Women who opt for breast reconstruction after a mastectomy have a strikingly high rate of complications, according to a new report. One in three develop a postoperative complication over the next two years, and one in five requires more surgery. In 5 percent of cases, reconstruction fails.
Those who used their own body tissue to rebuild a breast had significantly higher rates of complications than those who used artificial implants, the study found.
The women who used tissue transplanted from the belly area also had weaker abdominal muscles that made simple activities like getting out of bed difficult. But they were more satisfied with their breasts at the end of the process and enjoyed a greater degree of sexual well-being than women with implants.
“The key takeaway from this research is that these are complicated decisions,” said Dr. Edwin Wilkins, a professor and researcher at Michigan Medicine and an author on both of the studies, published on Wednesday in JAMA Surgery. “These operations are not without risk.”
Dr. Andrea L. Pusic, chief of plastic surgery and reconstructive surgery at Brigham and Women’s Hospital in Boston, also an author on both of the studies, said the findings are not meant to be prescriptive. “These papers aren’t saying women should have one operation or another,” she said. “They’re about filling in the blanks that aren’t always explained to women, so they know the pros and the cons and can make good decisions.”
Dr. Pusic said the complication rate after reconstruction is probably “higher than what we’ve been telling people” but emphasized that “choosing reconstruction largely restores satisfaction with your breasts and psychosocial functioning. But it’s not uncommon to have bumps in the road.”
The studies were based on data from the Mastectomy Reconstruction Outcomes Consortium, which Dr. Wilkins and Dr. Pusic lead. It followed some 2,300 women who had breast reconstruction surgery between Feb. 1, 2012 and July 31, 2015 at 11 medical centers in the United States and Canada. More than half of the women had artificial implants inserted. About a third had reconstructions using their own tissue, a procedure known as autologous reconstruction.
The patients were followed for two or more years after the surgery. During this time, researchers tracked all medical complications and evaluated quality of life using a questionnaire called the BREAST-Q, which looked at satisfaction with the breasts as well as psychosocial, physical and sexual well-being.
The researchers defined complications broadly, including even minor problems like a wound that took extra time to heal and required an antibiotic ointment. Still, the authors and other plastic surgeons said the results were eye-opening.
“I was surprised the difference was so stark between the autologous reconstruction and the implant, and that the autologous tissue flap complication rate was so high,” said Dr. David H. Song, chairman of the department of plastic surgery at Georgetown University School of Medicine, who was not involved in the research but was a co-author of a commentary on the studies.
But Dr. Song said the research, which followed women for only a few years, did not take into account that many women with implants might need to undergo additional surgery down the line because implants may need to be replaced after 10 years or so.
Some advocates for breast cancer survivors and women who have undergone breast reconstruction were not surprised by the figures. “I have heard lots of horror stories,” said Geri Barish, principal officer of 1 in 9, a breast cancer group on Long Island.
Alise Nacson, a 41-year-old researcher in Washington, said she underwent an eight-hour procedure last year that used tissue, including fat, skin and blood vessels, from her belly to create new breasts after a double mastectomy. But the surgery on her left side failed when the transplanted tissue, called a “‘flap,” was rejected, leaving her with only one reconstructed breast. Now she is facing another operation.
“I lost a flap, which is one of the worst outcomes,” Ms. Nacson said. On the other hand, she said, “I love the breast that I have, and I adore having a flesh breast.”
Donna Lo Nigro, a 43-year-old mother of two from Wading River, N.Y., had a double mastectomy followed immediately by reconstruction with implants in 2015. Within months, she developed a painful infection and abscess in one breast, and eventually had to have both implants replaced. Then a replacement operation failed, and she had to have the second set of implants removed.
In April of 2016, she decided to try using her own tissue for breast reconstruction and had a nearly 12-hour-long procedure, which was successful. “It’s fabulous, and I’ve had no complications,” Ms. Lo Nigro said.
The research identified several factors that increase the risk of developing a complication, including being older, being overweight, smoking, undergoing a bilateral reconstruction procedure, undergoing radiation therapy during or after reconstruction or having had chemotherapy.
Although patients are often encouraged to have reconstruction immediately after mastectomy, patients who delayed reconstruction were found to be significantly less likely to develop complications than those undergoing immediate reconstruction.
While the new information is helpful, some doctors were skeptical that it would make decisions much easier for cancer patients.
“Patients trying to make a decision about surgery have just been told they have cancer,” said Dr. Deanna J. Attai, a breast surgeon and assistant clinical professor at David Geffen School of Medicine at the University of California, Los Angeles. “That alone is enough to shake even the strongest of clear thinkers.”