Reducing Infectious Complications in Implant Based Breast Reconstruction: Impact of Early Expansion and Prolonged Drain Use

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The most common modality of breast reconstruction continues to be implant based, with infection being the most significant complication. Risk factors including radiation, obesity, and smoking have been associated with infection and other surgical complications. We hypothesized that prolonged drain use may likewise be associated with postoperative complications, particularly infection, and that early postoperative expansion may allow for earlier drain removal and improved outcomes.


A retrospective chart review was performed to identify all immediate, tissue expander–based breast reconstruction patients using acellular dermal matrix. Time to first expansion, postoperative day (POD) of drain removal, and complication data including infection, seroma, wound separation, and skin necrosis were collected. Early expansion was defined as occurring before POD14, and prolonged drain duration as removal after POD21. Logistic regression was used to identify risk factors for complications. Fisher’s exact test was used to compare complications between early and late drain removal and early and late expansion. Spearman correlation was used to define the relationship of early expansion and drain duration.


Three hundred twenty-three breast reconstructions met inclusion criteria. Our overall infection rate was 11.8%, seroma was 2.2%, skin necrosis 1.9%, and wound separation 4.3%. Logistic regression revealed prolonged drain use as an independent risk factor for infection (odds ratio, 3.3; P = 0.002). Earlier expansion was correlated with earlier post operative drain removal (r = 0.3, P = 0.001) with fewer early expansion patients (7.4%) requiring prolonged drain use than those undergoing late expansion (24.7%). Smoking was also associated with skin flap necrosis (odds ratio, 8.0; P = 0.002).


Prolonged drain use was associated with postoperative infection and may represent an independent source of infection or may be an indicator of delayed healing. Early tissue expansion was associated with earlier drain removal and so may help avoid infectious complications and improve outcomes. Early expansion was not associated with an increase in complications. Results from this study have informed our current drain management practice. Whether this has led to a reduction in our infection rate is a future topic of study.

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