Complications of reconstructive and aesthetic breast surgery

INTRODUCTION — Complications following reconstructive or aesthetic breast surgery are important considerations for women pursuing these options.

Reconstructive breast surgery following total mastectomy can be performed using implants as well as one's own tissues (autologous laps). Reconstruction following partial mastectomy can be performed using a variety of oncoplastic techniques that involve tissue rearrangement. Each type of reconstruction has its own set of complications.

Aesthetic breast surgery includes breast augmentation, reduction, and mastopexy, which are usually performed using tissue rearrangement techniques or by using breast implants.

The complications related to reconstructive and aesthetic breast surgery will be reviewed here. Issues related to the indications for and choice of a type of breast reconstruction are discussed elsewhere. (See "Overview of breast reconstruction" and "Options for autologous flap-based breast reconstruction" and "Implant-based breast reconstruction and augmentation".)

INCIDENCE — Although most women who have reconstructive or aesthetic breast surgery do not experience significant complications and are highly satisfied, a range of problems can occur any time after the procedure is performed. Accurate complication rates may be difficult to identify and compare between studies due to variables such as differing types of reconstruction, surgeon experience, and patient factors and comorbidities, as well as the duration of patient follow-up [1-7].

Representative studies are as follows:

●In a retrospective review of over 18,000 procedures, the incidence of noninfectious complications was 10.3 percent after mastectomy plus implant, 11.7 percent for mastectomy plus implant and flap, and 17.4 percent after mastectomy plus flap [8].

●In another large review, the incidence of surgical site infection (SSI) following immediate reconstruction was similar following implant and autologous reconstruction (8.9 and 9.3 percent, respectively) [9]. For delayed reconstruction, the incidence of SSI was 5.7 percent following implants and 13.9 percent following autologous reconstruction. Wound complications resulted in more secondary procedures following immediate implant versus immediate autologous reconstruction (1.92 versus 1.11, respectively); however, the incidence of SSI after secondary procedures was lower for implants compared with autologous reconstructions (3.2 and 11.6 percent, respectively).

●Two-year follow-up from the Mastectomy Reconstruction Outcomes Consortium (MROC) study, which included 2343 patients, has been reported [10]. Various types of reconstruction were used and included implant, expander-implant, and flap reconstruction. The overall complication rate was 32.9 percent with reoperative complications occurring in 19.3 percent. Wound infections were noted in 9.8 percent (230 patients). Patients who had any type of autologous reconstruction had significantly higher odds of developing any complication compared with those undergoing tissue expander-implant reconstruction. Of the autologous reconstructions, only patients that had DIEP flap reconstruction had significantly lower odds of infection when compared with patients that had expander-implant reconstruction.

In general, complications following reconstructive or aesthetic breast surgery can be classified as:

●Complications inherent to surgery and common to all, in general (eg, infection, venous thromboembolism, hematoma, delayed healing, abnormal scar). (See 'Local surgical complications' below.)

●Complications specifically related to the reconstruction (eg, flap ischemia or failure, fat necrosis, capsular contracture, implant failure). (See 'Flap-related complications' below and 'Implant-based complications' below.)

●Complications related to donor tissue sites. (See 'Donor-tissue-related complications' below.)

RISK FOR COMPLICATIONS — Certain patient factors, and others specifically associated with the treatment of breast cancer, increase the risk for some complications. Patient factors include smoking, obesity, and older age [11,12]. Radiation therapy also increases the overall risk. However, in most studies, neither neoadjuvant nor adjuvant chemotherapy has been shown to influence complication rates following flap-based or implant-based breast reconstruction, although wound healing may be delayed [13-20]. In one study of 899 patients, premature removal of tissue expanders occurred more frequently among those receiving neoadjuvant or adjuvant therapy compared with no such therapy [21]. In another study of 233 patients, of whom 38 percent were treated with hormone therapy, the incidence of wound healing complications was significantly increased in the hormone therapy group (61 versus 28 percent) [22]. Wound healing complications included fat necrosis (26 versus 8.3 percent), surgical site infection (15 versus 2.8 percent), delayed wound healing (49 versus 13 percent), and development of grade III/IV capsular contracture (55 versus 9.1 percent).

Other factors that influence the overall rate of complications include type of mastectomy, type of implant, type of flap, use of fat grafting, breast size (implant-based), bilateral surgery [23], and prior abdominal surgery (transverse rectus abdominis muscle [TRAM] flap). The influence of mastectomy weight also influences complication rates. In a review of 704 consecutive patients and 1041 mastectomies, the overall complication rate following mastectomies that were <500 grams, between 500 and 100 grams, and >1000 grams was 14, 17.6, and 25.7 percent, respectively (p = 0.002) [24].

Patients older than 65 may have an overall increased risk for perioperative complications compared with younger patients, likely related to medical comorbidities, but age does not appear to be a predictor of reconstructive failure [5,11,15,25]. As an example, for flap-based reconstruction, rates of flap thrombosis do not appear to be significantly different in older compared with younger patients [25].

The use of acellular dermal matrices (ADMs) is sometimes implicated as a risk factor for complications following tissue expander and implant reconstruction. In a prospective multicenter study known as the Mastectomy Reconstruction Outcomes Consortium (MROC), there were no significant differences in overall complication rate, major complications, wound infections, or reconstructive failure at two years following reconstruction when comparing ADM and non-ADM cohorts [26]. In a multicenter randomized trial comparing two different ADMs in 230 patients (387 breasts), 22 ADM-related postoperative complications (5.7 percent) occurred during the 12-month follow-up period [27]. The incidence of infection was similar and ranged between 4.3 and 7.1 percent.

Prepectoral reconstruction, which is an innovation whereby the tissue expander or implant is placed above the pectoralis major muscle rather than beneath it, also does not appear to be associated with any increased risk for complications. In a review that compared immediate prepectoral tissue expander placement (51 patients, 84 breasts) to subpectoral placement (115 patients, 186 breasts), there was no significant difference in overall complications (17.9 versus 18.8 percent) [28]. Specific complications included hematoma in 2.4 percent, seroma in 3.6 percent, cellulitis in 4.8 percent, and explantation in 1.2 percent. In another review of 353 prepectoral reconstructions, complications included infection in 4.5 percent, seroma in 2 percent, mastectomy skin necrosis in 2.5 percent, and no capsular contractures.

Prepectoral conversion procedures are increasing whereby an implant that was originally positioned under the pectoralis muscle for reconstructive purposes is being replaced with a new implant positioned above the pectoralis major muscle. In a review of 73 implant pocket conversions in 41 women, the most common indications were animation deformity (87.8 percent), pain related to the implant (34.1 percent), capsular contracture (26.8 percent), or asymmetries and implant displacements (9.8 percent) [29]. Following the conversion, complications included hematoma, seroma infection, and dehiscence, all with an incidence of 2.4 percent. Minor sequelae of the conversion included rippling and wrinkling (19.5 percent), edge visibility (4.9 percent), and the need for secondary fat grafting (26.9 percent).

Radiation therapy

Effect on implant-based reconstruction — Radiation-related complication rates are highest among women undergoing expander/implant reconstruction, regardless of the timing of administration of radiation therapy [30-46]. In a comprehensive review from the Mastectomy Reconstruction Outcomes Consortium (MROC), differences in outcomes were compared following radiation therapy in the setting of autologous or prosthetic breast reconstruction [47]. In 622 patients who had radiation, complications occurred in 25.6 percent following autologous reconstruction and in 38.9 percent following prosthetic reconstruction. Among 1625 patients who did not have radiation, complications occurred in 28.3 percent following autologous reconstruction and in 21.8 percent following prosthetic reconstruction.

