67 Implant loss and associated risk factors following implant-based breast reconstruction INTRODUCTION Implant-based breast reconstruction remains the most popular method to reconstruct the breast after a mastectomy,1 partly due to the notable increase in prophylactic bilateral mastectomies.2, 3 Generally, implant-based breast reconstruction is performed in two stages. First, a tissue expander (TE) is placed in the breast, which is replaced by a definitive implant during a second surgery. Alternatively, a single-stage surgery can be performed using a directto-implant (DTI) approach. Implant-based breast reconstruction is considered a simple, safe, and cost-effective technique without donor-site morbidity. Other advantages of implant-based breast reconstruction compared with autologous breast reconstructions are a shorter operative time, quicker overall recovery, and a shorter length of hospital stay.4 Among other complications, such as surgical site infections (SSI), skin flap/nipple necrosis, hematoma, and seroma,5 implant loss is the most severe and is reported in 1.8%–16.9% of all implant-based breast reconstructions.6-9 This wide range is presumably based on the variations in inclusion criteria, implant loss definitions, and follow-up time. Reoperations associated with implant loss result in a substantial increase in hospital costs and a significant decrease in patient satisfaction.10 A growing body of literature has emerged over the years, and several risk factors for implant loss have been described, such as an older age, obesity, an active smoking status, and DTI reconstruction.10 However, a risk assessment model to improve patient information and decision-making for the optimum type of mastectomy and reconstruction has not been created. The objectives of this study were to evaluate the incidence of implant loss and other complications following implant-based breast reconstructions, identify the risk factors associated with implant loss, and create a practical risk model. Ultimately, the study findings could be used to help patients make informed decisions and decrease the risk of implant extrusion through personalized therapy. METHODS Study design All patients who underwent a mastectomy—followed by immediate breast reconstruction, either a two-stage or a DTI breast reconstruction—between January 2016 and December 2019 in Alrijne Hospital and Leiden University Medical Centre were retrospectively included in this study. The patient variables were extracted from the patient records, including age, body mass index (BMI), bra size, medical comorbidities, the American Society of Anesthesiologists score, smoking status, tumor characteristics, previous breast radiotherapy, and (neo-) adjuvant therapy. Additional surgical characteristics were collected, including 5
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