Red Breast Syndrome and Early Postoperative Complications in Immediate Prepectoral Implant-Based Reconstruction Using Braxon® Acellular Dermal Matrix: A Retrospective Cohort Study

Background: Red breast syndrome (RBS) is a self-limited, non-infectious erythema historically linked to acellular dermal matrices (ADMs) in breast reconstruction. Recent reports suggest a declining incidence, potentially related to ADM advancements. This study evaluates the contemporary incidence of RBS and postoperative complications in patients undergoing immediate prepectoral reconstruction with a specific porcine ADM (Braxon®, Decomed s.r.l., Venice, Italy). Methods: This is a retrospective cohort study of all consecutive patients who underwent immediate prepectoral breast reconstruction with ADM (Braxon®) at our institution. Patients were identified from a prospectively maintained database. The study included all procedures performed between August 1, 2020, and October 31, 2024 (the data cutoff date for analysis). Data on demographics, surgical details, and postoperative outcomes were collected. Complications were classified as minor (managed conservatively) or major (requiring reoperation). RBS was defined by strict clinical criteria excluding infection. Univariate analysis assessed risk factors for complications. Results: No cases of RBS were observed (0/95, 0%). Early minor complications included seroma (7/95, 7.3%), skin necrosis (4/95, 4.2%), and infection (1/95, 1%). Major complications requiring reoperation occurred in 15.8% (15/95) of cases, with an overall implant loss rate of 13.7% (13/95). Preoperative radiotherapy significantly increased early complications (RR = 3.2, p = 0.013) and implant loss risk six-fold (RR = 6.17, p = 0.007). Postoperative radiotherapy was associated with higher capsular contracture rates (RR = 3.73, p = 0.008). Smoking, necrosis, infection, and dehiscence were significant predictors of implant loss (p < 0.05). Conclusion: Notably, no cases of RBS were identified in this cohort, supporting the safety of Braxon® ADM in prepectoral reconstruction and contributing to evidence of its declining incidence. This absence may be attributed to specific ADM properties, surgical technique, and patient selection. However, radiotherapy and smoking remain critical, modifiable risk factors for implant-related complications.