title: Reducing Infectious Complications in Implant Based Breast Reconstruction: Impact of Early Expansion and Prolonged Drain Use.
abstract: BACKGROUND
  The most common modality of breast reconstruction continues to be implant based, with infection being the most significant complication. Risk factors including radiation, obesity, and smoking have been associated with infection and other surgical complications. We hypothesized that prolonged drain use may likewise be associated with postoperative complications, particularly infection, and that early postoperative expansion may allow for earlier drain removal and improved outcomes.
  
  
  METHODS
  A retrospective chart review was performed to identify all immediate, tissue expander-based breast reconstruction patients using acellular dermal matrix. Time to first expansion, postoperative day (POD) of drain removal, and complication data including infection, seroma, wound separation, and skin necrosis were collected. Early expansion was defined as occurring before POD14, and prolonged drain duration as removal after POD21. Logistic regression was used to identify risk factors for complications. Fisher's exact test was used to compare complications between early and late drain removal and early and late expansion. Spearman correlation was used to define the relationship of early expansion and drain duration.
  
  
  RESULTS
  Three hundred twenty-three breast reconstructions met inclusion criteria. Our overall infection rate was 11.8%, seroma was 2.2%, skin necrosis 1.9%, and wound separation 4.3%. Logistic regression revealed prolonged drain use as an independent risk factor for infection (odds ratio, 3.3; P = 0.002). Earlier expansion was correlated with earlier post operative drain removal (r = 0.3, P = 0.001) with fewer early expansion patients (7.4%) requiring prolonged drain use than those undergoing late expansion (24.7%). Smoking was also associated with skin flap necrosis (odds ratio, 8.0; P = 0.002).
  
  
  CONCLUSIONS
  Prolonged drain use was associated with postoperative infection and may represent an independent source of infection or may be an indicator of delayed healing. Early tissue expansion was associated with earlier drain removal and so may help avoid infectious complications and improve outcomes. Early expansion was not associated with an increase in complications. Results from this study have informed our current drain management practice. Whether this has led to a reduction in our infection rate is a future topic of study.
authors.affiliation: From the *Department of Plastic and Reconstructive Surgery, University of Virginia, Charlottesville; and †Department of Plastic and Reconstructive Surgery, Eastern Virginia Medical School, Virginia Beach, VA.
authors.forename: Kasandra R
authors.initials: KR
authors.lastname: Hanna
authors.forename: Alexandra
authors.initials: A
authors.lastname: Tilt
authors.forename: Michael
authors.initials: M
authors.lastname: Holland
authors.forename: David
authors.initials: D
authors.lastname: Colen
authors.forename: Byers
authors.initials: B
authors.lastname: Bowen
authors.forename: Madeline
authors.initials: M
authors.lastname: Stovall
authors.forename: Andy
authors.initials: A
authors.lastname: Lee
authors.forename: Jessica
authors.initials: J
authors.lastname: Wang
authors.forename: David
authors.initials: D
authors.lastname: Drake
authors.forename: Kant
authors.initials: K
authors.lastname: Lin
authors.forename: Theodore
authors.initials: T
authors.lastname: Uroskie
authors.forename: Chris A
authors.initials: CA
authors.lastname: Campbell
mesh_terms: D000328:Adult; D000368:Aged; D019928:Breast Implantation / Q000295:instrumentation / Q000379:methods*; D018427:Breast Implants; D004322:Drainage / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D009336:Necrosis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D012307:Risk Factors; D049291:Seroma / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D012867:Skin / Q000473:pathology; D013529:Surgical Wound Dehiscence / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors; D015626:Tissue Expansion / Q000295:instrumentation / Q000379:methods*; D015625:Tissue Expansion Devices; D016896:Treatment Outcome