PURPOSE: Breast implants are utilized extensively for cosmetic and reconstructive purposes. This combined with the prevalence of surgical cardiothoracic disease results in a population of patients with breast implants requiring sternotomy or thoracotomy. We hypothesized that patients were at greatest risk for breast implant–related complications during anterior or medial cardiothoracic approaches. The aim of this study is to evaluate breast implant risks and complications during subsequent cardiothoracic surgery using a meta-analysis of the existing literature specific to this unique and understudied population.
MATERIALS AND METHODS: A meta-analysis using PubMed/Medline, Embase, and Scopus was performed using “breast implant thoracotomy” (23 results), “breast implant sternotomy” (14 results), “iatrogenic breast implant rupture” (9 results), and “cardiac surgery breast implant” (356 results) as search terms. Titles were evaluated for relevance, and duplicates were consolidated resulting in 18 articles, years of publication 1993–2018. The methodologic quality of included studies was independently assessed using the Methodological Index for Non-Randomized Studies guidelines. Average number of MINORS criteria was 3 out of 7. These were reviewed for patient characteristics, surgical approaches, and complications. Statistical analyses were completed with SPSS version 25.
RESULTS: Twenty-seven patients with an average age of 58.37 years (23–84) were identified. Average time from breast implant placement to thoracic surgery was 14.9 years (33% reconstructive implants, 67% esthetic implants). Cardiac valvular surgery (mitral valve) was the most common surgery (14/27 patients; 51.8%). The most common approach was a minimal access minithoracotomy (18/27 patients; 67%). Implant preservation occurred in 13 patients (48.1%); same implant removal and replacement at the time of the cardiac operation in 7 patients (25.9%); and implant exchange for new prostheses in 5 patients (18.5%). Eleven patients (40.7%) had postoperative complications: implant rupture (9 patients), intrathoracic implant migration (6 patients), free silicone in the thorax (7 patients), and delayed hematoma in the implant capsule (1 patient). The average time from surgery to complication was 17.05 months (10/27 reported). Average follow-up was 11.5 months (10/27 reported). The implant preservation group had a complication rate of 78.6% versus a 21.4% complication rate for patients who had implant removal and/or replacement (P < 0.0001). Significant predictors of complications were reconstructive versus esthetic implant (87.5% versus 12.5%, respectively), pulmonary lesion (100% versus 20% for other indications; P < 0.0001), and VATS (100% versus 20% for patients with other approaches; P = 0.02). Mitral valve repair (14.3% versus 69.2% for other indications; P = 0.004) and minimal access approach (16.7% versus 85.7% for other approaches) correlated negatively with complications. These individual primary predictors were not significant when combined using a regression model.
CONCLUSIONS: Our study demonstrated that implant preservation was associated with increased risk of breast implant–related complications during cardiothoracic surgery. Patients with reconstruction-related breast implants undergoing VATS for pulmonary indications were at greatest risk for an implant-related complication. Further study evaluating prospective treatment algorithms may demonstrate decreased complications using a breast implant removal and replacement strategy in high-risk patients.