The reasons for failure of implant-based breast reconstruction causing a change from an implant-based reconstruction to autologous tissue included capsular contracture causing pain and/or cosmetic deformity [n = 106 (77 percent)], dissatisfaction with the aesthetic result without capsular contracture [n = 15 (11 percent)], impending exposure of the implant/infection [n = 8 (6 percent)], and unknown [n = 8 (6 percent)] (Table 2). Of the 106 patients with capsular contracture causing pain and/or cosmetic deformity, 47 patients had irradiated implants, 14 had an irradiated tissue expander, and five had radiation therapy to the breast after lumpectomy. Of the 15 patients without capsular contracture but with an unacceptable cosmetic result, three patients had radiation therapy to their implants and one had radiation therapy to the tissue expander. Of the eight patients with impending implant exposure, three patients had radiation therapy to the implant and four patients had irradiated tissue expanders. Radiation therapy did not significantly affect motivation for change to autologous reconstruction (p = 1.0).
Fifty-five cases were bilateral (40 percent) and 82 were unilateral (60 percent), for 192 total flaps (Table 3). Time from implant placement to implant removal and autologous reconstruction averaged 53 ± 43 months. Flap types included deep inferior epigastric perforator flap [n = 92 (48 percent)], muscle-sparing transverse rectus abdominis myocutaneous flap [n = 79 (41 percent)], pedicled transverse rectus abdominis myocutaneous flap [n = 13 (7 percent)], superior gluteal artery perforator flap [n = 4 (2 percent)], and diagonal upper gracilis flap [n = 4 (2 percent)]. Complications requiring operative intervention included partial flap loss [n = 5 (3 percent)], hematoma [n = 5 (3 percent)], vascular compromise requiring intervention for salvage [n = 2 (1 percent)], and total flap loss [n = 1 (1 percent)]. Complications not requiring operative intervention included minor wound healing of the donor site [n = 4 (2 percent)], seroma of the abdomen or breast [n = 4 (2 percent)], and cellulitis of the abdomen [n = 2 (1 percent)]. Forty-six patients (34 percent) had operative revisions to their autologous breast reconstruction, with 12 patients (9 percent) undergoing more than one procedure. Nipple-areola complex reconstruction was not included in analysis. Operative revisions to autologous breast reconstruction included revision of shape [n = 30 (22 percent)], fat grafting [n = 19 (14 percent)], debulking liposuction [n = 9 (7 percent)], placement of implant to increase volume [n = 3 (2 percent)], and placement of latissimus flap to increase volume [n = 2 (1 percent)].
When comparing BREAST-Q responses between post–implant-based reconstruction but before autologous breast reconstruction and after autologous breast reconstruction, there were multiple statistically significant results. Thirty-four patients (23 percent) had questionnaires available at both time points for analysis. There was a statistically significant increase in satisfaction with appearance of breasts (p < 0.001), psychosocial well-being (p < 0.001), and physical well-being of the chest and upper body (p = 0.003). Satisfaction with overall outcomes was also significantly increased (p < 0.001). Changes in sexual well-being were not statistically significant (p = 0.3). A statistically significant decrease in physical well-being of the abdomen was also observed (p = 0.001). Only patients with abdominal flaps were included in the analysis of abdominal well-being (n = 33) (Fig. 2). Increased body mass index or laterality did not influence overall satisfaction to a significant degree. In addition, patients with a history of radiation therapy did not have any significant differences with satisfaction or well-being in any category. Postoperative implant/preoperative autologous tissue reconstruction BREAST-Q surveys were filled out an average of 4.0 ± 5.8 months (range, <1 to 27 months) before flap reconstruction. Average follow-up with postoperative autologous tissue reconstruction BREAST-Q data available was 15 ± 11 months (range, 1.5 to 36 months).
Breast reconstruction after mastectomy, either implant-based or autologous, is becoming more popular, with 109,256 procedures reported in 2016.10 A large majority of these procedures, over 80 percent, are implant-based. Generally, implant reconstruction is a simpler procedure and is available to more patients. Autologous reconstruction is performed less often, as not all patients are candidates and the complexity of the procedure is greater. The procedures are longer and also have donor-site morbidity. However, autologous tissue can provide a more naturally shaped breast and eliminate the long-term risks of capsular contracture and implant infection/exposure, which are associated with implant-based reconstruction. Both implant and autologous tissue reconstruction have a high degree of patient satisfaction and quality of life.1–7
Although multiple studies exist examining either implant reconstruction or autologous reconstruction, few studies investigate the subset of patients in whom implant-based reconstruction failed and autologous tissue reconstruction was ultimately performed.8 , 9 In the few existing studies, a high degree of patient satisfaction is reported, yet none uses a validated patient-reported outcomes tool in their assessment. Our study used the validated BREAST-Q. This is a patient-reported tool and was completed prospectively.
