Technical aspects of immediate breast reconstruction with implants: Five year follow-up

The Failed Breast Implant in Postmastectomy Reconstruction: A Systematic Literature Review of Complications of Implant-Based Breast Reconstruction

BACKGROUND

Breast cancer is the most diagnosed malignant neoplasia of female patients worldwide in 2019. Survival has increased making it necessary to offer breast reconstructive procedures to improve quality of life and self-esteem. Implant-based breast reconstruction is the most common approach, making it necessary to quantify the associated complications.

METHODS

A systematic literature review of the PubMed, Cochrane, and Web of Science databases was performed. A total of 9608 citations were identified, and 44 studies met the inclusion criteria.

RESULTS

Studies included reported the incidence of complications either per patient or per breast leading consequently to 2 complication rates depending on the type of reporting. A total of 14.3% of patient-related and 28.8% of breast-related complications while undergoing implant-based reconstruction were reported.Among total complications reported, 72.6% of patient-related and 48.5% of breast-related complications were classified as major complications.A total of 37.6% of patients respectively 15.1% of breasts required prosthesis explantation due to severe complications. Depending on reporting, 9.7% of patients and 4% of breasts required autologous flap reconstruction due to reconstructive failure.

CONCLUSIONS

High complication and failure rates are associated with implant-based breast reconstruction. Lacking randomized controlled trials, the choice between implant-based and autologous breast reconstruction has to be made individually for each patient.

Long-term oncologic safety of immediate reconstructive surgery in patients with invasive breast cancer: a retrospective matched-cohort study

Objective

Immediate reconstruction (IR) is a safe and effective surgical treatment for patients with breast cancer. We aimed to assess the prognosis, aesthetic outcomes, and patient satisfaction of IR compared with breast conservation surgery (BCS) and total mastectomy (TM).

Methods

This retrospective matched-cohort study was conducted between May 2005 and December 2014. We established two cohorts according to the tumor (T) size of breast cancer. In the T≤3cm group, cases (IR) and controls (BCS or TM) were matched for age, pathological tumor size, and pathologic nodal status in a 1:1:1 ratio. In the T>3cm group, cases (IR) and controls (TM) were matched with the same factors and ratio. The primary outcome was the 5-year disease-free survival (DFS). The secondary outcome was patient satisfaction and quality of life.

Results

A total of 12,678 breast cancer patients were assessed for eligibility, of which 587 were included (T≤3 cm group: 155 IR vs 155 BCS vs 155 TM; T>3cm group: 61 IR vs 61 TM). In the T≤3 cm cohort, patients who underwent IR had no difference compared with those who underwent BCS or TM regarding the 5-year DFS (P=0.539); however, an improved aesthetic satisfaction, psychosocial, and sexual well-being were achieved in the IR group (P<0.001). In the T>3 cm cohort, the IR group had a worse median 5-year DFS (P=0.044), especially for Her2+ or triple-negative breast carcinoma (TNBC) subtypes compared with the TM group.

Conclusions

IR improves aesthetic satisfaction, psychosocial, and sexual well-being for breast cancer patients with T≤3 cm. For patients with T > 3 cm invasive breast cancer, TM is superior to IR as it predicts a better 5-year DFS.

Risk reducing mastectomy, breast reconstruction and patient satisfaction in Norwegian BRCA1/2 mutation carriers

The aim of this study was to evaluate the outcome of risk-reducing mastectomy in BRCA1/2 mutation carriers with and without breast cancer. Uptake, methods of operation and reconstruction, complications, patient satisfaction and histopathological findings were registered at all five departments of genetics in Norway. Data from 267 affected and unaffected BRCA1/2 mutation carriers were analyzed, including a study-specific questionnaire returned by 178 mutation carriers. There was a steady increase in the uptake of risk-reducing mastectomies during the study period. Complications were observed in 106/266 (39.7%) women. Patient satisfaction was high. The majority of women expressed great relief after risk-reducing mastectomy and would have chosen the same option again.

Operative risks associated with contralateral prophylactic mastectomy: a single institution experience

BACKGROUND

The purpose of this study was to determine if newly diagnosed breast cancer patients undergoing contralateral prophylactic mastectomy (CPM) experience more complications than patients undergoing unilateral mastectomy (UM).

METHODS

A total of 600 patients underwent either UM or CPM between January 2009 and March 2012 for unilateral breast cancer. Operative complications were classified as minor (aspirations, infection requiring antibiotics, partial flap and nipple necrosis, minor bleeding, delayed wound healing) or major (hematoma or seroma requiring operation, infection requiring rehospitalization, blood product transfusion, total flap or nipple loss, implant removal), mixed (both minor and major complications), or multiple. Chi-square and multivariate logistic regressions were used for the analysis.

