Publication: Caracterización de la reconstrucción mamaria inmediata con prótesis o expansor y sustitutos acelulares
Authors
Nova Tayant, Óscar
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Escuelas::Escuela Internacional de Doctorado
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Piñero Madrona, A. ; Moreno Villalba, Ramón Andrés ; Nieto Díaz, Anibal
Publisher
Universidad de Murcia
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DOI
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info:eu-repo/semantics/doctoralThesis
Description
Abstract
Introducción
La reconstrucción inmediata postmastectomía heteróloga es la modalidad reconstructiva más frecuente en el panorama quirúrgico actual. En los últimos años, los avances técnicos (principalmente empleo de sustitutos acelulares) y las mejoras en las técnicas quirúrgicas han hecho posible colocar las prótesis en el plano prepectoral. Sin embargo, el empleo de los sustitutos acelulares ha suscitado controversias con respecto al riesgo de complicaciones postoperatorias.
Objetivos
Estudiar la relación entre diferentes variables clínicas, epidemiológicas, anatomopatológicas y quirúrgicas y la aparición de complicaciones en la reconstrucción mamaria inmediata. De forma secundaria: 1) Analizar la posible asociación entre el empleo de sustitutos acelulares y el desarrollo de complicaciones en la reconstrucción postmastectomía tanto oncológica como en la cirugía reductora de riesgo. 2) Determinar si el plano reconstructivo está asociado a diferencias en las tasas de complicaciones. 3) Estudiar la asociación entre el tipo de incisión de la mastectomía y el desarrollo de complicaciones de tipo isquémico. 4) Analizar la eventual relación entre el tipo de reconstrucción, con prótesis o expansor, y el riesgo de complicaciones, en aquellas pacientes intervenidas de mastectomía con reconstrucción inmediata que recibieron radioterapia adyuvante.
Material y métodos
Estudio retrospectivo observacional unicéntrico de pacientes intervenidas en el Hospital Virgen de la Arrixaca desde 2016 a 2024. Se analizaron un total de 451 pacientes. Se analizaron de forma descriptiva diferentes variables clínico-epidemiológicas, anatomopatológicas y quirúrgicas y se estudió su asociación con la aparición de diferentes tipos de complicaciones, empleando diferentes tipos de test estadísticos en función de la naturaleza de dichas variables.
Resultados
El tabaquismo (p 0,004) y el empleo de ADM (p 0,008) se asociaron a complicaciones globales, el empleo de ADM (p 0,028) se asoció a necrosis (p 0,007), mientras que el empleo de QTa (p 0,037) y ADM (p 0,021) se asociaron a mayor riesgo de infección. Por último, el empleo de ADM (p 0,018) se asoció a mayor riesgo de dehiscencia. En las pacientes sometidas a radioterapia adyuvante, no hubo diferencias en cuanto al riesgo de desarrollar complicaciones, independientemente del tipo de reconstrucción empleada o el plano de reconstrucción. En cirugía reductora de riesgo, el empleo de sustitutos acelulares en el plano prepectoral se asoció a un mayor riesgo de desarrollar cualquier tipo de complicación (tanto global como tipo específico).
Conclusiones
1) Existen múltiples factores de riesgo para el desarrollo de complicaciones en la reconstrucción mamaria inmediata heteróloga, entre los que se encuentran el tabaquismo activo, un índice de masa corporal elevado, edad avanzada, riesgo preanestésico elevado o empleo de sustitutos acelulares. 2) El empleo de sustitutos acelulares está asociado a un mayor riesgo de complicaciones, sobre todo de infección del lecho quirúrgico y dehiscencia de la herida quirúrgica. 3) No existen diferencias entre el tipo de incisión y la tasa de complicaciones. 4) No existen diferencias entre el plano reconstructivo y una mayor tasa de complicaciones. 5) La reconstrucción inmediata con prótesis en pacientes susceptibles de radioterapia adyuvante no comporta un mayor riesgo de complicaciones, por lo que puede considerarse una técnica segura.