When evaluating radiation-related complications, it is important to differentiate whether the radiation occurred prior to or after the reconstruction. The end results of the complex tissue changes induced by radiation include scar formation at the implant/tissue interface, capsular contracture, malposition, distortion, and impaired skin healing that can lead to incisional dehiscence. Other complications associated with implant reconstruction include implant rupture or extrusion, and implant malpositioning.

In a review of 218 women following total skin-sparing mastectomy and implant reconstruction, 85 had prior radiation therapy and 133 had postmastectomy radiation [48]. Patients with prior radiation therapy had more complications after the first stage of reconstruction compared with after the second stage, including higher rates of explantation (15 versus 5 percent) and infection (20 versus 8 percent). Patients receiving postmastectomy radiation therapy had low complication rates after the first stage, when they had not yet received radiation; however, complication rates after the second stage of expander/implant exchange were significantly higher, and nearly fourfold higher compared with patients with prior radiation therapy. Radiation therapy is usually delivered in fractionated doses; however, there is some enthusiasm in hypofractionated doses to reduce the incidence of adverse events. In a prospective study of 67 women, tissue expander loss was 24 percent of patients after hypofractionated radiation therapy compared with 7.3 percent prior to radiation therapy at a median follow-up of 32 months [49].

In the setting of radiation therapy, single-stage direct-to-implant immediate reconstruction may provide an advantage to staged reconstruction. In a review of 1286 women, the cumulative incidence of any reconstruction complication at a median 5.8 years follow-up was lower for single compared with staged implant reconstruction (18.2 versus 36.8 percent), but still higher compared with autologous reconstruction (15.1 percent) [50]. However, it is important to recognize that single-stage direct-to-implant reconstruction may not be an option based on preoperative factors as well as intraoperative factors. The primary determinant to proceed with direct-to-implant reconstruction is related to the residual blood supply of the skin following the mastectomy. (See "Overview of breast reconstruction", section on 'Timing of breast reconstruction'.)

A retrospective review of 213 patients (387 breasts) compared outcomes following immediate reconstruction with tissue expanders-implants in four cohorts that included: prepectoral positioning with radiation therapy, prepectoral without radiation therapy, submuscular positioning with radiation therapy, and submuscular without radiation therapy [51]. Complication rates were higher in the radiated group (prepectoral 38.6 percent, submuscular 34 percent) compared with the nonradiated group (prepectoral 26.2 percent, submuscular 29.2 percent). The most common complications included capsular contracture (radiated 15.1 percent, nonradiated 10.4 percent), infection (radiated 18.4 percent, nonradiated 11.9 percent), and seroma (radiated 15.7 percent, nonradiated 10.9 percent).

Effect on autologous reconstruction — Autologous tissue appears to withstand radiation-induced tissue damage better than implant-based reconstructions, and there does not appear to be an increase in the risk of major complications; however, flaps may experience radiation-related fat necrosis, fibrosis, atrophy, and flap contracture [13,52-62].

Although autologous tissue reconstructions may be better able to withstand radiation-induced tissue damage [52-54,63-65], they are still subject to radiation-related fat necrosis, fibrosis, atrophy, and flap contracture. Delayed autologous flap reconstruction usually provides improved cosmetic results with the fewest complications (picture 1) [66]. However, this concept has been challenged in several studies that contend that patient-reported outcomes are no different when comparing radiation therapy before or after flap reconstruction [67].

The incidence of late complications (fat necrosis, flap volume loss, flap contracture) is significantly higher in immediate reconstructions that have undergone radiation therapy [62,68-70]. In a retrospective study of 113 women who underwent postmastectomy radiotherapy and breast reconstruction, early complications were seen more frequently in patients having radiation first while late complications were more common in patients who had breast reconstruction first (32 and 44 percent, respectively) [71]. In another study comparing immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction followed by radiation therapy with radiation therapy and subsequent delayed flap reconstruction, the incidence of late complications was significantly higher in the immediate compared with the delayed reconstruction group (88 versus 9 percent) [69]. Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct contour deformities resulting from flap shrinkage and contracture.

In a systematic review and meta-analysis, data from 1927 patients who underwent immediate breast reconstruction and 1546 who underwent delayed reconstruction were reviewed [72]. Pooled complication rates were similar between immediate and delayed breast reconstruction in the setting of postmastectomy radiation. Early complications included flap loss, fat necrosis, thrombosis, seroma, hematoma, infection, and skin dehiscence. Late complications included fibrosis or contracture, severe asymmetry, hyperpigmentation, and decreased flap volume. Comparative complication rates (immediate versus delayed, respectively) included fat necrosis (14.91 versus 8.12 percent), flap loss (0.99 versus 1.80 percent), hematoma (1.91 versus 1.14 percent), infection (11.66 versus 4.68 percent), and thrombosis (1.51 versus 3.36 percent); however, seroma rates were significantly lower (2.69 versus 10.57 percent).

Transferring nonirradiated tissue to the mastectomy site may avoid some of the radiation-associated wound healing complications. Tissues severely damaged by radiation therapy can be resected and discarded at the time of the reconstruction, and the skin "paddle" of the designed flap can be tailored to replace the missing breast surface skin. In general, prior radiation therapy increases the amount of tissue required for breast reconstruction, and this may limit flap selection. The use of stacked flaps provides a solution to increase the amount of skin available for autologous reconstruction.

Smoking — Smoking is universally considered to be a risk factor for surgical complications, and smoking adversely affects wound healing and blood supply [12,73-75]. (See "Risk factors for impaired wound healing and wound complications", section on 'Smoking and nicotine replacement therapy'.)

Smoking is an independent risk factor for the development of perioperative complications and is associated with an increased risk of reconstructive failure. For implant-based reconstruction, the incidence of mastectomy flap necrosis, infection, and loss of implant is increased with tobacco use [76]. Many reconstructive surgeons insist that patients have quit smoking before proceeding with autologous or implant-based reconstruction. However, the risk for some complications may persist even among those who quit smoking before surgery.

To illustrate these points, in a study of 155 smokers, 76 ex-smokers, and 517 nonsmokers who had breast reconstruction with TRAM flaps following mastectomy, various complications were assessed [75]. Mastectomy flap necrosis developed in significantly more smokers compared with ex-smokers and nonsmokers (7.7 versus 2.6 and 1.5 percent, respectively). Fat necrosis following TRAM flap reconstruction was noted in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis occurred in 7.9 percent of smokers, 4.3 percent of ex-smokers, and 1.0 percent of nonsmokers.

In one series, compared with nonsmokers, smokers who underwent a transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction had significantly higher rates of mastectomy skin flap necrosis (19 versus 9 percent), donor site complications (26 versus 14 percent), and TRAM flap necrosis (4.4 versus 0.8 percent) [77]. There were no significant differences in complication rates between nonsmokers and former smokers. Because of the increased risk for complications, many surgeons consider active smoking to represent a contraindication to TRAM flap reconstruction. (See "Options for autologous flap-based breast reconstruction", section on 'Pedicled TRAM flap'.)

Tobacco use also poses significant risks to women considering prosthetic reconstruction. In these patients, mastectomy skin flap necrosis due to the nicotine effect, as well as generalized tissue hypoxia due to the carbon monoxide, can increase the risks of tissue necrosis, delayed healing, and infection.

Obesity — Breast reconstruction in patients with obesity presents a challenge for plastic surgeons. Obesity increases the incidence of adverse events following autologous or implant-based reconstruction [12].

Early studies reported higher complication rates and disappointing aesthetic results in this population compared with normal-weight women [78-86]. In a later review of the National Surgical Quality Improvement Program database, body mass index (BMI) >40 remained associated with a significantly increased risk of perioperative (30 day) complications compared with patients who were not obese; however, there were no significant differences when comparing implant-based and flap-based reconstruction in patients with severe obesity [87]. In another review of 612 flap reconstructions in 404 patients, patients with a BMI >40 had a significantly increased rate of total flap loss (8 versus 0.5 percent), total major postoperative complications (12 versus 3 percent), and delayed abdominal wound healing (72 versus 44 percent) [88]. Also notable is that patients who are obese compared with not obese are more likely to develop necrosis of the mastectomy skin flaps (21.3 versus 9.8 percent) [89].

