Analysis of Secondary Surgeries after Immediate Breast Reconstruction for Cancer Compared with Risk Reduction

Abstract

Background: This study sets out to compare reconstructive practice between patients undergoing immediate breast reconstruction (IBR) for cancer and those who opted for risk reduction (RR), with an emphasis on examining patterns of secondary surgery. Methods: Data collection was performed for patients undergoing mastectomy and IBR at a teaching hospital breast unit (2013–2016). Results: In total, 299 patients underwent IBR (76% cancer versus 24% RR). Implant-based IBR rate was similar in both groups (58% cancer versus 63% RR). Reconstruction loss (5.3% cancer versus 4.2% RR) and complication (16% cancer versus 12.9% RR) rates were similar. Cancer patients were more likely to undergo secondary surgery (68.4% versus 56.3%; P = 0.025), including contralateral symmetrization (22.8% versus 0%) and conversion to autologous reconstruction (5.7% versus 1.4%). Secondary surgeries were mostly planned for cancer patients (72% planned versus 28% unplanned), with rates unaffected by adjuvant therapies. This distribution was different in RR patients (51.3% planned versus 48.7% unplanned). The commonest secondary procedure was lipomodeling (19.7% cancer versus 23.9% RR). For cancer patients, complications resulted in a significantly higher unplanned secondary surgery rate (82.5% versus 38.8%; P = 0.001) than patients without complications. This was not evident in the RR patients, where complications did not lead to a significantly higher unplanned surgery rate (58.9% versus 35.2%; P = 0.086). Conclusions: Most of the secondary surgeries were planned for cancer patients. However, complications led to a significantly higher rate of unplanned secondary surgery. Approximately 1 in 4 RR patients received unplanned secondary surgery, which may be driven by the desire to achieve an optimal aesthetic outcome.

Long‐term outcomes of breast reconstruction and the need for revision surgery

“…We agree with the assertions of Jones et al that immediate BRs should not be seen or sold to patients as a 'one off procedure', and suggest that all patients should be counselled as to the need for potential revisions in the future. 10 The associations found between smoking and revision surgery are consistent with current scientific understanding of the higher risk of post-operative complications caused by smoking. 17,18 A higher risk of complications will thereby increase the risk of requiring revision surgery.…”

“…Also, a study by Jones et al, investigating secondary surgeries in BR, found an unplanned secondary surgery rate of 28% in patients having a reconstruction for cancer and 25% in patients having risk reducing surgery. 10 These rates are across all types of reconstruction.…”

“…This is consistent with the historical body of evidence, which suggests that post-reconstruction radiotherapy heralds poorer outcomes and increased complications in women undergoing BR. 5,7,10,12,19 This is particularly the case in implant-based reconstruction, owing to the increased risk of capsular contracture. 5,19,20 However, we found that pre-reconstruction radiotherapy was not a risk factor for revision surgery, even when adjusting for confounding factors.…”

“…However, in a study similar to ours by Jones et al, no relationship between BMI and need for revision surgery was found. 10 A study by Huo et al found that obesity was associated with higher odds of infection, wound and perfusion complications after expander-implant-based reconstruction, as well as higher odds of perfusion complications after autologous reconstruction. 21 We did not find any literature on the effect of low BMI on reconstructive outcomes.…”

“…Revision surgery may be required for a variety of reasons in order to maintain or improve chest wall symmetry. 10 As a woman's body ages and changes, so too does her reconstruction, but often in a different way to a non-reconstructed breast. In addition, complications of previous surgery or radiotherapy may necessitate revision.…”