RESULTS

Of the 600 patients, 391 (65 %) underwent UM and 209 (35 %) underwent CPM. Across all complication groups, there were significantly more complications in the CPM group versus the UM group (41.6 vs. 28.6 %, p = 0.001). Major complications alone were significantly greater in the CPM versus the UM group (13.9 vs. 4.1 %, p < 0.001). When adjusting for age, body mass index, smoking and diabetes history, AJCC stage, reconstruction, previous radiation therapy, and adjuvant therapy, CPM patients were 1.5 times more likely to have any complication (odds ratio [OR] 1.53; 95 % CI 1.04-2.25, p = 0.029) and 2.7 times more likely to have a major complication compared with UM patients (OR 2.66; 95 % CI 1.37-5.19, p = 0.004).

CONCLUSIONS

CPM patients have an increased risk of complications, especially major complications requiring rehospitalization or reoperation. These complications may influence patient and physician decisions to choose CPM.

Subcutaneous tissue expansion and subsequent subpectoral implantation for breast reconstruction in Asian patients: safety and outcome

Asian women are generally thin with smaller breasts. The objective was to investigate the outcomes for patients who underwent 2-stage breast reconstruction using subcutaneous expansion followed by subpectoral implantation. Between 2003 and 2008, 22 patients underwent subcutaneous expansion and subsequent submuscular implantation for 23 breast reconstructions. Mean age was 44.6 ± 7.0 years. The outcome was assessed with a pain visual analog scale, a questionnaire, and the cosmesis. Mean expansion volume was 350.3 ± 80.8 mL. Mean implant size was 306.7 ± 84.6 mL. The complication rate was 8.6%, 13.0% in first and second stages. Mean pain scale was 2 ± 1.4. At a mean follow-up of 42.5 ± 18 months, patient's satisfaction was 3.2 ± 0.9. Overall shape of the reconstructed breast was rated as 2.8 ± 0.5. Subcutaneous expansion with subsequent subpectoral implantation is feasible and reliable in low body mass index, nonsmoking, nonradiated patients with small and projective breasts.

Breast surgeons performing immediate breast reconstruction with implants - assessment of resource-use and patient-reported outcome measures

Oncoplastic surgery, including immediate breast reconstruction (IBR), is expanding as a result of public demand. IBR in women with breast carcinoma is resource intense and the reconstruction is often completed concurrently with adjuvant oncological treatment. A series of 223 patients with implant-based IBRs, performed by breast surgeons 2005-2008, were analysed for use of resources and outcome. Low overall major complication rates (19,7%) were identified, even though 41% of the patients had received post-mastectomy radiation. A total of 1.1 reoperations per patient were required. Patient-reported outcomes using the EQ-5D and a disease-specific questionnaire at a median of four years follow-up were analysed. Patients' general health-state was high (0.83), whereas negative impact on intimate situations and the sensibility of the breast was reported. Our audit concludes that trained breast surgeon specialists perform implant-based IBRs with a satisfactory outcome when evaluated by subjective and objective analyses.

Immediate reconstruction with implants in women with invasive breast cancer does not affect oncological safety in a matched cohort study

Physicians are still concerned about the oncological safety regarding immediate breast reconstruction (IBR) in breast cancer patients. This study aimed to evaluate possible differences between local, regional, and distant recurrences between women having implant-based reconstruction versus women operated with mastectomy alone. Secondary aims were to evaluate time to oncological treatment as well as disease-free and breast-cancer-specific survival. In a retrospective cohort designed study, 300 reconstructed patients with invasive breast cancer were matched with 300 patients from the population-based Regional Breast Cancer Register of the Stockholm-Gotland health-care region operated with mastectomy alone. They were matched for age, tumor size, nodal stage, and year of operation. Also included were patients treated with neoadjuvant chemotherapy and postoperative radiotherapy. The median follow-up for both the groups was 11.5 years (range 2-20). There were no significant differences in the local recurrence rate, 8.2% in the IBR group and 9.0% in the control group or in the regional recurrence rate, 8.2% versus 9.7%. Distant metastases occurred more frequently in the control group (27.1%) when compared to the IBR group (20.3%). There were no significant differences in time to treatment or in complications rate. Breast cancer mortality was 17% for the IBR group and 23% in the control group during follow-up. This long-term follow-up survey with a well-matched control group demonstrates that IBR with implants is safe to offer patients with invasive breast cancer without any negative effect on the oncological safety.

