Bilateral Breast Reconstruction: Indications, Limitations, and Outcomes

The indications for bilateral mastectomy, including contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) continue to evolve. The associated increased demand for bilateral breast reconstruction warrants careful evaluation of both the oncologic imperatives and outcomes specific to bilateral reconstructions. The authors evaluated the indications and outcomes of autologus bilateral breast reconstructions in terms of perioperative complications, morbidity, and patient satisfaction in an effort to devise a reasonable strategy for reconstructive options.

A retrospective review of bilateral autologous and implant reconstructions done between 1995–2005 was utilized. Outcomes, complications, indications, and patient satisfaction among subgroups of consecutive patient populations undergoing bilateral implant and/or autologous reconstruction were compared to similar cases of unilateral reconstruction.

Between July 2000 and July 2005, 1200 consecutive cases of unilateral breast reconstruction were performed at the M.D. Anderson Cancer Center. Of these, 68% (816 cases) utilized autologous tissue, and 32% (384 cases) were implant–based reconstructions. Three hundred ninety consecutive cases of bilateral breast reconstruction were performed over the same period of time. Of these, autologous tissues were utilized for reconstruction in 38% (148 cases) of cases, and implants were utilized in 62% (242 cases). The number of bilateral breast reconstructions performed was 36% higher during the study period, compared to the preceding 5-year period of 1995–2000.

Three hundred cases of consecutive bilateral abdominal flaps for breast reconstruction were compared to a similar cohort of unilateral abdominal flaps for breast reconstruction. The bilateral cases demonstrated an overall flap loss rate of 1%, partial flap loss rate of 4%, hernia rate of 3%, comparable to unilateral reconstruction, yet the bulge rate of 5.5%, utilization of prosthetic mesh (18%), and subjective reports of abdominal weakness was significantly higher in the bilateral cases. The majority of bilateral cases underwent immediate reconstruction (70%), primarily for unilateral cancer with a prophylactic contralateral procedure (78%).

The overall complication rate was comparable in the index breast (8.4%), compared to the prophylactic side (6.3%, NS). Total complications were higher in the autologous group (32%,) compared to the implant–based group (21%) and this likely related to the absence of an abdominal donor site in the latter group. The autologous flap failure rate was only 1%, whereas long–term implant failure rate approached 8%. The revision rate averaged 0.8 procedures per patient in the autologous group versus 2.5 procedures per patient in the implant–based group during the study period. Only 40% of the bilateral free abdominal flap patients went on to undergo nipple reconstruction, and only 28% underwent micropigmentation to complete the areola reconstruction. This was significantly different from the implant–based group in which 68% of the patients sought nipple/ areolar reconstruction.

Overall patient satisfaction was 43% favorable and 18% unfavorable in the autologous group and this related primarily to the patient's involvement (as compared to physician's determinant) in the decision to undergo the preventative mastectomy and reconstructive choice. Patient satisfaction with autologous reconstructions was not significantly different,compared to implant–based reconstructions (41%).

In CPM, perioperative complications are just as common in the index as the preventative breast, and favorable patient satisfaction rates are less than 50% for both autologous, as well as implant–based, reconstructions. Accordingly, careful scrutiny of the indications and expectations are critical prior to the general endorsement of CPM or BPM, regardless of the surgical technique used for reconstruction. Bilateral breast reconstruction utilizing autologous techniques can be safely performed, yet poses certain challenges in terms of the amount of autologous tissue volume that is available, compared to the breast volume that is desired, and this may adversely impact the outcome. Harvest of two lower abdominal flaps appears to increase abdominal donor–site morbidity, regardless of the type of flap utilized. Donor–site morbidity and deformity, a prolonged convalescence, and the sheer scope of a bilateral autologous reconstructive effort have stifled both patient and surgeon enthusiasm for the autologous approach. Similarly, increased operative times and declining reimbursements for autologous bilateral breast reconstructions in the United States have undoubtedly impacted the surgical decision process. These combined factors appear to have led to an increased utilization of implant–based techniques in patients presenting for bilateral breast reconstruction. Issues such as the utilization of separate surgical teams, improved operative planning and efficiency, abdominal flap choice, alternate flaps, and staging the bilateral reconstructive effort deserve further study to assess how they might possibly affect outcome.

Compared to implant–based reconstructions, bilateral breast reconstruction utilizing autologous tissues is optimal for providing permanent, living replacements of the surgically removed breasts. These types of reconstructions are not without complication and carry significant risks for abdominal donor–site deformity and morbidity. Implant–based reconstructions, while carrying less risk for morbidity and complication rates, are not permanent and provide less optimal aesthetic results. Patient satisfaction in bilateral reconstructions is less than 50% for both implant and autologous groups and does not relate to the type of reconstruction performed. Further study is warranted to assess the impact of separate surgical teams, improved operative planning and efficiency, abdominal flap choice, alternate flaps, and staging the bilateral reconstructive effort in autologous breast reconstructions.