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Each year more women choose to undergo breast reconstruction after mastectomy. According to the American Society of Plastic Surgeons, 107,240 breast reconstructions were performed in 2019.1 Of these, 72,000 were 2-stage procedures in which tissue expanders are used prior to the insertion of permanent implants. This is the most common breast reconstruction technique.
However, there are questions about whether 2-stage implants are prone to deteriorating over time. For this reason Akhil K. Seth, MD, and Peter G. Cordeiro, MD, of Memorial Sloan Kettering Cancer Center (MSKCC) in New York, New York, undertook a study to analyze the stability of these implants. The investigators conducted a retrospective review of patients who had undergone 2-stage prosthetic breast reconstruction.2
Dogma or Data?
The MSKCC team noted that ideas about poor long-term results of breast reconstruction were based on “surgical dogma” and not objective data. The studies that exist are short term. There are simply not enough long-term studies to support the idea that these implants do not last, that they can result in poor aesthetic outcomes often from an increase in capsular contracture and scarring around the implant, and that patients are dissatisfied. Furthermore, these inadequate data may lead to the concept that immediate autologous reconstruction is more sustainable than implant-based reconstruction.
Autologous reconstruction is not ideal for everyone. The patient may have preoperative comorbidities or not enough donor-site tissue. There is another consideration as well: Patients may not want the additional surgery and recovery associated with a tissue donor site. 2
Patient-Reported Outcomes
To obtain data on long-term results, Drs Cordeiro and Seth analyzed the long-term outcomes of 2-stage implant-based breast reconstruction in 2284 patients that Dr Cordeiro operated on between 1994 and 2016. They assessed patient follow-up outcomes for up to 12 years, with an average of 5.5 years. The team used the BREAST-Q questionnaire, which includes physical, psychosocial, and sexual well-being scores.3 Patients scored their results annually either electronically or at their outpatient appointments; each visit and patient score was considered individually, as were the surgeon’s scores.
In terms of aesthetics, the team evaluated scores for bilateral and unilateral reconstructions, as well as for breasts that were irradiated and nonirradiated. The lowest scores were for unilateral irradiated breasts; the highest were for bilateral, nonirradiated breast reconstructions. Although irradiated breasts demonstrated high rates of capsular contracture, the condition actually improved in all patients as time went on. The researchers found that the aesthetic scores and capsular contracture rates either improved or remained stable over the entire 12-year follow-up period.
In terms of satisfaction with their breasts, initially the nonirradiated patients were more satisfied with their breasts than were the irradiated patients. However, they only reported that score in the first year. As the study went on, the contrast between satisfaction of nonirradiated and irradiated patients became less significant, and patients concluded that they were satisfied with their outcomes over the long term. The researchers found similar results for the patient-reported scores of psychosocial well-being and sexual well-being over the course of the study.
No overall decrease in any measured patient-reported outcomes were reported over the 12 years of the study. In addition, the investigators noted that scores for satisfaction with outcomes actually increased significantly over time. 2
This unique long-term study of 2284 patients undergoing 2-stage implants by the same surgeon and followed up for 12 years demonstrates that this type of breast reconstruction is sustainable over time. It leads to stable aesthetic outcomes, as well as improving patient satisfaction and well-being. The oncology nurse should be able to use this information to guide patients regarding prosthetic breast reconstruction. “These results contradict the surgical dogma surrounding prosthetic breast reconstruction and therefore should be given significant consideration when counseling patients,” the investigators concluded.
References
1. American Society of Plastic Surgeons. Plastic Surgery Statistics Report: ASPS National Clearninghouse of Plastic Surgery Procedural Statistics. American Society of Plastic Surgeons; 2019. Accessed September 30, 2020. https://www.plasticsurgery.org/documents/News/Statistics/2019/plastic-surgery-statistics-full-report-2019.pdf
2. Seth AK, Cordeiro PG. Stability of long-term outcomes in implant-based breast reconstruction: an evaluation of 12-year surgeon- and patient-reported outcomes in 3489 nonirradiated and irradiated implants. Plast Reconstr Surg. 2020;146(3):474-484. doi:10.1097/PRS.0000000000007117
3. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124(2):345-353. doi:10.1097/PRS.0b013e3181aee807
