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Surgical complications in immediate and delayed breast reconstruction: A systematic review and meta-analysis

  • Dany Y. Matar
    Affiliations
    Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA

    Washington University in St. Louis, St. Louis, MO, 63130, USA
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  • Mengfan Wu
    Affiliations
    Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA

    Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, 518036, China
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  • Valentin Haug
    Affiliations
    Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA

    Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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  • Dennis P. Orgill
    Affiliations
    Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA
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  • Adriana C. Panayi
    Correspondence
    Corresponding author at: Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
    Affiliations
    Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA
    Search for articles by this author
Published:August 21, 2022DOI:https://doi.org/10.1016/j.bjps.2022.08.029

      Summary

      Background

      Because of improved aesthetic results, immediate breast reconstruction has become the most widely used timing of reconstruction following mastectomy. Many studies report complication rates between immediate and delayed reconstructions at certain medical institutions, but no systematic reviews exist to summarize the literature. This systematic review was conducted to assess the outcomes in women who underwent immediate versus delayed breast reconstruction following mastectomy for breast cancer.

      Methods

      Cochrane, PubMed, and EMBASE electronic databases were screened, and data were extracted from included studies. The clinical outcomes assessed were surgical complications, length of postoperative hospital stay, and reoperation rate.

      Results

      A total of 30 studies met the inclusion criteria for the review and provided enough data to be included in the meta-analysis (14,034 patients). Women receiving immediate breast reconstruction were significantly more likely to experience surgical complications (OR 1.30, 95% CI 1.03, 1.65; p = 0.03). Sensitivity analysis showed that women receiving immediate reconstruction were also more likely to experience infection (OR 1.41, 95% 1.04, 1.92; p = 0.03) and hematoma/seroma (OR 2.01, 95% CI 1.27–3.17; p = 0.003). Furthermore, a separate sensitivity analysis showed no significant differences in reported outcomes when comparing studies whose patient cohorts received post-mastectomy radiation therapy (PMRT).

      Conclusions

      This study provides evidence that immediate breast reconstruction generally increases the risk of complications in comparison with delayed reconstruction. Additional prospective and observational studies are needed to determine the role of PMRT and reconstruction surgical technique in the incidence of complications between immediate and delayed reconstructions.

