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Revisions in Implant-based Breast Reconstruction: How Does Direct-to-Implant Measure Up?
Amy S. Colwell, MD, Emily M. Clarke-Pearson, MD, Alex Lin, MS, Catherine Hertl, MD, William G. Austen, MD.
Massachusetts General Hospital, Boston, MA, USA.

Purpose: Immediate direct-to-implant breast reconstruction is increasingly performed following mastectomy for breast cancer treatment or prevention. The advantage over traditional tissue expander-implant reconstruction includes the potential for fewer surgical procedures.
Methods: Retrospective single institution three surgeon review identified patients undergoing direct-to-implant reconstruction with acellular dermal matrix and tissue expander-implant reconstruction without acellular dermal matrix from 2006-2011. Patients were prospectively followed through July 2014.
Results: 683 implant-based reconstructions were performed in 483 women followed an average of 5 (range 2.5-8) years. 462 were direct-to-implant while 221 were tissue expander-implant reconstructions. The average age was 49, mean BMI 25, 10% were smokers, and 16% had radiation.
There was no difference in total revision rates between direct-to-implant and tissue expander-implant reconstruction (21.0% vs. 19.9%, p=0.743). Subgroup analysis showed no difference in revision for malposition (3.5% vs. 5.4%, p=0.225), size change (6.7% vs. 5.4%, p=0.519), fat grafting (8.6% vs. 9.5%, p=0.717), or capsular contracture (4.6% vs. 3.2%, p=0.395).
Multivariate regression analysis showed complications were associated with higher rates of revisions for malposition or size in both groups (OR 2.8, CI 1.56-5.12, p=0.001). Smoking, preoperative radiation, skin necrosis, and one surgeon were associated with higher rates of fat grafting while increasing BMI had lower rates. Postoperative radiation (OR 2.9, CI 1.02-8.37, p<0.05) and hematoma (OR 7.0, CI 1.25-39.62, p=0.027) were predictive of revision for capsular contracture.
Conclusions: Direct-to-implant and tissue expander-implant reconstructions were associated with similar revision rates in this series. Surgical complications, radiation, and surgeon preference influenced the rate of revision in both groups.


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