In a multicenter, prospective analysis comparing complication rates of expander-implant and TRAM reconstructions, higher body mass index was associated with a greater likelihood of postoperative complications [84]. These results have been observed in patients who have implants or tissue expanders placed under the pectoralis major muscle; however, similar complications have been observed between patients who are and are not obese when the tissue expander or implant is placed above the pectoralis major muscle (prepectoral reconstruction) [90]. Free-flap breast reconstruction in patients who are severely obese is associated with a high risk of total flap loss, major postoperative complications, and delayed abdominal wound healing [88].

Not all breast reconstructions exhibit an increased risk for complications in patients who are obese [91,92]. In a small study of 71 women who underwent perforator flap surgery (eg, deep inferior epigastric perforator [DIEP] flap), 33 had a BMI <25, 26 had a BMI 25 to 30, and 12 had a BMI of 30 to 35 [91]. Rates of fat necrosis were 11.4 percent for the BMI <25, 6.7 percent for BMI 25 to 39, and 6.7 percent for the patients with BMI 30 to 35; there were no significant differences in rates of flap complications.

A study compared outcomes and complications in 133 patients with obesity (BMI >30 kg/m2) who had either prepectoral (65 patients, 128 breasts) or subpectoral (68 patients, 129 breasts) reconstruction [93]. All complications occurred at a significantly higher rate in patients who had subpectoral compared with prepectoral reconstruction. Comparative complication rates for subpectoral versus prepectoral reconstruction, respectively, included: seroma (13.3 percent versus 3.1 percent); surgical site infection (9.4 percent versus 2.3 percent); capsular contracture (7.0 percent versus 0.8 percent); and any complication (25.8 percent versus 14.7 percent). Multivariate logistic regression identified subpectoral, diabetes mellitus, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant, independent predictors of any complication. Subpectoral placement of implants in patients with obesity increased the odds of any complication three-fold compared with prepectoral placement of implants in patients with obesity.

LOCAL SURGICAL COMPLICATIONS

Seroma/hematoma — Seromas can develop following virtually any technique for breast reconstruction. Most seromas occur following removal of a drain. The early occurrence of breast seroma is relatively common following implant placement and less common following flap-based breast reconstruction. Seromas can also occur at both the donor and recipient sites of autologous tissue reconstruction. As an example, for latissimus dorsi donor sites, seroma rates as high as 12 to 21 percent have been reported [94,95]. In a series of deep inferior epigastric perforator (DIEP) flaps, abdominal wall seroma occurred at the donor site in 5 percent [96]. Seroma at the tissue donor site may require percutaneous aspiration or reinsertion of a surgical drain.

Significant fluid accumulation within the breast implant pocket (within the capsule) may cause asymmetry, breast enlargement, and discomfort [97]. Seroma formation adds additional risks of implant rotation, malposition, and infection. The use of an acellular dermal matrix (ADM) may increase the incidence of seroma formation, and the adherence of the ADM can become compromised if a seroma is not treated.

Excessive drainage may also result from increased movement of the expander or implant, possibly the result of a too large pocket, but more likely from too much activity by the patient. If seroma develops with drains still in place, the patient should be cautioned to reduce activity.

Seromas that occur early can be drained percutaneously (with or without ultrasound guidance), with or without placement of a short-term drainage catheter. Care must be taken to avoid damaging an implant. If an infection is suspected, the drained fluid can be sent for culture. If a drain is placed, it is typically left in place for one to two weeks until drainage is ≤30 mL over a 24 hour period.

Late fluid collections around an implant are rare, and the etiology is not well understood. The evaluation of a late fluid collection may include comprehensive fluid analysis (including cell counts, microbiology) and ultrasound or magnetic resonance (MR) imaging depending on the patient's clinical situation. An oncologic evaluation may be indicated. All seromas occurring more than one year after surgery should be sent for cytology to rule out breast-implant-associated anaplastic large cell lymphoma (ALCL) [98]. (See 'Anaplastic large cell lymphoma' below.)

The differential diagnosis of late fluid collection includes:

●Hematoma

●Infection with or without biofilm formation (see 'Infection' below)

●Implant rupture (see 'Rupture of silicone gel implants' below)

●Synovial metaplasia

●Inflammation

●Double capsule formation

●Malignancy

●Implant-associated ALCL (see 'Anaplastic large cell lymphoma' below)

●Idiopathic causes

If infection and malignancy have been ruled out, surgical exploration with complete capsulectomy, implant removal (with possible placement of a new implant), and drain placement may be needed if the fluid collection persists after percutaneous drainage [99]. An alternative viewpoint suggests that late fluid collections are most commonly seen with textured surface implants and that the problem is a mechanical issue caused by friction between the rough surface of the textured prosthesis and the fibrous capsule. If this is thought to be the case, then the textured implant can be removed and replaced with a smooth implant [100].

Bleeding and hematoma — The incidence of hematoma is overall low (<2 percent). The affected breast is usually enlarged, tender, and may have ecchymosis or bruising.

Postoperative hematoma typically develops within the first 12 to 24 hours after surgery. Less commonly, a hematoma presents days or weeks after surgery and may be associated with minor injury or trauma to the breast. In a review of 3474 implant procedures, the incidence of a postoperative hematoma was 0.92 percent [101]. The average time to identification was 37 days, but the majority were identified within 14 days. Late hematomas can also occur and are thought to be related to trauma, clotting disorders, overactivity, and use of intraoperative corticosteroids [102]. When analyzed for possible etiology for hematoma formation (location, incision, type of implant), no factor was found to predispose to hematoma formation.

Careful pocket dissection with attention to hemostasis generally prevents these complications. Certain medications, such as platelet inhibitors, anticoagulants, and androgenic hormones, may predispose to bleeding, and their use should be discouraged prior to surgery. Drains may be placed in the breast pocket, but there is no evidence that they decrease hematoma recurrence rates [103]. Postoperative breast compression after breast augmentation is not effective for preventing hematoma, although it is still practiced by some surgeons. In a trial of 130 patients undergoing breast augmentation, postoperative compression did not reduce the frequency of postoperative bruising or hematoma formation; 38 percent of patients complained about the use of compression [104].

Treatment involves exploration of the breast, drainage of the hematoma, and establishing hemostasis. Any underlying coagulation abnormalities must be addressed and corrected. Unfortunately, hematoma formation is associated with subsequent capsular contracture [105,106]. (See 'Capsular contracture' below.)

Skin necrosis — The incidence of mastectomy flap necrosis is a moderately common complication that occurs in 18 to 30 percent of patients following immediate breast reconstruction [107]. In spite of the best planning, which includes a preoperative discussion between the general surgeon performing breast surgery and the plastic surgeon performing the reconstruction, areas of skin necrosis on the mastectomy skin flap can still occur. It is wise to discuss this complication and inherent risk with the patient in advance.

The incidence of this complication has increased with techniques such as nipple-sparing mastectomies and direct-to-implant reconstruction, which have become common practice in many centers. Studies have demonstrated that the incidence of mastectomy skin flap necrosis is higher with nipple-sparing mastectomy due to hypoperfusion of the nipple-areolar complex (NAC). The incidence is variable and ranges from 0 to 48 percent [108]. Factors that predispose to higher rates of skin flap necrosis include increased body mass index (BMI), tobacco usage, and prior breast irradiation [109]. The use of laser-assisted near-infrared fluorescent angiography with indocyanine green (ICG) perfusion has significantly decreased the incidence in overall complications and, in one study, reduced the incidence of mastectomy skin flap necrosis from 15.1 to 4 percent [110].