      Keywords

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      References

        • Jagsi R
        • Jiang J
        • Momoh AO
        • et al.
        Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States.
        J Clin Oncol. 2014; 32: 919-926
        • Albornoz CR
        • Bach PB
        • Mehrara BJ
        • et al.
        A paradigm shift in US breast reconstruction: Increasing implant rates.
        Plast Reconstr Surg. 2013; 131: 15-23
        • Al-Ghazal S.
        • Sully L.
        • Fallowfield L.
        • Blamey R.
        The psychological impact of immediate rather than delayed breast reconstruction.
        Eur J Surg Oncol (EJSO). 2000; 26: 17-19
        • Qureshi A.A.
        • Odom E.B.
        • Parikh R.P.
        • Myckatyn T.M.
        • Tenenbaum M.M.
        Patient-reported outcomes of aesthetics and satisfaction in immediate breast reconstruction after nipple-sparing mastectomy with implants and fat grafting.
        Aesthet Surg J. 2017; 37: 999-1008
        • Olsen MA
        • Nickel KB
        • Fox IK
        • et al.
        Incidence of surgical site infection following mastectomy with and without immediate reconstruction using private insurer claims data.
        Infect Control Hosp Epidemiol. 2015; 36: 907-914
      1. (editors)Higgins JPT Green S Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 updated March 2011. The Cochrane Collaboration, 2011 ([Internet])
        • Panayi A
        • Agha RA
        • Sieber BA
        • Orgill DP.
        Impact of obesity on outcomes in breast reconstruction: A systematic review protocol.
        Int J Surg Protocols. 2016; 2: 1-4
        • Wells G.
        • Shea B.
        • O'connell D.
        • Peterson J.
        • Welch V.
        • Losos M.
        • Tugwell P.
        The Newcastle-Ottawa Scale (Nos) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses.
        Ottawa Hospital Research Institute, Ottawa, ON, Canada2000
        • Moher D
        • Cook DJ
        • Eastwood S
        • Olkin I
        • Rennie D
        • Stroup DF.
        Improving the quality of reports of meta-analyses of randomised controlled trials: The QUOROM statement. Quality of reporting of meta-analyses.
        Lancet. 1999; 354: 1896-1900
        • Alderman A.K.
        • Wilkins E.G.
        • Kim H.M.
        • Lowery J.C.
        Complications in postmastectomy breast reconstruction: Two-year results of the Michigan breast reconstruction outcome study.
        Plast Reconstr Surg. 2002; 109: 2265-2274
        • Alstrup T.
        • Christensen B.O.
        • Damsgaard T.E.
        ICG angiography in immediate and delayed autologous breast reconstructions: Peroperative evaluation and postoperative outcomes.
        J Plast Surg Hand Surg. 2018; 52: 307-311
        • Beugels J.
        • Bod L.
        • van Kuijk S.M.J.
        • Qiu S.S.
        • Tuinder S.M.H.
        • Heuts E.M.
        • Piatkowski A.
        • van der Hulst R.R.W.J
        Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions.
        Breast Cancer Res Treat. 2018; 169: 349-357
        • Billig J.
        • Jagsi R.
        • Qi J.
        • Hamill J.B.
        • Kim H.M.
        • Pusic A.L.
        • Buchel E.
        • Wilkins E.G.
        • Momoh A.O.
        Should immediate autologous breast reconstruction be considered in women who require postmastectomy radiation therapy? A prospective analysis of outcomes.
        Plast Reconstr Surg. 2017; 139: 1279-1288
        • Browne J.P.
        • Jeevan R.
        • Gulliver-Clarke C.
        • Pereira J.
        • Caddy C.M.
        • van der Meulen J.H.P.
        The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer.
        Cancer. 2017; 123: 3460-3467
        • Carlson G.W.
        • Page A.L.
        • Peters K.
        • Ashinoff R.
        • Schaefer T.
        • Losken A.
        Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction.
        Ann Plast Surg. 2008; 60: 568-572
        • Chang E.I.
        • Chang E.I.
        • Soto-Miranda M.A.
        • Zhang H.
        • Nosrati N.
        • Ghali S.
        • Chang D.W.
        Evolution of bilateral free flap breast reconstruction over 10 years.
        Plast Reconstr Surg. 2015; 135 (946e–953e)
        • Cheng M.-H.
        • Lin J.-Y.
        • Ulusal B.G.
        • Wei F.-C.
        Comparisons of resource costs and success rates between immediate and delayed breast reconstruction using DIEP or SIEA flaps under a well-controlled clinical trial.
        Plast Reconstr Surg. 2006; 117: 2139-2142
        • Cook J.
        • Waughtel J.
        • Brooks C.
        • Hardin D.
        • Hwee Y.K.
        • Barnavon Y.
        The muscle-sparing latissimus dorsi flap for breast reconstruction.
        Ann Plast Surg. 2017; 78: S263-S268
        • DeBono R.
        • Stevenson J.H.
        • Thompson A.
        Immediate versus delayed free TRAM breast reconstruction: An analysis of perioperative factors and complications.