Introduction Immediate heterologous postmastectomy breast reconstruction is currently the most common reconstructive modality in surgical practice. In recent years, the introduction of acellular dermal matrices (ADM) and improvements in surgical techniques have enabled prosthesis placement in the prepectoral plane. However, the use of acellular substitutes has raised concerns regarding postoperative complications, and there are no current clinical guidelines definitively establishing their indication. Objectives To evaluate the relationship between various clinical, epidemiological, histopathological, and surgical variables and the development of complications following immediate breast reconstruction. Secondary objectives included: (1) assessing the association between ADM use and complication rates in both oncologic and prophylactic settings; (2) analyzing whether the reconstructive plane influences complication rates; (3) evaluating whether the type of mastectomy incision is associated with ischemic complications; and (4) determining the impact of reconstruction type (implant vs. expander) on complication risk in patients undergoing adjuvant radiotherapy. Materials and Methods A retrospective, single-center observational study was conducted, including patients treated at Hospital Clínico Universitario Virgen de la Arrixaca and its affiliated hospitals (Hospital San José Viamed, Hospital QuirónSalud Murcia, and Hospital Ribera de Molina de Segura) between 2016 and 2024. A total of 451 patients were analyzed—297 in the oncological group and 174 in the risk-reducing surgery group—with a minimum follow-up of one year. Descriptive and inferential analyses were performed to explore associations between clinical-pathological and surgical variables and the development of various postoperative complications, using appropriate statistical tests. Results In the oncologic surgery group, 32.7% of patients (97 cases) developed complications. Univariate analysis identified smoking (OR 1.99; 95% CI 1.25–3.18; p=0.004) and ADM use (OR 1.62; 95% CI 1.14–2.32; p=0.008) as risk factors for overall complications. ADM use was also associated with increased risk of skin necrosis (OR 2.38; 95% CI 1.27– 4.43; p=0.007), surgical site infection (OR 1.66; 95% CI 1.08–2.55; p=0.021), and wound dehiscence (OR 1.57; 95% CI 1.08–2.28; p=0.018). Chemotherapy was also linked to higher infection risk (OR 1.97; 95% CI 1.04–3.73; p=0.037). In the subgroup of patients receiving adjuvant radiotherapy, no significant differences were found in complication rates according to reconstruction type (implant vs. expander) or reconstructive plane (prepectoral vs. retropectoral). In risk-reducing surgery, the use of ADM in the prepectoral plane was associated with a higher risk of both overall and specific complications when compared to immediate reconstruction with polyurethane implants. Conclusions Multiple risk factors for complications in immediate heterologous breast reconstruction were identified, including active smoking, high body mass index, advanced age, elevated anesthetic risk, and ADM use. 2) ADM use is associated with a higher incidence of complications, particularly surgical site infections and wound dehiscence. 3) No significant differences were observed between incision type and complication rates. 4) No association was found between reconstructive plane and increased complication rates. 5) Immediate implant-based reconstruction in patients undergoing adjuvant radiotherapy does not entail a higher risk of complications and may be considered a safe technique.
Introduction Immediate heterologous postmastectomy breast reconstruction is currently the most common reconstructive modality in surgical practice. In recent years, the introduction of acellular dermal matrices (ADM) and improvements in surgical techniques have enabled prosthesis placement in the prepectoral plane. However, the use of acellular substitutes has raised concerns regarding postoperative complications, and there are no current clinical guidelines definitively establishing their indication. Objectives To evaluate the relationship between various clinical, epidemiological, histopathological, and surgical variables and the development of complications following immediate breast reconstruction. Secondary objectives included: (1) assessing the association between ADM use and complication rates in both oncologic and prophylactic settings; (2) analyzing whether the reconstructive plane influences complication rates; (3) evaluating whether the type of mastectomy incision is associated with ischemic complications; and (4) determining the impact of reconstruction type (implant vs. expander) on complication risk in patients undergoing adjuvant radiotherapy. Materials and Methods A retrospective, single-center observational study was conducted, including patients treated at Hospital Clínico Universitario Virgen de la Arrixaca and its affiliated hospitals (Hospital San José Viamed, Hospital QuirónSalud Murcia, and Hospital Ribera de Molina de Segura) between 2016 and 2024. A total of 451 patients were analyzed—297 in the oncological group and 174 in the risk-reducing surgery group—with a minimum follow-up of one year. Descriptive and inferential analyses were performed to explore associations between clinical-pathological and surgical variables and the development of various postoperative complications, using appropriate statistical tests. Results In the oncologic surgery group, 32.7% of patients (97 cases) developed complications. Univariate analysis identified smoking (OR 1.99; 95% CI 1.25–3.18; p=0.004) and ADM use (OR 1.62; 95% CI 1.14–2.32; p=0.008) as risk factors for overall complications. ADM use was also associated with increased risk of skin necrosis (OR 2.38; 95% CI 1.27– 4.43; p=0.007), surgical site infection (OR 1.66; 95% CI 1.08–2.55; p=0.021), and wound dehiscence (OR 1.57; 95% CI 1.08–2.28; p=0.018). Chemotherapy was also linked to higher infection risk (OR 1.97; 95% CI 1.04–3.73; p=0.037). In the subgroup of patients receiving adjuvant radiotherapy, no significant differences were found in complication rates according to reconstruction type (implant vs. expander) or reconstructive plane (prepectoral vs. retropectoral). In risk-reducing surgery, the use of ADM in the prepectoral plane was associated with a higher risk of both overall and specific complications when compared to immediate reconstruction with polyurethane implants. Conclusions Multiple risk factors for complications in immediate heterologous breast reconstruction were identified, including active smoking, high body mass index, advanced age, elevated anesthetic risk, and ADM use. 2) ADM use is associated with a higher incidence of complications, particularly surgical site infections and wound dehiscence. 3) No significant differences were observed between incision type and complication rates. 4) No association was found between reconstructive plane and increased complication rates. 5) Immediate implant-based reconstruction in patients undergoing adjuvant radiotherapy does not entail a higher risk of complications and may be considered a safe technique.
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