The current issue of the journal JAMA Surgery has 3 interesting articles regarding breast reconstruction. Two of the articles compare the differences between autologous breast reconstruction (using the patient’s own tissues) and implant-based reconstruction. (Santosa, KB, et. al. JAMA Surg. 2018;153(10):891-899 and Bennett, KG, et. al. Jama Surg. 2018;153(10): 901-908 ) The article by Dr. Santosa and colleagues looked at patient satisfaction with breast reconstruction in a group of 2013 women and found that at 2 years patients who underwent autologous reconstruction were more satisfied with their reconstruction than patients with implants. The authors state that this was, however, balanced somewhat by a “worsened abdominal (or donor site) well-being.” This might have also been balanced by the results of the preceding paper in this issue of JAMA Surgery. Dr. Bennett and her colleagues looked at 2 year complication rates in patients undergoing various forms of breast reconstruction. This prospective study looked at 2343 patients undergoing 7 different techniques of reconstruction. Their results “revealed high rates of overall complications and reoperative complications, with significantly higher odds of complications associated with autologous reconstruction compared with implant techniques.” Although the two implant based reconstructions in the study had a significantly lower incidence of complications, these percentages were not small. Reconstructions using tissue expanders followed by a permanent implant had the lowest complication rate of all (26.6 %).
In summary, these two studies looked at the comparison between implant-based reconstruction and non-implant or autologous reconstruction from two different points of view. One being the risks and complications of the procedures. The other being how satisfied the patients were with the results. In the complication study, the implant group came out on top and in the satisfaction study the results were reversed. Clearly the decision to have a breast reconstruction and to decide on the best technique is a complicated one and requires a long and careful consideration after a detailed consultation with a patient’s physicians and surgeons.
Many surgeons including me have expressed for a variety of reasons concerns that autologous fat reconstruction of the breast would theoretically lead to a higher incidence of recurrence of breast cancer. The third article by Krastev, T, et. al. (JAMA Surg. Published online October 10, 2018. doi:10.1001/jamasurg.2018.3744 ) looked at the rate of cancer relapse in patients undergoing autologous fat reconstruction versus an age matched control group that did not have autologous fat reconstructions. This 5 year study did not find any difference in the two groups. Thus, for this initial period, at least, autologous fat reconstruction does not appear to increase the risk of recurrence of breast cancer. This is a very important and encouraging result. I hope the authors will continue to follow the patients for a longer period which, in my opinion, would be necessary to answer this question more thoroughly.