Tissue Expander-Based Breast Reconstruction at a Major Safety-Net Hospital: Managing the Outsized Risk of Infection

Background: Immediate tissue expander (TE) breast reconstruction is reported to have the highest rate of postoperative infection among reconstructive modalities. The risk of infection is higher among patients treated at safety-net hospitals. Objectives: The goal of this study was to identify significant contributing factors to the elevated infection risk at our major safety-net institution. Methods: A retrospective chart review was conducted on all TE-based reconstruction patients with a diagnosis of postoperative infection between 2015 and 2019. Preoperative, perioperative, and postoperative risk factors for infection were determined and compared across patient and procedure demographics. Results: Two hundred forty-three patients, for a total of 412 breast reconstructions, were included in our study. Significant preoperative selection factors were identified to contribute to the elevated risk of infection, including the following: older age, higher BMI, and diabetes. Significant intraoperative and postoperative contributing factors included greater mastectomy weight, larger TE's and intraoperative fill volume, and longer drain duration. Doxycycline treatment for infected patients resulted in a significantly higher rate of resolution. Conclusions: Safety-net hospital population patients undergoing TE breast reconstruction are at higher risk for postoperative infection. Personal and procedural risk factors are identified. Balancing the benefits of immediate breast reconstruction with TEs with the elevated risk of postoperative infection remains challenging. Implementation of more stringent eligibility criteria may help mitigate the risk of infection.