A systematic review and meta-analysis found an overall lower risk of major complications when preoperative ICG was used [111]. For evaluating mastectomy flaps, ICG reduced the risk of major complications and loss of reconstruction. For autologous reconstruction, ICG significantly reduced the risk of major and also minor complications.

Minimizing skin flap necrosis following mastectomy requires preservation of the subdermal plexus, gentle retraction of the skin flaps, and minimization of thermal damage. In the setting of autologous reconstruction, a conservative approach with local care may be considered [109]. Skin/flap necrosis related to the autologous flap reconstruction is discussed below. (See 'Flap necrosis/loss' below.)

If swelling, discoloration, or signs of ischemia occur in the early postoperative period, measures to limit further injury might include removing any volume that has been added to the expander, further protecting the incision and skin edges, and avoiding any pressure from external dressings. The application of topical nitroglycerin ointment is effective in reducing the incidence of mastectomy skin flap necrosis. In a randomized controlled trial comparing nitroglycerin with placebo, mastectomy flap necrosis developed in fewer patients receiving nitroglycerin ointment compared with placebo (15.3 versus 33.8 percent) [112]. Alternatively, hyperbaric oxygen therapy may help improved the healing rate; however, the difference was not statistically significant [113].

If the affected portion of necrotic skin is small and closure is possible without excessive tension, it may be wise to debride and close the incision. It is important to eliminate internal pressure from the expander volume by partially or totally deflating the tissue expander and waiting until complete demarcation has occurred. One must be sure that complete demarcation has occurred, or too early an attempt at closure may result in further loss and a more difficult recovery. If a larger skin flap loss is observed, a more conservative approach may be possible if the expander is protected by muscle coverage or ADM and no signs of infection are present. The larger the skin loss, the further the setback in time of reconstruction. Appropriate cultures and acceptable wound care treatment are necessary to eliminate infection as an etiology or result. Expansion may be resumed once skin closure is achieved.

Persistent breast pain — Breast pain that extends beyond the typical postoperative course should be evaluated for underlying causes such as infection, chest wall injury, capsular contracture, and radiation injury. Persistent significant breast pain suggests a nerve injury [114]. (See "Clinical manifestations and diagnosis of postmastectomy pain syndrome" and "Postmastectomy pain syndrome: Risk reduction and management".)

For patients with breast pain and animation deformity secondary to spasm of the pectoralis major muscle in the setting of subpectoral breast implants, a prepectoral conversion procedure that involves placing the pectoral muscle back to its normal position and placing a new implant above the pectoralis major muscle can be considered. In a review of 102 such procedures, there were no reports of postoperative pain following the procedure [115].

Infection — Infection following prosthetic or autologous reconstruction can place the breast at risk. Infection following autologous reconstruction is uncommon and generally occurs in <5 percent of cases. In a study that evaluated 200 flaps, infection was noted in 3.8 percent of TRAM flaps and 2.4 percent of DIEP flaps. This included the breast or the abdominal donor site [116]. The presence of radiation in the setting of a latissimus dorsi flap and implant does not appear to increase the incidence of infection. In another study, the incidence of infection was 4.1 percent without radiation and 6.1 percent with radiation, a difference that was not significant [117]. In a systematic review that compared prosthetic reconstruction with total muscle coverage versus partial muscle coverage and ADM, the incidences of infection were 3.2 and 3.4 percent, respectively [97]. In a series of 171 consecutive two-stage expander/implant reconstructions, the rate of infection requiring expander removal was 1.2 percent, while 1.8 percent of the tissue expanders were complicated by spontaneous deflation [35].

The incidence of infection following prosthetic reconstruction is variable and ranges from 0 to 30 percent [118]. In a retrospective review of 292 patients who underwent 469 two-stage prosthetic breast reconstructions, the incidence of infection was 14.1 percent [119]. The most common outcome was explantation in 40.9 percent, followed by secondary implant insertion in 21.2 percent with operative salvage in 18.2 percent. Independent risk factors for infection included body mass index, preoperative radiation, necrosis, seroma, and hematoma.

The diagnosis of implant or tissue expander infection requires prompt treatment. Some redness and swelling is normal and expected initially in the postoperative period, so a careful assessment is required. Peri-implant gas has been reported in the absence of infection and in itself may be related to altitude change, implant rupture, or type of implant [120]. Initial management may consist of empiric oral antibiotic therapy. Any fluid collection around the implant should be drained and cultured, whenever possible. This is frequently performed after ultrasound identification of a peri-implant fluid collection. Cellulitis should resolve within a short period of time. If the signs and symptoms progress, the patient should be admitted and started on intravenous antibiotics. Any wound drainage should be cultured, and appropriate specific antibiotic coverage provided. If the patient has skin breakdown or incisional dehiscence, or lack of resolution within 24 to 48 hours of treatment, operative exploration should be considered. Ongoing drainage from the incision raises concerns about an implant or deep infection. (See "Breast implant infections".)

Although there are reports of salvaging early expander implant infections with appropriate antibiotics and irrigation of the pocket, the presence of a biofilm on the implant may preclude salvage. An infected implant should be removed, and the pocket irrigated and suitably drained. Three to six months may be required to demonstrate the absence of infection, after which time breast reconstruction can resume.

Mondor disease (superficial thrombophlebitis of the epigastric veins) — Mondor disease is an uncommon condition more commonly occurring after breast augmentation [121], but it has been reported following breast reconstruction [122]. It is more commonly seen with transverse inframammary incisions, which may disrupt vertically oriented superficial veins of the thorax and cause venous stasis followed by thrombosis. In a large series of 2052 breast augmentations, the overall incidence of Mondor disease was 0.63 percent [123]. For the inframammary incisions (n = 1026), the incidence was 1.07 percent. It presents as a firm or painful cord on the anterior abdominal wall leading up to the breast, typically within the first month after surgery. It generally resolves over a short period of time with supportive care. Although the veins recanalize in one to two months, warm compresses and nonsteroidal anti-inflammatory medications may be offered for symptomatic relief.

FLAP-RELATED COMPLICATIONS — The main flap reconstruction complications pertain to flap viability or relate to the donor tissue site. Other complications include fat necrosis, acute partial flap loss, and lower abdominal laxity or hernias. Although it has not been systematically studied, the impact of latissimus dorsi harvest on shoulder function appears to be minimal [124].

The types of flaps (pedicled or free) used in breast reconstruction are described separately. These include the free or pedicled transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric artery (SIEA) perforator flap, superior gluteal artery perforator (SGAP) flap or the inferior gluteal artery perforator (IGAP) flap, transverse upper gracilis (TUG) flap, and profunda artery perforator (PAP) flap. Given the differing anatomy at each of these sites, the propensity for problems with flap viability differs among these. (See "Options for autologous flap-based breast reconstruction".)

A retrospective review of the National Surgical Quality Improvement Program database, including 3296 patients undergoing autologous breast reconstruction, found that patients undergoing autologous free flap reconstruction (n = 609) had the highest overall rates of complications compared with patients undergoing pedicled TRAM flaps (n = 1608) or latissimus dorsi flaps (19.4 versus 13.4 versus 7.1 percent, respectively) [125]. Patients undergoing autologous free flap reconstruction also had a higher rate of reoperation (15.6 versus 9.9 versus 5.7 percent, respectively) and a higher rate of flap failure (5.7 versus 3.4 versus 1.3 percent, respectively). However, the differences were not significant. Flap failure and reoperation rates are typically less than 2 and 5 percent, respectively, when performed by experienced surgeons. In a review of 758 DIEP flaps, the incidence of partial flap failure was 2.5 percent and total flap failure was 0.5 percent. Return to the operating room was necessary in 5.9 percent of patients primarily because of venous congestion in 3.8 percent [96].