Our results show a high degree of satisfaction and quality of life. Significant increases were seen in satisfaction with breast appearance, psychosocial well-being, and physical well-being of the chest and upper body. Improvements in physical well-being of the chest and upper body in many patients could be attributable to removal of a tight implant and firm, painful capsule at the time of autologous tissue reconstruction. Even those that did not perceive pain or tightness when their implants were in place may see improvement when they are removed, as they now have a comparison. Interestingly, patients have a persistent decrease in physical well-being of their abdomen, even at an average follow-up of 15 months. However, satisfaction with overall outcome is still significantly improved. Therefore, we can infer that although patients do recognize physical impairment of the abdomen, this is not enough to affect their overall satisfaction with autologous reconstruction. This is an important consideration for preoperative counseling with respect to expected outcomes and the decision to proceed with autologous tissue reconstruction.
Satisfaction and quality of life in breast reconstruction may be influenced by multiple factors, including body mass index, laterality, and radiation therapy. A higher body mass index and reconstruction in the setting of radiation therapy can relate to lower satisfaction and quality of life.11–13 Contralateral prophylactic mastectomy with bilateral reconstruction can relate to higher satisfaction with breasts when compared to unilateral reconstruction.14 Age has not been shown to impact satisfaction and quality of life; however, we wanted to include this parameter in our examination for completeness.6 , 15 Our study did not show any impact of age, body mass index, laterality, or radiation therapy in terms of satisfaction with overall outcome. Thus, patients who desire implant removal and autologous tissue reconstruction should not be dissuaded based on age, body mass index, laterality, or radiation therapy.
We defined reconstructive failure as either an implant loss attributable to complication (e.g., infection, exposure, capsular contracture) or patient-driven motivation attributable to dissatisfaction with the implant-based reconstruction. In this study, reconstructive failure was largely attributable to the pain and aesthetic deformity caused by capsular contracture (77 percent). The incidence of capsular contracture in implant-based reconstruction in patients without radiation therapy is low, with a recent study observing Baker grade III/IV capsular contracture in 4 percent of patients.16 The incidence increases in the setting of radiation therapy. A recent meta-analysis showed a Baker grade III/IV capsular contracture rate of 37.5 percent in a pooled analysis of radiation therapy applied to either tissue expanders or implants.17 Rates of capsular contracture can also vary depending on whether the implant or tissue expander was irradiated. Cordeiro et al. observed Baker grade III/IV capsular contracture in 17 percent of patients who had radiation therapy to their tissue expander versus 51 percent of patients who had radiation therapy to their implant.16 Of the 106 patients whose motivation was capsular contracture, a majority (62 percent) had prior radiation therapy. In addition, many of those patients had radiation therapy to their implant. The use of implant-based reconstruction in the setting of radiation therapy is beyond the scope of this article. Other reasons for failure included impending implant exposure/infection and aesthetic concerns with no capsular contracture.
Regardless of reason for implant failure, this study shows that changing to autologous tissue after implant removal is safe. Autologous tissue reconstruction may be more challenging in this patient population because of increased scarring in patients with capsular contracture and/or vascular changes seen in patients with radiation therapy. However, the complication rates observed in this study are similar to those described in the literature. Largo et al. report a total flap loss rate of 1 percent in a series of 7443 free flaps for breast reconstruction.18 Our study had only one flap loss in 192 flaps, for a rate of less than 1 percent.
The average time from implant placement to implant removal and autologous tissue reconstruction was 3.5 years. Many patients with implant-based reconstruction may be satisfied initially but, as time goes on, become dissatisfied with the result. A study of 219 patients found that in the longer postreconstruction period (>5 years), those who underwent implant-based reconstruction become more dissatisfied with their breasts compared with those who underwent autologous reconstruction.19 The reasons for this are multifactorial but may include changes in body habitus, implant malposition, progressive effects of radiation therapy, or development of capsular contracture over time. Yearly follow-up beyond just the initial postreconstruction phase may be important to capture these patients.
This study has several limitations. This is a retrospective review of prospectively collected data, and patient numbers are limited. Additional studies with a larger sample size are needed to verify these findings. Furthermore, our BREAST-Q completion rate for both time points of the study is low (23 percent). Later in the series, from 2011 to the present time, there was a much greater compliance with the BREAST-Q; however, the overall completion rate is low and, as such, there may be an element of selection bias in this study. Although the average follow-up after autologous tissue reconstruction was 15 months, longer follow-up is needed to determine whether satisfaction or well-being change, especially the decrease in physical well-being of the abdomen. Lastly, the BREAST-Q survey does not address the donor site in patients that had flaps from other donor sites beside the abdomen. Our study had six such patients.
Autologous breast reconstruction after failed implant-based reconstruction is motivated largely by capsular contracture causing pain and/or aesthetic deformity and is a safe procedure with a low complication rate. Satisfaction and quality of life have been found to be significantly improved using a validated survey tool.
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