An Algorithm for Salvage of Implant-Threatening Complications in Breast Reconstruction.

BACKGROUND: Implant-based breast reconstruction is associated with postoperative infectious and wound-related complications that may compromise reconstructive outcomes, particularly in cohorts predominantly undergoing immediate reconstruction. Optimal management remains controversial, with no universally accepted salvage algorithm. METHODS: We conducted a retrospective cohort study of 198 patients (285 breasts) who underwent implant-based reconstruction between 2013 and 2023, the majority of whom underwent immediate reconstruction. Implant-threatening complications were defined as surgical site infection according to Centers for Disease Control and Prevention (CDC) criteria, full-thickness skin necrosis, or deep wound dehiscence. A standardized institutional salvage protocol incorporating antibiotic therapy with or without surgical intervention was applied. Outcomes included implant salvage and final reconstruction status at the end of follow-up, and logistic regression was used to identify predictors of salvage failure. RESULTS: Implant-threatening complications occurred in 28.3% of patients, with salvage achieved in 51.8% of cases. All patients in the salvage group achieved final reconstruction, compared to 44.4% in the nonsalvage group (p < 0.01). The most common complications were skin necrosis and wound dehiscence, followed by infection, and Gram-negative organisms predominated among culture-positive cases. Resistant organisms (p = 0.04), implant extrusion (p = 0.008), and prior radiation therapy (p = 0.019) were independent predictors of salvage failure. CONCLUSION: A protocol-based salvage approach may facilitate implant preservation and improve final reconstruction rates. Early, case-specific conservative management, tailored to local microbiologic patterns, may optimize outcomes.