Flap necrosis/loss — Flap failure is an uncommon event following breast reconstruction and occurs when the blood supply to the flap has been lost. This may occur because of arterial occlusion, venous occlusion, or both. Total flap failure occurs when the entire flap is compromised whereas partial flap necrosis occurs when only a segment of the flap's blood supply is compromised. In general, pedicle flaps such as the latissimus dorsi and the TRAM flap for which the blood supply is not reconnected have less failure (<1 percent) compared to the free flaps such as the DIEP flap (2 to 5 percent) in which the blood supply has to be reconnected using an operating microscope or loupes [126]. Total flap loss (≤1 percent) necessitates surgery to remove necrotic tissue and to perform an additional procedure to reconstruct the breast [84,127]. Acute partial flap loss, usually manifested by small areas of skin loss, is usually treated nonoperatively with dressing changes to promote secondary healing. Fat necrosis and/or partial flap loss occur when a fatty region of the flap does not receive enough blood supply. The resulting tissue fibrosis and/or calcification can simulate a mass in the reconstructed breast on postoperative physical examinations.

Some studies show that DIEP flaps have a less robust blood supply compared with TRAM flaps and therefore an increased risk of fat necrosis [128,129]. Other studies suggest that rates of partial flap loss and fat necrosis are no higher for perforator flaps compared with pedicled TRAM procedures [130]. One study compared 105 women who underwent bilateral pedicled TRAM flaps with 58 women who had bilateral DIEP flap reconstructions; there were significantly higher rates of partial skin loss, wound dehiscence, and fat necrosis with the DIEP flaps [129]. In another series of 758 DIEP flaps, 6 percent of patients were returned to the operating room for flap-related problems [96]. Partial flap loss occurred in 2.5 percent and total flap loss in less than 1 percent. Fat necrosis occurred in 13 percent (risk factors were smoking and postreconstruction radiation therapy). In a retrospective review of 170 gluteal artery perforator flaps, 8 percent of patients required a return to the operating room with a 6 percent rate of vascular complications and total flap failure rate of 2 percent [131].

Donor-tissue-related complications — Active smoking, obesity, diabetes, collagen vascular disease, postmastectomy radiation therapy, and the presence of certain abdominal scars all increase the risk of complications for the flap and problems with wound healing at the lower abdominal donor site. In a study that reviewed function and strength following autologous breast reconstruction using free abdominally based flaps (DIEP, TRAM, and SIEA flaps), 51 patients were included with a mean follow-up of 8.1 years [132]. Assessments included upper and lower abdominal function with outcomes reported on the SF-36 and the Breast-Q abdominal well-being module. Free flap reconstruction was associated with improved long-term quality of life across key domains of physical and mental health with little functional impairment and no long-term differences based on the type of flap or whether it was unilateral or bilateral.

Hernia/bulge/laxity — A hernia is defined as having a fascial defect, whereas a bulge is a fascial laxity but without a fascial defect [133]. Both can occur following abdominal flap reconstruction and are ultimately related to the degree to which the abdominal wall is violated during the operation.

The incidence of these complications was 8 percent in one series [84] and 3 percent in another [127]. In a study comparing bilateral pedicled TRAM flaps with bilateral DIEP flaps, abdominal wall hernia and laxity rates were similar [129]. The incidence of hernia in one series of DIEP flaps was 0.7 percent [96]. Donor site morbidity for bipedicled DIEP free flap breast reconstructions does not appear to differ compared with unipedicled unilateral and unipedicled bilateral DIEP flaps [134].

Although minor laxity is commonly asymptomatic, significant abdominal wall laxity/hernia generally requires surgery for definitive repair. The repair for an abdominal bulge is typically with plication of the anterior rectus sheath with reinforcement with a mesh [135]. A true hernia will require repair using more advanced techniques. (See "Rectus abdominis diastasis", section on 'Surgical repair' and "Management of ventral hernias" and "Overview of component separation".)

Patient-reported outcomes — In a review of the Mastectomy Reconstruction Outcomes Consortium (MROC) database, 720 patients with at least one-year follow-up were prospectively evaluated for abdominal donor-site and breast complications [136]. Patient-reported outcomes were measured using the BREAST-Q and Patient- Reported Outcomes Measurement Information System surveys. The entire cohort included patients who had either pedicled TRAM flap reconstruction (89 patients), free TRAM flap reconstruction (115 patients), DIEP flap reconstruction (445 patients), or SIEA flap breast reconstruction (71 patients). Although all abdominally based flaps are viable breast reconstruction options, the DIEP and SIEA flaps were associated with higher abdominal physical well-being than pedicled and free TRAM flaps. The advantage of the SIEA flap is that the anterior rectus sheath is not violated; however, higher rates of donor-site complications may diminish patient satisfaction.

IMPLANT-BASED COMPLICATIONS — Common complications of breast reconstruction using implants and expanders include capsular contracture and implant failure (eg, rupture, deflation, malposition).

Capsular contracture — Capsular contracture is an inherent risk of implant usage. When a breast implant is placed, a capsule of fibrous tissue forms around it. The capsule is typically thin and does not cause any symptoms, but in some cases it may progress to a more firm and calcified capsule that can cause breast pain, tenderness, and distortion [137-150].

Most contractures (92 percent) appear to occur within 12 months after surgery [137]. However, this finding is disputed by a series of 3495 implants in 1529 women that found that the incidence of symptomatic capsular contracture did not diminish after one or two years; rather, the cumulative risk for developing contracture was increased the longer the implant was in place [106].

For patients having prosthetic breast reconstruction, the use of an acellular dermal matrix (ADM) can reduce the incidence of capsular contracture. In a study that compared 123 patients reconstructed with ADM with 80 patients reconstructed without ADM, the capsular contracture rate was 3.8 percent with ADM and 19.4 percent without ADM [151].

Risk factors — There are many factors that contribute to the development of capsular contracture, including the size of the implant, the patient's scarring tendency, and circulating bacteria, among others. Although not proven, capsular contracture is hypothesized by some to result from a low-grade subclinical bacterial infection and formation of bacterial biofilm [137,152]. There is some evidence to support an immunologic theory of capsular contracture that involves a chronic inflammatory process [137]. Avoidance of smoking may decrease the incidence of capsular contracture (8 percent for smokers versus 3 percent for nonsmokers, in one study) [153]. Avoidance of hematoma may also decrease capsular contracture rates [105,106]. (See "Implant-based breast reconstruction and augmentation", section on 'Preventing capsular contracture'.)

Capsular contracture may be more common after breast reconstruction (compared with augmentation), particularly if radiation therapy is used [137,154]. In one small review, capsular contractures developed in only 3 percent of patients, but four of the five cases occurred in previously irradiated patients [118]. No definitive studies are available looking at the effects of chemotherapy on capsular contracture.

Capsular contracture rates may be lessened by the use of implants with a textured shell rather than a smooth shell [33,34,137,155]. An unusual finding of a "double capsule" was reported in a series of 14 patients who received Biocell textured implants [156]. In three of these cases, there was also an associated late seroma. An early systematic review had suggested textured implants reduced the incidence of early capsular contracture in subglandular breast augmentation [157]. The results were less robust more than one year after implant placement.

Partial or complete submuscular or subfascial implant placement also appears to be associated with a lower rate of capsular contracture. In a multicenter study of more than 500 patients, the use of subglandular positioning of the prosthesis increased the risk of capsular contracture almost eightfold compared with submuscular positioning [158]. Similarly, in a study that followed patients enrolled in the Core and 410 nonrandomized trials, the risk of capsular contracture was significantly reduced for subpectoral compared with subglandular placement (risk ratio 0.45, 95% CI 0.35-0.59) [159]. A large study of 812 breast augmentation procedures from a single plastic surgery practice reported that capsular contracture rates were no different for submuscular versus subglandular placement or for saline compared with silicone implants [105].