Sensation Following Immediate Breast Reconstruction with Implants

Sensation is a neglected aspect of the outcome of breast reconstructions with implants. The aim of this prospective study was to evaluate the cutaneous somatosensory status in breasts following mastectomy and immediate reconstruction with permanent adjustable prostheses and to analyze the patients' subjective experience of the sensation. Twenty-four consecutive patients diagnosed with invasive or in situ breast carcinoma were examined preoperatively and 2 years after mastectomy and reconstruction, for assessment of perception thresholds for touch, cold, warmth, and heat pain above and below the areola. Von Frey filaments and a Peltier element-based thermode were used. The patients completed a questionnaire concerning their experienced sensation in the reconstructed breast. Using quantitative somato-sensory testing, the sensation to all the examined modalities was significantly impaired compared to preoperatively. Most affected was the area above the areola. Patients given postoperative radiotherapy (n = 9) did not differ from those without radiotherapy (n = 15) regarding any of the modalities. All patients reported reduced sensation in the reconstructed breast compared to that preoperatively. Twenty-three patients stated that the reconstructed breast felt different from the other breast; nevertheless 16 reported that the reconstructed breast felt like a real breast. The study revealed sensation impairment following mastectomy and immediate reconstruction with implants. Patients should be informed about this effect preoperatively to allow adequate expectations regarding the sensation outcome. However, two-thirds of the study patients considered that the reconstructed breast felt like a real breast, which must be one of the main purposes of a breast reconstruction.

Immediate breast reconstruction with implants after skin-sparing mastectomy: a report of 96 cases

BACKGROUND

Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has become increasingly popular as an effective treatment for patients with early-stage breast cancer requiring mastectomy. This study aimed to evaluate the clinical outcomes of IBR using permanent gel breast implants and Becker expandable breast implants after SSM.

METHODS

A review of 96 patients undergoing IBR with Beck expandable or permanent gel breast implants after SSM from July 2002 to December 2006 was performed. Of the 96 patients, 30 had IBR after SSM with conservation of the nipple-areola complex (NAC). The mean patient age was 42 years (range, 29-57 years). Aesthetic outcomes were assessed according to the breast volume, shape, and symmetry with the opposite breasts after a mean follow-up period of 44 months.

RESULTS

The aesthetic outcomes were graded as excellent for 29 patients, good for 47 patients, fair for 12 patients, and poor for 8 patients. The overall complication rate was 11.5% (11/96). The complications included prosthesis loss after skin flap necrosis subsequent to hematoma formation (n = 1), skin necrosis (n = 2), partial necrosis of preserved NAC (n = 1), capsular contracture (Baker 4, n = 2), wound infection not involving the prosthesis (n = 2), inversion of the injection port (n = 2), and seroma (n = 2).

CONCLUSION

This study demonstrates that prosthetic breast reconstruction is a safe, reliable method with minimal complications and good to excellent aesthetic results for the majority of patients with early-stage breast cancer. For selected patients, NAC-sparing mastectomy can be performed without increasing the risk of local recurrences. Success depends on patient selection, proper incision for SSM, total coverage of the prostheses with muscles, and careful intra- and postoperative management.

Long-Term Sensibility Following Nonautologous, Immediate Breast Reconstruction

Immediate breast reconstruction after mastectomy, using submuscular expander prostheses, is well established in the treatment of breast cancer. The aim of this study was to survey the postoperative cutaneous somatosensory status and to analyze the patients' subjective opinion about the sensibility in the reconstructed breast. Fourteen patients were included and examined 3-6 years after reconstruction. The untreated contralateral breast served as control. None of the patients had received any locoregional radiotherapy. The perception thresholds to touch, cold, warmth, and heat pain were assessed and a questionnaire about the patients' subjective experience of sensibility was completed. In the quantitative somatosensory testing, statistically significant impairment concerning all the examined modalities was demonstrated. The least affected was the heat pain modality. In the questionnaire, the patients reported weaker nonmodality specific sensibility from the reconstructed breast compared with the control breast. More than half of the patients reported that the reconstructed breast felt like a real breast. In conclusion, the study revealed long-term, overall sensibility impairment following nonautologous, immediate breast reconstruction.

Reconstruction mammaire par prothèse : vieillissement et résultats esthétiques tardifs

The long cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate breast reconstruction with various types of implant has been prospectively analysed over a 10-year period. 334 patients who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (<2 months) was 9.1%, with an explantation rate of 1.6%. The late complication rate (>2 months) was 23%, with a pathological capsular contracture rate of 11% at two years and 15% at five years, and an implant removal rate of 7%. The revisional surgery rate was 30.2%. The cosmetic results were prospectively assessed using an objective five point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorates in a linear fashion from an initial acceptable result in 86% of patients two years after completion of their reconstruction to only 54% at five years. This fall off in the cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient or the type of mastectomy incision employed. Radiotherapy was not a significant factor as only 28 patients were irradiated. However, on Cox model analysis pathological capsular contracture was the only factor which significantly contributed to a poor cosmetic outcome(P<0.0001 (relative risk 6.3). In spite of a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of those patients without a capsular contracture who demonstrated a deterioration in their cosmetic scores, it became clear that a possible reason for their poor result was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis as the patients aged.