Secondary Logo

Autologous Breast Reconstruction after Failed Implant-Based Reconstruction

Evaluation of Surgical and Patient-Reported Outcomes and Quality of Life

Coriddi, Michelle, M.D.; Shenaq, Deana, M.D.; Kenworthy, Elizabeth, M.D.; Mbabuike, Jacques, M.D.; Nelson, Jonas, M.D.; Pusic, Andrea, M.D., M.H.S.; Mehrara, Babak, M.D.; Disa, Joseph J., M.D.

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 373–379
doi: 10.1097/PRS.0000000000005197
Breast: Original Articles
Free
Outcomes: Patient-Reported Health
Press Release

Background: There is a subset of patients who initially undergo implant-based breast reconstruction but later change to autologous reconstruction after failure of the implant reconstruction. The purpose of this study was to examine outcomes and quality of life in this group of patients.

Methods: After institutional review board approval, a retrospective chart review of a prospectively maintained database was performed and BREAST-Q surveys were evaluated.

Results: One hundred thirty-seven patients underwent autologous breast reconstruction following failed implant-based reconstruction with 192 total flaps. Failure of implant reconstruction was defined as follows: capsular contracture causing pain and/or cosmetic deformity [n = 106 (77 percent)], dissatisfaction with the aesthetic result [n = 15 (11 percent)], impending exposure of the implant/infection [n = 8 (6 percent)], and unknown [n = 8 (6 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)]. Thirty-four patients (23 percent) had BREAST-Q surveys. There was a statistically significant increase in overall outcomes (p < 0.001), satisfaction with appearance of breasts (p < 0.001), psychosocial well-being (p < 0.001), and physical well-being of the chest (p = 0.003). A statistically significant decrease in physical well-being of the abdomen was observed (p = 0.001).

Conclusions: Autologous breast reconstruction after failed implant-based reconstruction has an acceptable complication rate and is associated with significantly improved patient satisfaction and quality of life.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evidence-Based Outcomes Article.

New York, N.Y.

From the Department of Surgery, Plastic and Reconstructive Surgery Section, Memorial Sloan Kettering Cancer Center.

Received for publication January 29, 2018; accepted June 29, 2018.

Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.

Joseph J. Disa, M.D., Department of Surgery, Plastic and Reconstructive Surgery Section, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, MRI Building 1007c, New York, N.Y. 10065, disaj@mskcc.org

Following mastectomy, patients have the choice of undergoing autologous or implant-based breast reconstruction. Multiple studies debate the superiority of each method of reconstruction in terms of patient satisfaction and quality of life. Satisfaction with breasts, sexual and psychosocial well-being, and overall outcome are higher with autologous breast reconstruction compared with implant-based reconstruction.1–6 Other studies show that implant-based reconstruction also has high patient satisfaction.7

Although either implant-based or autologous reconstruction can have high satisfaction rates, there is a subset of patients who initially choose implant-based reconstruction but decide later to change to autologous reconstruction because of failure of the implant-based reconstruction. Few articles have examined this population.8 , 9 Visser et al. note that autologous reconstruction after implant-based reconstruction is a safe procedure with a low complication rate, and common motivations for changing from implant to autologous breast reconstruction include physical pain or tightness, dissatisfaction with the aesthetic result, and technical failure requiring removal of the implant because of infection.8 They also report that patient satisfaction and quality of life improve after autologous breast reconstruction, but these data were based on an invalidated survey tool that patients completed retrospectively.8 Therefore, the aim of this study was to examine our series of patients in which implant-based reconstruction failed and subsequently autologous tissue reconstruction was performed, with a focus on examining satisfaction and quality of life using the validated BREAST-Q. Secondary aims include the following: examining motivations for changing to autologous tissue; evaluating the surgical success of the procedure; and analyzing factors that may influence outcomes such as age, body mass index, laterality, and radiation therapy.

