations during preoperative discussions and when providing informed consent for second-attempt implant-based breast reconstruction.

Clinical Question/Level of Evidence: Risk, III.

Introduction

Implant-based breast reconstruction is the most commonly used method of breast reconstruction after mastectomy, with approximately 100,000 cases performed in the United States annually.[1] Several studies have confirmed the safety of implant-based breast reconstruction and its positive effect on quality of life. However, complications that occur after this reconstruction modality are not uncommon.[2–15] In a multicenter cohort study of 2343 patients, the overall 2-year complication rate in direct-to-implant and tissue expander/implant reconstruction was 31 percent and 27 percent, respectively; infection rates were 15 percent for the former and 10 percent for the latter.[3]

Infection is a dreaded complication of implant-based breast reconstruction and its management varies according to the severity of presentation.[16] Over the past decade, there has been a shift in the treatment paradigm for infected implants, with many surgeons challenging the traditional doctrine of removing all infected devices.[16,17] Several immediate salvage techniques have been proposed, ranging from antibiotic therapy to operative intervention and implant replacement.[16,17] However, the subset of patients who do not respond to nonoperative management require implant explantation.[17] Although several studies have evaluated the infection and complication rates of implant-based breast reconstruction and have identified several risk factors that predispose patients to implant failure,[3–5] the literature on the outcomes of those undergoing a second implant-based breast reconstruction after the first implant-based breast reconstruction is explanted is scarce.[17–19]

We hypothesized that second-attempt implant-based breast reconstruction, either at the time of device exchange or delayed after a failed infected device, is safe but has a higher risk of failure than a first-attempt implant-based breast reconstruction. Our primary goal was to assess surgical and patient-reported outcomes of breast reconstruction in this patient cohort. Our secondary goal was to identify potential risk factors for failure and complications of second-attempt implant-based breast reconstruction.

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