What is direct to implant breast cancer reconstruction?
When you have breast cancer there is a growing trend to do a single stage reconstruction, where you do “direct to implant” reconstruction. Usually this is a breast implant wrapped in acellular dermal matrix (ADM). It is a great operation for many reasons. It is a single stage, you wake up with a breast, and you are done. ADM is thought to add thickness, lower rates of capsular contracture, and help create a more natural breast shape. The position in front of the pectoral muscle removes animation issues, where the breast jumps when you exercise.
What are the drawbacks?
Doing things in a single stage with thin overlying tissue is riskier. You can have issues with skin quality, skin loss, implant exposure, infection and more. This study is looking at an issue called “Red Breast Syndrome.” In this, the breast turns red after direct to breast implant, with the redness in the skin over the ADM. There are no other signs of infection.
When a breast turns red after implant reconstruction, even if it is not an infection, most patients are started on antibiotics. Many have extended stays.
Study on Red Breast Syndrome:
This was a study published in Aesthetic Surgery Journal, July 2025. “Early Onset Red Breast Syndrome: The Incidence, Risk Factors, and Clinical Outcomes in Prepectoral Direct to Implant Breast Reconstruction. “
- Retrospective consecutive direct to implant reconstructions, followed for at least 1 year after surgery
- Smooth silicone implants were fully wrapped in ADM. The ADM varied – CG CryoDerm, CG Derm, and MegaDerm. Only the Megaderm was sterilized by gamma irradiation.
- ADM thickness was selected based on the projection of the contralateral breast, with thicker (2-3mm) ADM chosen to give additional fullness where needed.
- 255 patients were in the study. Of these 25 got Red Breast Syndrome
- They looked at age, mastectomy type, incision type, difference between implant size and mastectomy weight, ADM type and size, implant projection (classic vs plus/high profile), if they had radiotherapy and chemotherapy.
- In their analysis, those who had Red Breast Syndrome had higher rates of complications– delayed wound healing, wound revision, infections, infections not responsive to antibiotics, and future conversion to autologous reconstruction. This was true EVEN when adjusted for BMI, age, etc.
RISK FACTORS for Red Breast Syndrome
Red Breast Syndrome is thought to be due to an issue of lymphatic drainage. This impairs antigens and immune cells that promote wound healing, fight infection, and promote recovery. It is also possible some of these cases are low grade, subclinical infections. Most surgical site infections in immediate direct to breast implant breast reconstructions occur after 30 days postop.
Most cases did resolve spontaneously within 2 weeks.
- Age, significantly higher rates at age 60 than age 30
- Higher implant projections
- Lower risk seen with prophylactic mastectomy
- Lower risk with a bigger difference between implant and mastectomy specimen weight – significant for a difference of 300cc less than the original breast (Compared to high risk when going larger than the mastectomy specimen)
What do I think?
I do not do a lot of breast cancer reconstruction, but I see a lot of breast implant patients with super thin skin flaps which are just like mastectomy flaps. This study shows that pressure on the skin flaps likely impairs lymphatic drainage. The size of the implant, the projection of the implant, your age – all these factors can make a sizable difference in your risk to heal.
I read these studies as breast cancer reconstruction patients give us great data on how to handle difficult breast augmentation and implant cases.
Here in the Bay Area, I see many patients who are super thin. They are at risk for lymphatic drainage issues just like the red breast syndrome breast cancer reconstruction patients are.
The information provided on this website is for general informational purposes only and does not constitute medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider for any questions regarding your health or medical condition.
