Postoperative Complications of Direct-to-Implant and Two-Staged Breast Reconstruction: A Stratified Analysis

<b>Background:</b> Post-mastectomy implant-based reconstruction can be performed as direct-to-implant (DTI) or two-staged reconstruction (TSR). Rigorous studies have explored postoperative complications between TSR or DTI, yet few have stratified outcomes by relevant populations, pre-operative findings, mastectomy characteristics, or plane of implant placement. We sought to compare the outcomes between these cohorts at our institution. <b>Methods:</b> All patients who underwent skin- or nipple-sparing mastectomy followed by DTI or TSR from 2011 to 2021 at a large academic medical center were included. Data included demographics, ADM use, mastectomy weight, plane of implant placement, and postoperative complications. <b>Results:</b> 295 patients were included. 271 (91.9%) received TSR, and 24 (8.1%) underwent DTI. Compared to TSR, DTI had a higher rate of NAC necrosis (<i>P</i> = .007) and dehiscence (<i>P</i> = .016). There was no difference in rate of other complications. Regardless of procedure, higher BMI (<i>P</i> = .002), higher grade ptosis (<i>P</i> = .01), and larger mastectomy weights (<i>P</i> = .022) were associated with increased risk of complication. Pre-pectoral placement was not associated with risk of NAC or mastectomy skin necrosis. Prior tobacco use was associated with higher risk of infection (<i>P</i> = .036) and dehiscence (<i>P</i> = .025). Neoadjuvant and adjuvant chemotherapy was associated with increased risk of capsular contracture(<i>P</i> = .009). <b>Conclusions:</b> Our study suggests that TSR may be preferred to minimize risk of NAC necrosis and wound dehiscence, especially in high-risk patients. Pre-pectoral placement did not significantly affect risk of mastectomy or NAC necrosis and should be considered in all cases to minimize morbidity. Higher risk conditions for alloplastic reconstruction include higher degrees of ptosis, history of tobacco use, and higher BMIs.