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Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study

Srinivasa, Dhivya R. M.D.; Garvey, Patrick B. M.D.; Qi, Ji M.S.; Hamill, Jennifer B. M.P.H.; Kim, Hyungjin M. Sc.D.; Pusic, Andrea L. M.D., M.H.S.; Kronowitz, Steven J. M.D.; Wilkins, Edwin G. M.D., M.S.; Butler, Charles E. M.D.; Clemens, Mark W. M.D.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5 - p 869–877
doi: 10.1097/PRS.0000000000003748
Breast: Outcomes Article
Video Discussion

Background: Direct-to-implant breast reconstruction offers time-saving advantages over two-stage techniques. However, use of direct-to-implant reconstruction remains limited, in part, because of concerns over complication rates.1,2 The authors’ aim was to compare 2-year complications and patient-reported outcomes for direct-to-implant versus tissue expander/implant reconstruction.

Methods: Patients undergoing immediate direct-to-implant or tissue expander/implant reconstruction were enrolled in the Mastectomy Reconstruction Outcomes Consortium, an 11-center prospective cohort study. Complications and patient-reported outcomes (using the BREAST-Q questionnaire) were evaluated. Outcomes were compared using mixed-effects regression models, adjusting for demographic and clinical characteristics.

Results: Of 1427 patients, 99 underwent direct-to-implant reconstruction and 1328 underwent tissue expander/implant reconstruction. Two years after reconstruction and controlling for covariates, direct-to-implant and tissue expander/implant reconstruction patients did not show statistically significant differences in any complications, including infection. Multivariable analyses found no significant differences between the two groups in patient-reported outcomes, with the exception of sexual well-being, where direct-to-implant patients fared better than the tissue expander/implant cohort (p = 0.047).

Conclusions: This prospective, multi-institutional study showed no statistically significant differences between direct-to-implant and tissue expander/implant reconstruction, in either complication rates or most patient-reported outcomes at 2 years postoperatively. Direct-to-implant reconstruction appears to be a viable alternative to expander/implant reconstruction. This analysis provides new evidence on which to base reconstructive decisions.


Video Discussion by Neil A. Fine, M.D., is Available Online for this Article.

Ann Arbor, Mich.; Houston, Texas; and New York, N.Y.

From the Section of Plastic Surgery and the Department of Biostatistics, University of Michigan; the Department of Plastic Surgery, M. D. Anderson Cancer Center; and the Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center.

Received for publication December 14, 2016; accepted May 31, 2017.

Disclosure:The authors report no conflicts of interest.

A Video Discussion by Neil A. Fine, M.D., accompanies this article. Go to and click on “Video Discussions” in the “Digital Media” tab to watch.

Dhivya R. Srinivasa, M.D., Section of Plastic Surgery, University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, Ann Arbor, Mich. 48109-0340,

©2017American Society of Plastic Surgeons