Late Surgical-Site Infection in Immediate Implant-Based Breast Reconstruction

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Sinha and colleagues have recently published in Plastic and Reconstructive Surgery a very interesting prospective, multicenter cohort study about patients submitted to mastectomy and immediate implant-based reconstruction.1 A total of 11 centers in the United States and Canada contributed to this study. A total of 1662 implant-based breast reconstructions in 1024 patients were evaluated for early versus late surgical-site infections.
We would like to congratulate the authors on their article, which systematically analyzes several factors to identify possible clinical predictors. We consider their work essential because implant-based breast reconstruction is currently the most popular method for breast reconstruction, and surgical-site infection is currently the major cause that leads to reconstructive failure.
Large multicenter trials regarding patients submitted to immediate implant-based reconstruction are fundamental for identifying predictors of surgical-site infections and thus improving surgical-site infection clinical management and development of preventative measures.
In our Breast Unit, we are performing a retrospective single-center trial on our population of patients submitted to immediate implant-based breast reconstruction. At present, we have evaluated a total of 477 first-stage breast reconstructions in 417 patients between March of 2013 and May of 2016. Different from the study by Sinha et al., which is multicenter, our work is a single-institution study, thus reducing variability in terms of surgical-site infection evaluation and treatment protocol, including the criteria for inpatient hospitalization and intravenous antibiotics, explantation versus salvage, and radiotherapy protocol.
Our preliminary data confirm that the majority of surgical-site infection complications in immediate implant-based breast reconstructions occur more than 30 days after first-stage breast reconstruction (mean time of presentation, 51 ± 59.8 days) and present a total infection rate of 9.2 percent, comparable to that declared by Sinha et al. In addition, we confirm obesity as a major predictor for surgical-site infection, although, different from Sinha et al., we observe a strong statistical relation between increased age and the development of local infection. Differing from Sinha et al., we analyzed as a possible risk factor axillary dissection that could be related to delayed seroma without finding any relations with infection. In contrast, we did not observe any relation between radiotherapy and surgical-site infection. It should be emphasized that we consider only patients submitted to first-stage breast reconstruction and, as confirmed by Sinha et al., radiation therapy is identified as a significant independent risk factor for late surgical-site infection, particularly following a second-stage tissue expander exchange procedure.
Nevertheless, moving from our long experience in adopting autologous fat graft in irradiated breasts to reduce pain syndrome,2–4 we developed a clinical protocol5 that widely adopts this regenerative procedure to reduce complications, obtaining a 5.6 percent reconstruction failure rate in patients submitted to immediate two-stage breast reconstruction followed by radiotherapy.
In conclusion, we consider studies such as the one published by Sinha et al. essential to critically evaluate outcomes in implant-based breast reconstruction, finding possible clinical predictors for surgical infection, analyzing therapeutic protocols, and comparing the experience of different centers.

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