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Original Investigation
September 20, 2017

Comparison of Wound Complications After Immediate, Delayed, and Secondary Breast Reconstruction Procedures

Author Affiliations
  • 1Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
  • 2Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
  • 3Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
  • 4Division of General Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
  • 5HealthCore, Inc, Wilmington, Delaware
JAMA Surg. 2017;152(9):e172338. doi:10.1001/jamasurg.2017.2338
Key Points

Question  Does the incidence of wound complications differ after implant and autologous immediate, delayed, and secondary breast reconstruction?

Findings  In this cohort study of 17 293 patients who underwent mastectomy, the incidence of surgical site infection was significantly higher after immediate (8.9%) compared with delayed (6.0%) and secondary (3.3%) implant reconstructions, with similar results for noninfectious wound complications. In contrast, the incidence of surgical site infection was similar after immediate (9.8%), delayed (13.9%), and secondary (11.6%) autologous reconstructions.

Meaning  Delayed implant rather than immediate implant reconstruction may be beneficial in some high-risk patients to reduce the risk of wound complications.


Importance  Few data are available concerning surgical site infection (SSI) and noninfectious wound complications (NIWCs) after delayed (DR) and secondary reconstruction (SR) compared with immediate reconstruction (IR) procedures in the breast.

Objective  To compare the incidence of SSI and NIWCs after implant and autologous IR, DR, and SR breast procedures after mastectomy.

Design, Setting, and Participants  This retrospective cohort study included women aged 18 to 64 years undergoing mastectomy from January 1, 2004, through December 31, 2011. Data were abstracted from a commercial insurer claims database in 12 states and analyzed from January 1, 2015, through February 7, 2017.

Exposures  Reconstruction within 7 days of mastectomy was considered immediate. Reconstruction more than 7 days after mastectomy was considered delayed if the mastectomy did not include IR or secondary if the mastectomy included IR.

Main Outcomes and Measures  International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI and NIWCs.

Results  Mastectomy was performed in 17 293 women (mean [SD] age, 50.4 [8.5] years); 61.4% of women had IR or DR. Among patients undergoing implant reconstruction, the incidence of SSI was 8.9% (685 of 7655 women) for IR, 5.7% (21 of 369) for DR, and 3.2% (167 of 5150) for SR. Similar results were found for NIWCs. In contrast, the incidence of SSI was similar after autologous IR (9.8% [177 of 1799]), DR (13.9% [19 of 137]), and SR (11.6% [11 of 95]) procedures. Compared with women without an SSI after implant IR, women with an SSI after implant IR were significantly more likely to have another SSI (47 of 412 [11.4%] vs 131 of 4791 [2.7%]) and an NIWC (24 of 412 [5.8%] vs 120 of 4791 [2.5%]) after SR. The incidence of SSI (24 of 379 [6.3%] vs 152 of 5286 [2.9%]) and NIWC (22 of 379 [5.8%] vs 129 of 5286 [2.4%]) after implant SR was higher in women who had received adjuvant radiotherapy. Wound complications after IR were associated with significantly more breast surgical procedures (mean of 1.92 procedures [range, 0-9] after implant IR and 1.11 [range, 0-6] after autologous IR) compared with women who did not have a complication (mean of 1.37 procedures [range, 0-8] after implant IR and 0.87 [range, 0-6] after autologous IR).

Conclusions and Relevance  The incidence of SSI and NIWCs was slightly higher for implant IR compared with delayed or secondary implant reconstruction. Women who had an SSI or NIWC after implant IR had a higher risk for subsequent complications after SR and more breast operations. The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy.