Abstract
Prepectoral breast reconstruction offers esthetic and recovery advantages but may be more vulnerable to complications due to the absence of muscular coverage. This study examined the clinical course of patients with failed prepectoral implant reconstruction. All consecutive prepectoral reconstructions performed between March 2017 and July 2022 at a single tertiary center were reviewed. Of 239 reconstructions, 42 (17.5%) ultimately failed, most commonly due to infection (50%). Sixteen patients (38%) underwent definitive reconstruction with a median interval of 379 days (IQR 249) from initial surgery to final reconstruction. The most common secondary reconstruction modalities were implant-based reconstruction (31%) and free-tissue transfer (31%). On multivariate analysis, increasing age, higher body mass index (BMI), and prior radiation were independently associated with implant loss. Failure of salvage after prepectoral reconstruction remains a major challenge and often results in delayed or abandoned reconstruction, highlighting the need for careful patient selection.
Keywords
Prepectoral implant-based breast reconstruction (IBBR) has grown in popularity as mastectomy technique has improved. This technique offers faster expansion, less postoperative pain, shorter operations, and avoidance of animation deformity. 1 Despite these advantages, the lack of vascularized muscle coverage narrows the margin for error: minor insults such as skin-flap ischemia/necrosis, incisional dehiscence, seroma, or infection can precipitate pocket contamination, necessitating rapid salvage attempts to prevent device loss. 2
We reviewed consecutive prepectoral reconstructions at a single tertiary center (March 2017-July 2022) under institutional review board approval. Threatened prosthesis was defined by erythema, drainage, dehiscence, or periprosthetic fluid without frank exposure; failed salvage was defined as inability to avoid explantation after threat recognition. Demographics, oncologic therapies, operative details, and outcomes were abstracted from the electronic medical record and stored in REDCap. Continuous data are presented as median (IQR), and categorical data are presented as percentages. Multivariable logistic regression evaluated factors associated with explantation, and significance was set at P < 0.05.
Among 239 patients (390 breasts) undergoing prepectoral IBBR, 42 patients (54 breasts) required explantation (patients: 17.5%; breasts: 13%). Most reconstructions were two-stage (91%), and most failures occurred during the expander phase (92%) with a median of 56 (94.3) days from index surgery to explantation. Direct-to-implant (DTI) failures occurred at a median of 61 (27) days. Infection/cellulitis was the most common terminal event (50%). Of the 42 patients with device loss, 16 (38%) ultimately underwent definitive reconstruction after a median of 379 (249) days and a median of 2 additional procedures (range, 1-4). Final reconstruction modalities included breast implants (31%), free-tissue transfer (31%), pedicled latissimus dorsi (25%), and latissimus plus implant (12.5%). Patients initially reconstructed bilaterally were more likely to proceed to definitive reconstruction after failure than unilateral cases (44% vs 27%; P = 0.25).
Multivariable Logistic Regression for Factors Associated With Explantation
Values are odds ratios (ORs) with 95% confidence intervals and P-values from models with patient-level cluster-robust standard errors. Continuous predictors scaled as follows: BMI per 5 kg/m2; mastectomy weight per 100 g; intraoperative fill per 100 mL; age per 1 year.
Abbreviations: OR, odds ratio; CI, confidence interval; BMI, body mass index; TE, tissue expander; NSM, nipple sparing mastectomy; SSM, skin sparing mastectomy; DTI, direct to implant.
Prepectoral IBBR offers meaningful benefits but is unforgiving of wound and infectious complications, particularly in radiated tissue. In our cohort, nearly 1 in 5 patients required explantation despite salvage attempts, and only 38% ultimately achieved definitive reconstruction after substantial delays, findings consistent with reconstruction fatigue and competing patient-level constraints. Management of threatened devices followed a stepwise protocol: local wound care ± office debridement for superficial dehiscence. Aspiration and antibiotics were used for seroma with escalation to operating room (OR) washout if persistent or infected. Oral then intravenous antibiotics were given for cellulitis with OR washout and explantation, if refractory. Adjuncts such as negative-pressure wound therapy with instillation and pocket-directed antimicrobial strategies reported in prior series may shorten time to definitive reconstruction and improve salvage in selected cases though results are heterogeneous and technique-dependent.3,4
Failure after prepectoral reconstruction remains a consequential event with substantial delays to definitive reconstruction and relatively low rates of successful salvage. Older age, higher BMI, and prior radiation were the strongest independent predictors of implant loss in our cohort. These findings underscore the importance of careful patient selection and risk-mitigation at index surgery, vigilant postoperative monitoring, and early counseling regarding the potential need for delayed or autologous reconstruction if salvage fails.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.