title: Management of Mastectomy Skin Necrosis in Implant Based Breast Reconstruction.
abstract: BACKGROUND
  Mastectomy skin necrosis is a significant problem after breast reconstruction. This complication may lead to poor wound healing and need for implant removal, which may delay subsequent oncologic treatment. We sought to characterize factors associated with mastectomy skin necrosis and propose a management algorithm.
  
  
  METHODS
  A retrospective review was performed on consecutive patients undergoing implant-based breast reconstruction by the senior author from 2006 through 2015. Patient-level factors including age, race, body mass index, history of hypertension, history of diabetes, history of smoking, and history of radiation were collected. Surgical factors including type of mastectomy, location of implant placement, and immediate versus delayed reconstruction were collected. The incidence and treatment of mastectomy skin necrosis were analyzed.
  
  
  RESULTS
  A total of 293 patients underwent either unilateral or bilateral implant-based breast reconstructions after mastectomy with a total of 471 reconstructed breasts. Mastectomy skin necrosis was observed in 8.1% of reconstructed breasts. Skin necrosis was not associated with age, hypertension, diabetes, prior radiation, or type of mastectomy. The incidence of skin necrosis was higher among smokers (17.9% vs 5.0%, P < 0.001), among patients with higher body mass index (11.4% vs 6.1%, P = 0.05), patients who underwent immediate reconstruction compared to delayed (9.6% vs 0%, P = 0.004), placement of expander under acellular dermal matrix compared with submuscular placement (12.0% vs 5.2%, P = 0.02), and use of higher initial expander fill volume compared with lower fill volume (11.4% vs 5.4%, P = 0.02).The median necrosis size was 8 cm. The median time to treatment was 15 days postoperatively. In 55% of patients minor necrosis was treated with clinic debridement, whereas 43% had larger areas of necrosis requiring operative debridement. The median size treated with clinic debridement was 5.5 cm, compared to 15 cm for operative debridement. All necrosis was treated in a timely fashion and did not delay adjuvant therapy.
  
  
  CONCLUSIONS
  Mastectomy skin necrosis occurred in 8.1% of breasts after implant-based reconstruction. Necrosis less than 10 cm can be treated successfully with local debridement in the clinic setting. Timely and appropriate treatment of skin necrosis with debridement and primary closure expedites wound healing and facilitates tissue expander breast reconstruction.
authors.affiliation: From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
authors.forename: Gloria R
authors.initials: GR
authors.lastname: Sue
authors.forename: Chao
authors.initials: C
authors.lastname: Long
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D062088:Acellular Dermis; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018427:Breast Implants; D003710:Demography; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008875:Middle Aged; D009336:Necrosis; D011183:Postoperative Complications / Q000473:pathology* / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D012867:Skin / Q000473:pathology*; D013524:Surgical Flaps