Back to Top | Article Outline

PATIENTS AND METHODS

After approval by the Memorial Sloan Kettering Cancer Center Institutional Review Board, a retrospective chart review of a prospectively maintained database was performed for patients who underwent autologous breast reconstruction following failed implant-based reconstruction between January of 1997 and July of 2017. Patients included were those who initially underwent delayed or immediate implant-based reconstruction after mastectomy and who ultimately changed to an autologous reconstruction. Anyone undergoing a mixed approach to reconstruction (i.e., bilateral reconstruction with unilateral implant and unilateral flap, or latissimus flap plus implant) were excluded from analysis. All autologous tissue reconstructions were performed at Memorial Sloan Kettering Cancer Center. Some patients underwent initial implant-based reconstructions and revisions at other institutions.

Demographic information including age, body mass index, lymph node procedures (i.e., sentinel node biopsy versus axillary lymph node dissection), comorbidities (i.e., smoking, diabetes mellitus), radiation therapy (i.e., before, during, or after reconstruction), and chemotherapy were recorded. Failure of implant reconstruction was defined as follows: implant exposure/infection, capsular contracture causing physical pain and/or unsatisfactory appearance, or unsatisfactory appearance without known capsular contracture. Surgical details including any revisions to either implant-based reconstruction or autologous reconstruction, laterality of the reconstruction, flap type, and complications after autologous reconstruction were also recorded.

Available prospectively completed BREAST-Q questionnaires were analyzed at two different time points: after implant-based reconstruction but before autologous breast reconstruction, and postoperatively after autologous breast reconstruction. For the first time point, the postimplant survey was used to assess satisfaction with breast appearance, psychosocial well-being, physical well-being of the chest and upper body, sexual well-being, and satisfaction with overall outcome. For each patient, the survey completed closest to autologous tissue reconstruction was used for analysis. The preoperative autologous tissue reconstruction survey was used if a postimplant survey was not available. To analyze physical well-being of the abdomen, only the preoperative autologous tissue reconstruction survey was used, as the implant-based survey does not have this category of questions. For the second time point, the postoperative autologous tissue-based reconstruction surveys were analyzed. The potential effect of age, body mass index, radiation therapy, or laterality (i.e., unilateral versus bilateral) on overall satisfaction with the reconstruction was an additional outcome measure. BREAST-Q surveys are routinely distributed in the office preoperatively and postoperatively at 1, 3, and 6 weeks; 3 and 6 months; and yearly. For each patient, the most recent survey was used in analysis.

The BREAST-Q is a Rasch-developed, validated survey instrument. Raw scores of 1 through 5 were converted with the Q-Score software program to scores from 0 to 100, with higher scores indicating greater satisfaction or quality of life. Statistical analysis was performed using Wilcoxon signed rank analysis to compare satisfaction and quality-of-life changes between survey time points. The t test and Pearson correlation coefficient were both used to analyze whether satisfaction with overall outcome was affected by radiation therapy, laterality, age, or body mass index. The t test was also used to specifically analyze whether history of radiation therapy had an effect on any category of satisfaction or well-being. Fisher’s exact test was used to examine potential associations with radiation therapy and motivation for changing to autologous reconstruction. The t test and Pearson correlation coefficient tests were conducted with Microsoft Excel for Mac 2011, Version 4.7.3 (Microsoft Corp., Redmond, Wash.). Fisher’s exact test and Wilcoxon signed rank analysis were conducted with IBM SPSS Version 22 (IBM Corp., Armonk, N.Y.). A value of p < 0.05 was considered significant. Summary and descriptive statistics were also used.

Back to Top | Article Outline

RESULTS

One hundred thirty-seven patients underwent autologous breast reconstruction following failed implant-based reconstruction. Demographic data are listed in Table 1. A representative patient is shown in Figure 1. Average age was 51.4 ± 8.9 years and average body mass index was 27.0 ± 3.9 kg/m2. Eighty-two patients received radiation therapy to either their implant [n = 58 (42 percent)], their tissue expander [n = 19 (14 percent)], or their breast after lumpectomy and before completion mastectomy [n = 5 (4 percent)]. Thirty-six patients (26 percent) underwent revisions to their implant-based reconstruction before autologous reconstruction, and nine patients (7 percent) underwent more than one revision. Revision procedures included fat grafting (n = 11), implant exchange with or without capsulectomy (n = 21), implant removal with tissue expander placement and subsequent exchange to implant (n = 3), other revisions of shape (n = 12), and seroma drainage (n = 1).