        Br J Plast Surg. 2002; 55: 111-116
        • Dewael S.
        • Vandevoort M.
        • Fabré G.
        • Nanhekhan L.
        Immediate versus delayed autologous breast reconstruction: A retrospective matched cohort study of irradiated patients.
        J Plast, Reconstruct Aesthet Surg. 2019; 72: 1769-1775
        • Drazan L.
        • Vesely J.
        • Hyza P.
        • Castagnetti F.
        • Stupka I.
        • Justan I.
        • Novak P.
        • Monni N.
        Bilateral breast reconstruction with DIEP flaps: 4 Years’ experience.
        J Plast, Reconstruct Aesthet Surg. 2008; 61: 1309-1315
        • Gschwantler-Kaulich D.
        • Leser C.
        • Salama M.
        • Singer C.F.
        Direct-to-implant breast reconstruction: Higher complication rate vs cosmetic benefits.
        Breast J. 2018; 24: 957-964
        • Hirsch E.M.
        • Seth A.K.
        • Dumanian G.A.
        • Kim J.Y.S.
        • Mustoe T.A.
        • Galiano R.D.
        • Fine N.A.
        Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation.
        Plast Reconstr Surg. 2012; 129: 354-361
        • Hughes K.
        • Brown C.
        • Perez V.
        • Ting J.W.
        • Rozen W.M.
        • Whitaker I.S.
        • Korentager R.
        The effect of radiotherapy on implant-based breast reconstruction in the setting of skin-sparing mastectomy: Clinical series and review of complications.
        Anticancer Res. 2012; 32 (2012 Feb): 553-557
        • Kronowitz S.J.
        • Feledy J.A.
        • Hunt K.K.
        • Kuerer H.M.
        • Youssef A.
        • Koutz C.A.
        • Robb G.L.
        Determining the optimal approach to breast reconstruction after partial mastectomy.
        Plast Reconstr Surg. 2006; 117: 1-11
        • Maalouf C.
        • Bou-Merhi J.
        • Karam E.
        • Patocskai E.
        • Danino A.M.
        The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy.
        Annales de Chirurgie Plastique Esthétique. 2017; 62: 630-636
        • Manyam B.V.
        • Shah C.
        • Woody N.M.
        • Reddy C.A.
        • Weller M.A.
        • Juloori A.
        • Naik M.
        • Valente S.
        • Grobmyer S.
        • Durand P.
        • Djohan R.
        • Tendulkar R.D.
        Long-term outcomes after autologous or tissue expander/implant–Based breast reconstruction and postmastectomy radiation for breast cancer.
        Pract Radiat Oncol. 2019; 9: e497-e505
        • Meshulam-Derazon S.
        • Shay T.
        • Lewis S.
        • Adler N.
        Immediate breast reconstruction: Comparative outcome study of one-stage direct-to-implant and two-stage/tissue expander techniques.
        Isr Med Assoc J. 2018; 20 (Jun): 340-344
        • Miller A.P.
        • Falcone R.E.
        Breast reconstruction: Systemic factors influencing local complications.
        Ann Plast Surg. 1991; 27: 115-120
        • Prantl L.
        • Moellhoff N.
        • von Fritschen U.
        • Giunta R.E.
        • Germann G.
        • Kehrer A.
        • Lonic D.
        • Zeman F.
        • Broer P.N.
        • Heidekrueger P.I.
        Immediate versus secondary DIEP flap breast reconstruction: A multicenter outcome study.
        Arch Gynecol Obstet. 2020; 302: 1451-1459
        • Sharabi S.E.
        • Baumann D.P.
        • Selber J.C.
        • Killon E.
        • Mericli A.F.
        • Liu J.
        • Caudle A.S.
        • Smith B.D.
        • Chavez-MacGregor M.
        • Schaverien M.V.
        Complications of contralateral prophylactic mastectomy: Do they delay adjuvant therapy?.
        Plast Reconstruct Surg. 2020; 146: 945-953
        • Steele K.H.
        • Macmillan R.D.
        • Ball G.R.
        • Akerlund M.
        • McCulley S.J.
        Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction and Radiotherapy (ABRAR study).
        J Plast, Reconstruct Aesthet Surg. 2018; 71: 185-193
        • Sternberg E.G.
        • Perdikis G.
        • McLaughlin S.A.
        • Terkonda S.P.
        • Waldorf J.C.
        Latissimus dorsi flap remains an excellent choice for breast reconstruction.
        Ann Plast Surg. 2006; 56: 31-35
        • Sue G.R.
        • Long C.
        • Lee G.K.
        Management of mastectomy skin necrosis in implant based breast reconstruction.
        Ann Plast Surg. 2017; 78: S208-S211
        • Sue G.R.
        • Sun B.J.
        • Lee G.K.
        Complications after two-stage expander implant breast reconstruction requiring reoperation.
        Ann Plast Surg. 2018; 80: S292-S294
        • Sullivan S.R.
        • Fletcher D.R.D.
        • Isom C.D.
        • Isik F.F.
        True incidence of all complications following immediate and delayed breast reconstruction.
        Plast Reconstr Surg. 2008; 122: 19-28
        • Trabulsy P.P.
        • Anthony J.P.
        • Mathes S.J.
        Changing trends in postmastectomy breast reconstruction.
        Plast Reconstr Surg. 1994; 93: 1418
        • Tran N.V.
        • Chang D.W.