In a retrospective review of 783 patients over a 10-year period, the incidence of capsular contracture was 6.5 percent and was correlated to a lateral sternal margin of less than 20 mm [160]. Rippling was correlated with a lateral sternal margin of <10 mm.

Classification — The Baker scale is commonly used to rate the significance and severity of breast implant capsules:

●Baker I – The breast is soft with no palpable capsule and looks natural

●Baker II – The breast is a little firm with a palpable capsule but looks normal

●Baker III – The breast is firm with an easily palpated capsule and is visually abnormal

●Baker IV – The breast is hard, cold, painful, and markedly distorted

Unless otherwise stated, studies generally consider Baker grades III and IV contracture to be significant enough to be classified as a complication. Baker grades I and II are generally not included in the complication rates and treatment recommendations.

Treatment — It is recommended that only breasts with Baker III and IV capsules have surgical treatment; however, nonsurgical options are available and may be tried before progressing to invasive procedures.

Massage of the breast with the intent of preventing or reducing breast firmness has been recommended, but there are no studies to support the effectiveness of this technique. External ultrasound has been promoted as a modality to reverse capsular contracture, but there is a lack of confirming studies supporting its effectiveness or lasting effect [161]. Medications have been studied to reduce the severity of capsular contracture.

●Two small series of patients had improvement in breast firmness after using zafirlukast (Accolate) 20 mg orally twice daily for three to six months [162,163]. Most improvement was seen in patients with early capsule formation.

●One larger study of 120 patients comparing zafirlukast to vitamin E treatment for six months found a significant improvement in breast pain and distortion in the zafirlukast group [164].

●Concerns about using medications as "off-label" treatments for capsular contracture have been raised since zafirlukast has been associated with severe hepatic dysfunction, including liver failure [165].

●Two non-peer-reviewed commentaries also reported some success with pharmacologic treatment of capsular contracture: Montelukast (Singulair) showed some improvement in contracture, but not to the same extent as that attained with zafirlukast [162], while papaverine hydrochloride, 150 mg twice daily, resulted in improvement in approximately two thirds of 700 patients [166].

●Flector Tissugel patch, a topical preparation containing the anti-inflammatory diclofenac, showed a high frequency of change from capsular contracture Baker II or III to Baker I after three weeks of treatment if started no later than three months after the onset of capsular contracture [167].

Closed capsulotomy, which requires manual compression of the breast to break up the capsular scar tissue, is not recommended, because it can cause a hematoma, implant rupture, and pseudoherniation [137]. Open capsulotomy involves internal circumferential and longitudinal incisions through the capsule. This leaves the capsule in place on the tissues but relieves the constriction of the implant pocket and improves the deformation of the implant. Open capsulectomy is similar to open capsulotomy, but the offending scar tissue and capsule are removed. An open capsulotomy may provide short-term improvement, but the recurrence rate is high. If there is risk in removing the capsule off the chest wall due to significant adherence, a partial (or anterior) capsulectomy may be performed instead. However, in one report of 120 patients with subglandular implants and Baker III or IV contracture, anterior-only capsulectomy had a higher recurrence rate compared with total capsulectomy (46 versus 11 percent) [168].

After a capsulectomy, a question is often raised if the excised capsule needs to be sent for a pathological examination. The only study to answer this question examined 434 capsules from 264 patients. Most (78.0 percent) were totally benign while 21.6 percent found inflammation, calcification, granuloma, and necrosis. Carcinoma was reported in only in one case (0.4 percent), but this patient was already known to have a recurrent breast cancer extending into the capsule. Unless there are specific signs or symptoms (seroma, tenderness, mass, skin ulceration, painful capsular contracture, or suspicion of malignancy or implant-associated anaplastic large cell lymphoma [ALCL]), there is no evidence to support the routine examination of an excised capsule by a pathologist [169].

Implant pocket repositioning from subcutaneous to a dual-plane position may reduce the recurrence of capsular contracture in breast augmentation patients. After capsulectomy, acellular dermal matrix (ADM) may be placed to facilitate the creation of a "dual plane" pocket [170,171]. The dual-plane position places the superior two thirds of the implant located beneath the pectoralis major muscle and the inferior one third in a subglandular position. The ability of ADMs to decrease capsular contracture may be due to the decreased levels of inflammation found on breast-pocket-integrated ADM surfaces compared with breast pocket capsules [172]. One retrospective series included saline and silicone gel implants originally in a submuscular position (54 patients) or subglandular position (31 patients) [173]. Conversion to a dual-plane position led to an improvement in Baker grade with 84 of 85 patients free of capsular contracture (Baker I) at an average follow-up of 12 months. In all cases, the implants were replaced with new saline or silicone gel implants.

Capsulectomy with implant removal and autologous tissue replacement should be offered to breast reconstruction patients in cases where significant capsular contracture continues to be a problem. It may also be offered to breast augmentation patients; however, costs of this option tend to make it prohibitively expensive if being paid for by the patient. Capsulectomy with implant removal and no further implant replacement should be considered in cases where significant capsular contracture continues to recur, causing patient dissatisfaction (or difficulty with breast imaging for cancer screening) despite all possible treatments (ie, capsulectomy with a new implant placed in a dual plane pocket and possible use of ADM) being used to alleviate the problem [170,174]. When these "out point" criteria are met [175], it may be in the patient's best interest to stop with any further surgical treatments, which may be futile and cause further harm and distress to the patient.

Deflation of tissue expanders and saline implants — Implant failure leads to a decrease in breast volume with the patient noticing that the breast becomes smaller over a few days. Deflation can occur with tissue expanders or saline implants. Tissue expander deflation can disrupt the reconstruction schedule. The cause may be a defect in the valve, fold fatigue over time, and improper puncture during a fill procedure. When recognized, exploration of the expander and possible replacement should be considered. Saline implants can also deflate with noticeable change in shape and volume. Most manufacturers have a warranty that covers replacement, including facility and anesthesia coverage up to the amounts specified in their warranties. It is important for both groups to include a discussion about deflation issues during the informed consent process.

A deflation within the first few days after implant placement suggests iatrogenic damage (suture needle or sharp instrument) or an improperly closed valve. Less commonly, a saline implant may leak later on due to a fill valve malfunction, iatrogenic damage (eg, needle puncture), or external physical trauma. After placement, implants commonly develop small pinhole defects in the shell over time. Saline leakage out into the implant pocket will be simply absorbed by the body. Saline implant failure is easy to detect due to the loss of breast volume. No clinical testing is needed, and the implant can be replaced when convenient for the patient; however, it may be better to replace the implant soon after deflation to preserve the size of the original implant pocket. Although most patients have their deflated saline implants removed, there is no evidence that not removing a deflated saline implant (due to patient desire or inability to undergo a procedure) has any negative health effects.

Rupture of silicone gel implants — In contrast to deflated saline implants, failure of a silicone gel implant is difficult to detect, even on physical examination, since the gel typically remains confined within the breast capsule (intracapsular rupture), although in some cases the gel may extrude into the breast tissue and beyond (extracapsular rupture).

Intracapsular "silent" ruptures are not readily detected, and many patients may not know that their implant is ruptured until it is detected on a routine mammogram or ultrasound. Extracapsular ruptures may cause local inflammation and granuloma formation resulting in a palpable or tender mass [176-178].

The Food and Drug Administration has recommended that women with silicone gel breast implants should undergo breast implant imaging three years after implant placement and then every two years thereafter [179]. Magnetic resonance (MR) imaging with a dedicated breast implant protocol is the most sensitive and specific imaging modality. However, the utility of this recommendation is questionable since implant rupture is uncommon in the first three to five years after placement [180-182]. An alternative to MR imaging to detect implant rupture is with the use of high-frequency ultrasound, which has been demonstrated to be as effective for the detection of rupture [183].

