Long-Term Outcomes of 1989 Immediate Implant-Based Breast Reconstructions: An Analysis of Risk Factors for Failure and Revision Surgery

Abstract

Background: Nipple- or skin-sparing mastectomy and immediate implant-based breast reconstruction (IBR) is potentially associated with long-term unfavorable outcomes, such as revision surgery and reconstruction failure. This large patient cohort study aimed to provide long-term data on the incidence of these outcomes and to identify predictive risk factors.

Methods: Between 2012 and 2019, 1989 mastectomies with IBR were performed in 1512 women in the authors' institute. A direct-to-implant method was used in 93% and a 2-staged method with tissue expander in 7%. Logistic regression analysis was used to identify patient- and treatment-related risk factors associated with revision surgery or reconstructive failure.

Results: The mean follow-up was 62.2 months. IBR failed in 6.7% of all breasts; thus, a breast was present in 93.3%. Age older than 44 years yielded a 2.6-fold, and radiotherapy, a 1.7-fold increased risk for reconstruction failure. Revision surgery was performed in 60% of all breasts. The mean number of revisions of all IBRs was 1.2 (range, 0 to 8; SD, 1.37). Factors associated with significantly higher rates of revision surgery were age older than 44 years (OR, 1.23), smoking (OR, 1.53), specimen weight greater than 492 g (OR, 1.39), implant volume greater than 422 g (OR, 1.95), and radiotherapy (OR, 1.51). Nipple preservation was protective for both outcomes (OR, 0.71 and 0.42, respectively). Direct-to-implant procedures did not require any surgical revision in 43% of these patients.

Conclusions: Despite the necessity of revision surgery in the majority of IBRs, nearly half of the breasts did not require any revision surgery, and long-term reconstruction failure rates are extremely low. Therefore, IBR should be offered to all eligible women undergoing mastectomy, while understanding the risks.

Clinical question/level of evidence: Risk, III.

Fig. 1.

Distribution of 1989 immediate breast reconstructions following mastectomy over the various interventional paths. Note that 793 breasts (40%) had their reconstruction finished at once (“final result at once”), 1855 cases (93%) had a breast at end of follow-up (indicated in green), and 134 (6.7%) showed absence of a breast at end of follow-up (indicated in red). *Other procedures = any elective reintervention for aesthetic corrections of the breast, elective autologous or hybrid reconstructions, or revisions for oncologic purposes. ^aWith autologous reconstruction, solely autologous tissue (eg, deep inferior epigastric perforator flap, transverse rectus abdominis flap, or latissimus dorsi flap) is used. ^bA hybrid reconstruction denotes combining autologous tissue transfer (latissimus dorsi flap or thoracodorsal flap) with the use of an implant. The bolded blocks represent the outcome measures. The continuous lines represent the division of groups into distinct outcomes over time. The dashed lines indicate the aggregation of groups into a specific cluster. [N]SSM/IBR, nipple- or skin-sparing mastectomy and immediate implant-based breast reconstruction.