Breast reconstruction with implants
Using retrospective analysis of medical records, researchers found that direct-to-implant breast reconstruction resulted in a greater risk of implant failure and skin flap necrosis (death of the breast skin after a skin-sparing mastectomy) compared with traditional breast reconstruction with tissue expanders and implants.
Reviewing 13 studies involving a total of 5,216 women, the researchers at the University of Pennsylvania compared rates of capsular contracture, seroma, infection, loss of the implant and other complications between women who had breast reconstruction with traditional tissue expanders and those who had direct-to-implant (“one-step) without tissue expanders.
They found similar rates of infection, seroma, hematoma and capsular contracture between the two group. Women who had direct-to-implant reconstruction, however, had a higher risk for flap necrosis. This group also had a higher risk for complete loss of the implant and a need for additional surgery—almost twice as high as women who had tissue expander/implant breast reconstruction.
Study authors noted that although direct-to-implant breast reconstruction offers distinct advantages over traditional expansion—avoiding the uncomfortable and lengthy expansion process, and also avoiding a second operation to swap out the tissue expander for a breast implant—placing a large implant under the pectoral muscle immediately following mastectomy can increase tension on the wound closure, which in some cases can lead to necrosis. Researchers concluded that, “Although many patients may go on to heal with only conservative wound care, a subset of patients are predisposed to further complications after flap necrosis, including those patients requiring postmastectomy radiation therapy or chemotherapy.”
Breast reconstruction with abdominal tissue flaps
Another study found that hernias requiring surgical repair within 4 years were not uncommon in women who had breast reconstruction with abdominal tissue flaps. The 8,246 women in the study who had breast reconstruction from 2008 to 2012 in California, Florida, Nebraska or New York, and included:
% of women % rate of hernia
in the study needing surgical repair
Pedicled TRAM 29.2 7.0
Free TRAM 30.0 5.7
DIEP 40.8 1.8
The pedicled TRAM group had the highest rate of hernia needing surgical repair. That's not surprising because hernia is known to be a common side effect of removing the rectus abdominal muscle(s). It’s also not surprising that patients who had breast reconstruction with a DIEP tissue flap, which preserves the abdominal muscles, fare far better—more women included in the sample had DIEP flap and also had the lowest rate of hernia.
Beyond the differences in procedures, it is also so important to choose a plastic surgeon who is very experienced and skilled with the procedure. It’s likely that many surgeons who perform DIEP, for example, probably have a much lower rate of hernia complications in their reconstruction patients than the 1.8% reflected in this study.
Sources: Basta MN, Gerety PA, Serletti JM, et al. “A Systematic Review and Head-to-Head Meta-Analysis of Outcomes following Direct-to-Implant versus Conventional Two-Stage Implant Reconstruction.” Plastic & Reconstructive Surgery (2015) Vol. 136, No. 6: p. 1135-44.
Shubinets V, Fox JP, Sarik JR, et al. “Surgically treated hernia following abdominal-based autologous breast reconstruction: prevalence, outcomes, and expenditures.” Plastic & Reconstructive Surgery, published online November 19, 2015.