Ruptured silicone gel implants should be removed due to the possibility of the gel material causing inflammation and other tissue reactions, particularly if the material spreads beyond the breast capsule (extracapsular rupture). If rupture is suspected or known, a capsulectomy is typically performed to remove the gel material from the breast pocket. Total capsulectomy should be considered given the possibility of anaplastic large-cell lymphoma (ALCL) in women with a ruptured textured surface breast implant.

Close observation is an option for those patients who do not wish to have a ruptured implant removed or exchanged due to cost or current overall satisfaction with their breasts. There is no clear evidence that any silicone granulomas that develop contribute to any systemic diseases [184,185]. However, cases of systemic symptoms similar to the ASIA (autoimmune/inflammatory syndrome induced by adjuvants) syndrome have been reported [186,187]. (See "Implant-based breast reconstruction and augmentation", section on 'Concerns over breast implants'.)

Implant exposure — Implant exposure can be a significant setback to a breast reconstruction schedule. Multiple factors contribute to the development of implant exposure, including too rapid expansion, thinning of the skin with areas of nonhealing, infection, seroma formation, incisional dehiscence, overactivity, and excessive external pressure from activity or bra resulting in compromised circulation. Any of these may be a factor and should be evaluated and resolved as much as possible. (See 'Skin necrosis' above and 'Infection' above.)

If the expander is in place, removing fluid from the expander may resolve the increased pressure leading to exposure. Unless this underlying etiology is corrected, closing the defect often results in failure because the pressure has not been relieved. Incisions that have been radiated and then reopened are prone to incisional dehiscence due to compromised fibroblast function and overactivity. Incisional dehiscence in the setting of a permanent implant can be salvaged if the etiology is purely mechanical and not infectious. Counter-incisions are often considered in these situations [30].

If dimensional planning and implant size are appropriate and infection, smoking, and external irritation are eliminated, attempts at closure may be fruitful. ADM can be used to reinforce thin tissues in the region of the incision, if necessary [174]. If the implant exposure is large and the etiology significant, removal of the implant may be warranted, allowing adequate time for closure and appropriate healing.

Malposition — Implant malposition can manifest laterally, medially, superiorly, or inferiorly. When implant malposition is associated with significant capsular contracture, treatment should focus on addressing the capsular contracture, but resolution of malposition may also require other techniques to achieve optimal results. (See 'Capsular contracture' above.)

Implant malposition can occur shortly after surgery or years later. It is common for implants to be in a higher than expected position for a few weeks after placement (especially when in a submuscular plane) and then to settle more inferiorly as the skin and soft tissue swelling and stretch resolve. The use of a breast support device (elastic band) may help facilitate the proper positioning of the implant. If there is continued malposition or asymmetry due to implant position on the chest wall, a surgical revision may be considered once the final implant position has occurred and swelling has resolved. This may be three to six months after the implants are placed. Correction of implant malposition may require one or more of the techniques listed below. Frequently, a capsulorrhaphy is performed to alter the border of the implant pocket to allow for better implant position [188]. ADM can also be used to reinforce the capsulorrhaphy if the problem is recurrent [174]. It should be noted that while good results are seen with sheets of ADM for correction of these deformities, the cost of these products is substantial [171].

●Lateral implant malposition – A laterally displaced implant is frequently due to overdissection of the lateral breast pocket or from prolonged pectoralis major muscle forces on the medial implant causing a lateral displacement. Occasionally, it may be due to oversized implants (too wide for the chest wall) or an unrecognized chest wall deformity that contributes to the appearance of the implants being positioned too laterally. Prevention of this type of malposition includes identification of chest wall deformities, proper implant width selection, careful lateral pocket dissection, and appropriate medial pectoralis muscle release. Correction of lateral displacement depends on the underlying cause and may require a medial pocket release, lateral capsulorrhaphy, new implant pocket creation [189], use of ADM [171], and placement of a narrower implant.

●Medial implant malposition and symmastia – Medial displacement is less common and in more severe forms can result in symmastia (also known as "synmastia") where the definition of the medial edge of each breast is lost and cleavage is absent. It may be due to excessive medial pocket dissection or from the use of implants that are too wide for the patient's chest [190]. Prevention of medial malposition and symmastia requires avoiding overdissection of the medial implant pocket and proper choice of implant width. Correction of medial displacement depends on the underlying cause and may include a medial capsulorrhaphy, new implant pocket creation [189] (including a "neosubpectoral pocket" [191]), and use of a narrower implant. Correction of symmastia is more challenging. If the above techniques are not suitable, placing a sheet of ADM medially in the pocket may be useful [170]. In severe cases, a staged procedure entails performing a capsulectomy and removing the implant followed by replacing the implants in a fresh pocket without extensive medial dissection.

●Superior implant displacement – A "high-riding" implant is very noticeable as it is difficult to reposition with a bra.

One cause is the placement of a large implant without releasing the inframammary crease to compensate for the implant size. Capsular contracture also commonly displaces the implant superiorly. Prevention of superior displacement should focus on proper inferior pocket creation and muscle release. Care should be taken to preserve the inframammary fold unless there is a specific need to do a careful and controlled lowering of this important structure. If superior displacement is unimproved three to six months after implant placement, the inferior pocket can be extended and the muscle released. If inframammary fold release is needed, it should be done carefully to prevent future inferior implant displacement.

Implants in a subpectoral pocket can move superiorly with pectoralis major muscle contraction. Correction of this problem may be achieved by transposing the implant to the subglandular plane and resuspending the pectoralis muscle [189]. This eliminates the pectoral forces on the implant and thereby the unwanted implant movement. This technique of switching the implant from a subpectoral position to a prepectoral position is also useful for severe animation deformities resulting from excessive contraction of the pectoralis major muscle [192].

●Inferior implant displacement (bottoming out) – Stretching of the inferior breast skin (bottoming out) or migration of the implant across the inframammary fold may lead to inferior implant displacement. Prevention of this deformity includes proper breast skin and soft tissue assessment with an appropriately matched implant. Care should be taken if the inframammary fold is released as this may allow for further implant inferior migration. Correction of inferior displacement depends on the underlying etiology. Inferior skin excess due to stretching may require a mastopexy, possibly with a smaller implant. In some cases, the inframammary fold needs to be repositioned superiorly. Sheets of ADM have been used to reinforce corrections of inferior implant displacements [170].

●Implant rotation malposition – In the case of round symmetric implants, which are the most common implant shape used, a rotation of the implant inside the pocket will not result in a change in the shape of the breast since the implant is symmetric around the axis of rotation. However, if an asymmetric (also known as a "shaped" or "anatomic") implant is used, the breast shape may change if the implant rotates inside the breast pocket. This results in the affected breast having more fullness in the area where the projecting pole of the implant is positioned. While not a common occurrence, the prevalence has been reported as high as 11 percent [193]. The exact mechanism of a malrotation is not known, but various factors may contribute to it, including extent of pocket dissection, not using drains, and the physical properties of the implant [194]. Correction of implant malrotation can be done by external manipulation if the rotation is dynamic. If the rotation is static, surgical options include suture anchoring the posterior tabs of the tissue expander onto the chest wall fascia, tightening the implant pocket using capsulorrhaphy techniques to create a hand-in-glove fit to prevent rotational deformities, implant exchange to round implant, and implant removal with implant replacement in the future if desired [193].

Anaplastic large cell lymphoma — There are a reports of a very rare type of cancer called anaplastic large cell lymphoma (ALCL) arising in the scar capsule adjacent textured silicone or saline-filled breast implants. (See "Implant-based breast reconstruction and augmentation", section on 'Concerns over breast implants'.)