        • Gupta A.
        • Kroll S.S.
        • Robb G.L.
        Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy.
        Plast Reconstr Surg. 2001; 108: 78-82
        • Yoon A.P.
        • Qi J.
        • Brown D.L.
        • Kim H.M.
        • Hamill J.B.
        • Erdmann-Sager J.
        • Pusic A.L.
        • Wilkins E.G.
        Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study.
        Breast. 2018; 37: 72-79
      2. OCEBM Levels of Evidence Working Group The Oxford 2011 Levels of Evidence.
        Oxford Centre for Evidence-Based Medicine, 2011: 5653 ([Internet])
        • Gart MS
        • Smetona JT
        • Hanwright PJ
        • et al.
        Autologous options for postmastectomy breast reconstruction: A comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program.
        J Am Coll Surg. 2013; 216: 229-238
        • Angarita F.A.
        • Dossa F.
        • Hermann N.
        • McCready D.R.
        • Cil T.D.
        Does timing of alloplastic breast reconstruction in older women impact immediate postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.
        Breast. 2019; 48: 58-64
        • Saheb-Al-Zamani M.
        • Cordeiro E.
        • O'Neill A.C.
        • Hofer S.O.P.
        • Cil T.D.
        • Zhong T.
        Early postoperative complications from National Surgical Quality Improvement Program.
        Ann Plast Surg. 2020; 86: S159-S164
        • Sanati-Mehrizy P
        • Massenburg BB
        • Rozehnal JM
        • et al.
        A comparison of postoperative outcomes in immediate versus delayed reconstruction after mastectomy.
        Eplasty. 2015; 15: e44
        • Chung CU
        • Wink JD
        • Nelson JA
        • Fischer JP
        • Serletti JM
        • Kanchwala SK.
        Surgical site infections after free flap breast reconstruction: An analysis of 2899 patients from the ACS-NSQIP datasets.
        J Reconstr Microsurg. 2015; 31: 434-441
        • Lankiewicz JD
        • Yokoe DS
        • Olsen MA
        • et al.
        Beyond 30 days: Does limiting the duration of surgical site infection follow-up limit detection?.
        Infect Control Hosp Epidemiol. 2012; 33: 202-204
        • Lovecchio F
        • Jordan SW
        • Lim S
        • Fine NA
        • Kim JY.
        Risk factors for complications differ between stages of tissue-expander breast reconstruction.
        Ann Plast Surg. 2015; 75: 275-280
        • Agha RA
        • Fowler AJ
        • Lee SY
        • et al.
        Systematic review of the methodological and reporting quality of case series in surgery.
        Br J Surg. 2016; 103 (74): 1253-1258
        • Gagnier JJ
        • Kienle G
        • Altman DG
        • Moher D
        • Sox H
        • Riley D
        • Group CARE
        The CARE guidelines: Consensus-based clinical case report guideline development.
        J Clin Epidemiol. 2014; 67: 46-51
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • Group PRISMA
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Turner L
        • Shamseer L
        • Altman DG
        • et al.
        Consolidated standards of reporting trials (CONSORT) and the completeness of reporting of randomised controlled trials (RCTs) published in medical journals.
        Cochrane Database Syst Rev. 2012; 11 (MR000030 77)
        • Turner L
        • Shamseer L
        • Altman DG
        • Schulz KF
        • Moher D.
        Does use of the CONSORT statement impact the completeness of reporting of randomised controlled trials published in medical journals? A Cochrane review.
        Syst Rev. 2012; 1 (78): 60
        • Agha RA
        • Lee SY
        • Jeong KJ
        • Fowler AJ
        • Orgill DP.
        Reporting quality of observational studies in plastic surgery needs improvement: A systematic review.
        Ann Plast Surg. 2016; 76 (79): 585-589
        • Agha RA
        • Fowler AJ
        • Rajmohan S
        • Barai I
        • Orgill DP
        • PROCESS Group
        The PROCESS statement: Preferred reporting of case series in surgery.
        Int J Surg. 2016; 36: 319-323 80
      3. WMA Declaration of Helsinki - Ethical principles for medical research involving human subjects. http://www.who.int/bulletin/archives/79%284%29373.pdf. Accessed 21 May, 2021

        • Agha RA
        • Fowler AJ
        • Herlin C
        • Goodacre TE
        • Orgill DP.
        Use of autologous fat grafting for breast reconstruction: A systematic review with meta-analysis of oncological outcomes.
        J Plast Reconstr Aesthet Surg. 2015; 68 (Feb): 143-161
        • Jenicek M.
        Clinical case reports and case series research in evaluating surgery. Part II. The content and form: uses of single clinical case reports and case series research in surgical specialties.
        Med Sci Monit. Oct 2008; 14 (RA149–RA162)
        • Agha RA
        • Orgill DP.
        Evidence-based plastic surgery: Its rise, importance, and a practical guide.
        Aesthet Surg J. 2016; 36: 366-371