In our study, only the pathologic N stage was significantly associated with higher risk of postoperative complications in patients who received mastectomy and IR using tissue expander. Chemotherapy and radiotherapy did not significantly affect postoperative complications. Of the 1,081 patients, 483 patients received adjuvant chemotherapy or radiotherapy and only six out of 483 patients delayed their adjuvant treatment because of postoperative complications.
Because insurance has covered breast reconstruction for breast cancer patients since April 2015 in Korea, patients have been able to select immediate breast reconstruction more easily. Several studies have demonstrated oncologic safety in the patients who underwent IR following mastectomy [11–13]. In addition, the majority of previous studies on the impact of chemotherapy or radiotherapy on postoperative complications after immediate breast reconstruction reported that chemotherapy or radiotherapy did not increase postoperative complications and immediate breast reconstruction did not affect the initiation of adjuvant treatment [3, 7–10, 14–21]. This study also reported that chemotherapy or radiotherapy did not affect postoperative complications in the patients who underwent immediate breast reconstruction with tissue expander.
Several studies reported that age, BMI, smoking, and DM were risk factors of postoperative complications in patients who underwent immediate breast reconstruction with tissue expanders or implants. Old age, increasing BMI, smoking, and DM can affect postoperative complications related to wound healing, leading to the removal of tissue expanders or implants [7, 22–24]. In this study, the mean age and BMI were 43.29 years and 21.98 kg/m2, respectively, indicating that this study was performed mostly on young, normal-weight patients. Because our study had small numbers of patients with DM or current smokers, the analysis of the impact of DM or smoking on postoperative complications was not powerful enough to determine associations.
Our study showed that the postoperative complication rate was only 5.5% and the median time from mastectomy to complication was 620 days (range 27 − 2,423 days). In addition, it is reported that only higher N stage was associated with postoperative complications. Lymphatic vessels play an important role in wound healing and wound healing is a complex process including inflammation, coagulation, and formation of granulation tissue with angiogenesis and lymphangiogenesis . Metastatic axillary lymph nodes which have architectural distorsion, loss of hilum, or cortical thickness can affect scar formation and sensory nerves in surrounding tissues, therefore, the higher the N stage, the more the removal of this axillary lymph nodes affects the lymph drainage of the arm, which can result in postoperative complication such as breast edema and delayed wound healing . In addition, previous studies have demonstrated that sentinel lymph node biopsy and ALND have association with postoperative complication such as lymphedema, wound infection, and seroma formation [27, 28]. In our study, the most common cause of complications was infections. Some studies have reported that the incidence of seroma formation was 3–85% after breast or axillary surgery and seroma aspiration was a risk factor for surgical site infection [29–32]. To improve the completion of breast reconstruction, surgeons try to prevent seroma formation at the surgical site by minimizing the dead space and educating patients on how to exercise the arm that is ipsilateral to the breast cancer [31, 33]. Other studies have demonstrated that early drain removal is safe to prevent seroma formation, however, there was no investigation of the timing of drain removal in our study [34, 35].
Although the probability of chemotherapy or radiotherapy increases as the pathologic prognostic stage increases, chemotherapy or radiotherapy was not significantly related to postoperative complication. It has been a controversy whether it is appropriate to do an IR or to do a delayed breast reconstruction in patients with advanced breast cancer. Chemotherapy may be associated toxicity, immunosuppression, and fat necrosis, which may lead to wound healing and PMRT may cause local damage such as fat necrosis, wound dehiscence, flap fibrosis [36, 37]. Therefore, clinicians have not actively recommended IR in patients who were expected to have adjuvant chemotherapy or radiotherapy because it is possible to increase the probability of recurrence by missing the appropriate timing of adjuvant chemotherapy or radiotherapy. However, surgical technique about breast reconstruction with tissue expander has improved over the past years, resulting in more natural, reassuring, and better results. Therefore, breast reconstruction surgery has recently been an indispensable part of breast cancer surgery. In addition to the development of surgical technique, chemotherapy or radiotherapy did not significantly increase postoperative complication and delay timing of adjuvant treatment in our study. In this study, 35 out of 59 patients who had postoperative complications underwent adjuvant chemotherapy or radiotherapy, and only six of 35 patients delayed their adjuvant treatment because of postoperative complication. Five patients suffered from infections during adjuvant chemotherapy and one patient with a headache was diagnosed with brain metastasis during adjuvant radiotherapy. Another 29 of 35 patients who underwent adjuvant treatment developed postoperative complications after adjuvant treatment.
This study had some limitations. It was a retrospective review and thus, had selection bias. Also, there are other variables in immediate autologous breast reconstructions because this study was limited to IR with tissue expander. Further studies overcoming these limitations can help to determine the effects of IR.
Several previous studies have reported oncologic safety and no difference in complications after IR following mastectomy in patients with breast cancer [11–13]. However, many surgeons still hesitate to perform immediate breast reconstruction for patients with high-stage breast cancer. This study will help guide the decision-making process for breast cancer patients who want to undergo IR with neoadjuvant or adjuvant treatment.