The usual clinical presentation is a peri-implant mass or fluid collection and the median time from implantation of the device is more than 10 years. The clinical features, diagnosis, and treatment of breast implant-associated ALCL is reviewed separately. (See "Breast implant-associated anaplastic large cell lymphoma".)

In general:

●For localized disease, the implant and surrounding capsule and any associated masses are removed. Associated axillary lymphadenopathy is excised for pathologic evaluation to determine if there is any tumor involvement. Any residual abnormalities are biopsied to identify any residual disease. (See "Breast implant-associated anaplastic large cell lymphoma", section on 'Treatment'.)

●For patients with disseminated disease, systemic treatment follows the rubric for de novo systemic ALCL. (See "Initial treatment of systemic anaplastic large cell lymphoma (sALCL)".)

Squamous cell carcinoma and B cell lymphoma — Breast implant-associated squamous cell carcinoma (BIA-SCC) and breast implant-associated B cell lymphoma (BIA-BCL) have been reported in the capsule surrounding the breast implant (textured or smooth, saline or silicone) [195-197]. In a review, the number of reported cases is approximately 20 for BIA-SCC and approximately 30 for BIA-BCL [198]. BIA-SCC presents with late-onset seroma or mass, whereas BCL may present with erythema and a periprosthetic effusion. The average length of time from implantation to BIA-SCC occurrence was 22.7 years (range 11 to 40).

The limited experience with BIA-SCC suggests that it is an aggressive pathology [195]. Mortality is 43.8 percent at six months [199]. Because of the rarity of these diseases' processes, formal management regimens have not been determined. Previous cases have included surgical en bloc excision of the implant, capsule, and tumor as well as chemotherapy and radiation therapy. BIA-BCL appear to be more responsive to chemotherapy, whereas BIA-SCC is less responsive to chemotherapy [196].

Breast implant illness — Breast implant illness (BII) represents a constellation of symptoms that include autoimmune disorders such as rheumatoid arthritis or Sjögren's disease, as well as nonspecific disorders such as fatigue, malaise, and fibromyalgia. Initial concerns with BII were investigated in the 1990s and felt to be unrelated to the implanted silicone implants [200]. Later reports, however, have once again shed inquiry on BII and whether there is an association with silicone-based implants [201]. This is a condition that continues to be investigated as more studies are needed to make any definitive conclusions. Issues pertaining to breast implants and systemic illness are reviewed elsewhere. (See "Implant-based breast reconstruction and augmentation", section on 'Breast implants and systemic illness'.)

AESTHETIC CONCERNS — The cosmetic outcome of implant-based breast reconstruction appears to deteriorate with time. In one series, 86 percent of patients reported acceptable appearance two years postoperatively, compared with only 54 percent at five years [202,203]. In a long-term study of primary breast augmentation, secondary procedures were required in 9 percent of patients [159].

Rippling and palpability — A common aesthetic concern is the rippling of the implant that can be seen through the breast tissue causing skin irregularities, typically in the lateral border of the breast. This problem is more common in thin patients and subglandular saline implant placement. Textured implants have been associated with an increased risk of wrinkling and waviness and therefore may be less suitable for patients with thin soft tissue coverage [106].

To minimize the risk of rippling, patients with a body mass index less than 18.5 may be better suited to submuscular placement or use of a silicone implant if a subglandular position is chosen [105]. Likewise, palpability of the implant, particularly in the lateral and inferior borders of the breast, is more common in thin patients and with saline implants. A change to a silicone implant may improve, but not necessarily eliminate, the palpability. Improvement in rippling has also been done by placing a sheet of acellular dermal matrix (ADM) in the appropriate area of the breast pocket [170,171] and by injection of autologous fat grafts in both aesthetic [204] and reconstructive cases [205].

Breast asymmetry — Asymmetry has as much to do with patient expectation as the skill and experience of the surgeon. The more the patient understands the challenges, the better the acceptance of the final result. Patients seeking immediate breast reconstruction may have an expectation of completely matched breasts on the first postoperative day; however, the shape of the reconstructed breast will always be different from the nonoperated breast because of the mastectomy scar and loss of volume interfering with breast projection.

In addition, most women have some level of preexisting asymmetry in volume, shape, and nipple-areolar complex. One should be careful in evaluating asymmetry, noting whether it is nipple areolar, inframammary fold, or shape and projection. Asymmetries should be noted and pointed out to the patient at the time of examination prior to any breast cancer surgery. It is always a better situation to present the patient findings in advance of the surgery. Preoperative discussions help these patients handle the possible changes.

It is not unusual for a breast reconstruction patient to have an ongoing challenge to achieve symmetry over her lifetime. Fold asymmetry should be addressed during the initial reconstruction, and certainly during the stage of implant placement. The use of ADM can assist in fixing the fold to exact levels. Secondary procedures on the affected or contralateral breast are often necessary [206,207]. Once the reconstruction is complete, adjustments to areolar position can be made, and, frequently, different levels of uplift to the opposite breast resolve the asymmetry. Postoperative breast asymmetry is more common following unilateral reconstruction when compared with bilateral, especially following nipple-sparing mastectomy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Seroma (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Breast surgery – Reconstructive breast surgery following total or partial mastectomy can be performed using autologous tissues or breast implants. Aesthetic breast surgery includes augmentation, reduction, or mastopexy and is performed using prosthetic devices or tissue rearrangement techniques. Each technique has its own set of complications. Most women do not experience significant complications and are highly satisfied; however, a range of problems can occur any time following reconstructive or aesthetic breast surgery, which are important to consider for women pursuing these options. (See 'Introduction' above.)

●Risk – The risk for some complications is increased for certain patient factors (eg, smoking obesity) and others associated with treatment of breast cancer (radiation therapy). Although wound healing may be delayed, chemotherapy (neoadjuvant, adjuvant) has not been shown to influence complication rates following implant-based or flap-based reconstruction. Other factors that influence the rate of complications include type of mastectomy, type of implant, type of flap, use of fat grafting, breast size (implant-based), and prior abdominal surgery (transverse rectus abdominis muscle [TRAM] flap). (See 'Risk for complications' above.)

●General complications – Complications inherent to breast surgery and common to breast reconstruction and aesthetic surgery include seroma, bleeding, hematoma, skin necrosis, infection, and suboptimal aesthetic appearance, among others. (See 'Local surgical complications' above and 'Aesthetic concerns' above.)

●Complications of flap-based reconstruction – Complications specifically related to flap reconstruction include flap ischemia/necrosis/loss, fat necrosis, and complications related to donor tissue sites. (See 'Flap-related complications' above.)

●Complications of implants – Complications related to breast implants include capsular contracture, and implant failure, exposure, or malposition. (See 'Implant-based complications' above.)

Other implant complications can include:

•Silicone implant rupture – Failure in silicone gel implants is difficult to detect since the gel typically remains confined within the breast capsule (intracapsular rupture), but in some cases it may extrude into the breast tissue and beyond (extracapsular rupture). Ruptured silicone gel implants should be removed due to the possibility of the gel material causing inflammation and other tissue reactions, particularly when rupture is extracapsular. (See 'Rupture of silicone gel implants' above.)

•Cancer – Rarely, cancer can develop in association with breast implants. These include breast implant-associated anaplastic large cell lymphoma, breast implant-associated squamous cell cancer and breast implant-associated B cell lymphoma. Treatment involves removal of the implant and surrounding capsule and potentially adjunctive therapy. Prophylactic breast implant removal in patients without symptoms or other abnormalities is not recommended. (See 'Anaplastic large cell lymphoma' above and 'Squamous cell carcinoma and B cell lymphoma' above.)

•Breast implant illness – Breast implant illness is a nonspecific condition that continues to be investigated. (See 'Breast implant illness' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledges Karol A Gutowski, MD, who contributed to an earlier version of this topic review.