Table 1

Table 1

Fig. 1

Fig. 1

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).

Table 2

Table 2

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)].

Table 3

Table 3

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).

Fig. 2

Fig. 2

Back to Top | Article Outline

DISCUSSION

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.

Back to Top | Article Outline

CONCLUSIONS

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.

Back to Top | Article Outline

REFERENCES

1. Pusic AL, Matros E, Fine N, et al. Patient-reported outcomes 1 year after immediate breast reconstruction: Results of the mastectomy reconstruction outcomes consortium study. J Clin Oncol. 2017;35:2499–2506.
2. Eltahir Y, Werners LL, Dreise MM, Zeijlmans van Emmichoven IA, Werker PM, de Bock GH. Which breast is the best? Successful autologous or alloplastic breast reconstruction: Patient-reported quality-of-life outcomes. Plast Reconstr Surg. 2015;135:43–50.
3. Pirro O, Mestak O, Vindigni V, et al. Comparison of patient-reported outcomes after implant versus autologous tissue breast reconstruction using the BREAST-Q. Plast Reconstr Surg Glob Open 2017;5:e1217.
4. Sgarzani R, Negosanti L, Morselli PG, Vietti Michelina V, Lapalorcia LM, Cipriani R. Patient satisfaction and quality of life in DIEAP flap versus implant breast reconstruction. Surg Res Pract. 2015;2015:405163.
5. Weichman KE, Broer PN, Thanik VD, et al. Patient-reported satisfaction and quality of life following breast reconstruction in thin patients: A comparison between microsurgical and prosthetic implant recipients. Plast Reconstr Surg. 2015;136:213–220.
6. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769–776.
7. Aguiar IC, Veiga DF, Marques TF, Novo NF, Sabino Neto M, Ferreira LM. Patient-reported outcomes measured by BREAST-Q after implant-based breast reconstruction: A cross-sectional controlled study in Brazilian patients. Breast 2017;31:22–25.
8. Visser NJ, Damen TH, Timman R, Hofer SO, Mureau MA. Surgical results, aesthetic outcome, and patient satisfaction after microsurgical autologous breast reconstruction following failed implant reconstruction. Plast Reconstr Surg. 2010;126:26–36.
9. Feng LJ, Mauceri K, Berger BE. Autogenous tissue breast reconstruction in the silicone-intolerant patient. Cancer 1994;74(Suppl):440–449.
10. American Society of Plastic Surgeons. 2016 plastic surgery statistics report. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2016/plastic-surgery-statistics-full-report-2016.pdf. Accessed November 19, 2017.
11. Rojas KE, Matthews N, Raker C, et al. Body mass index (BMI), postoperative appearance satisfaction, and sexual function in breast cancer survivorship. J Cancer Surviv. 2018;12:127–133.
12. Albornoz CR, Matros E, McCarthy CM, et al. Implant breast reconstruction and radiation: A multicenter analysis of long-term health-related quality of life and satisfaction. Ann Surg Oncol. 2014;21:2159–2164.
13. Nelson JA, Disa JJ. Breast reconstruction and radiation therapy: An update. Plast Reconstr Surg. 2017;140(Advances in Breast Reconstruction):60S–68S.
14. Momoh AO, Cohen WA, Kidwell KM, et al. Tradeoffs associated with contralateral prophylactic mastectomy in women choosing breast reconstruction: Results of a prospective multicenter cohort. Ann Surg. 2017;266:158–164.
15. Sisco M, Johnson DB, Wang C, Rasinski K, Rundell VL, Yao KA. The quality-of-life benefits of breast reconstruction do not diminish with age. J Surg Oncol. 2015;111:663–668.
16. Cordeiro PG, Albornoz CR, McCormick B, et al. What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic reconstruction: Radiation to the tissue expander or permanent implant? Plast Reconstr Surg. 2015;135:1509–1517.
17. Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res. 2017;218:108–116.
18. Largo RD, Selber JC, Garvey PB, et al. Outcome analysis of free flap salvage in outpatients presenting with microvascular compromise. Plast Reconstr Surg. 2018;141:20e–27e.
19. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg. 2009;124:1–8.
©2019American Society of Plastic Surgeons