Management and complication investigation among breast cancer patients undergoing immediate implant-based breast reconstruction: A Chinese multicenter study (CSBrS-012)

To the Editor: Immediate implant-based breast reconstruction (IBBR) has become the primary option for postmastectomy reconstruction.[1] A retrospective study was conducted to investigate the current management status and complications of patients with breast cancer who underwent immediate IBBR after mastectomy in China through a questionnaire survey. The study was approved by the Ethics Committee of the First Hospital of China Medical University (No. [2024]579). This questionnaire contains two parts: (I) Overview of the participating hospitals and the overall situation of breast reconstruction surgeries performed from January 1, 2022, to May 31, 2022. (II) Details of immediate IBBR surgery at each hospital. The data collection cutoff date was December 12, 2023, with a median follow-up of 17 months. The detailed questionnaire and flowchart summarizing the research design and patient selection process can be found in the supplementary document and Supplementary Figure 1, https://links.lww.com/CM9/C693. Statistical significance was set at P <0.05. The χ2 test, Fisher’s exact test, and logistic regression were used. A total of 32 hospitals distributed across 20 provinces in China participated in the survey. Breast reconstruction accounted for 11.19% (1119/9997) of the mastectomy cases, 80.52% (901/1119) of which were immediate IBBR, and 771 patients who underwent reconstruction of 820 breasts provided valid data. The proportion of patients with immediate one-stage IBBR was 81.10% (665/820), and the proportion of patients with immediate two-stage IBBR was 18.90% (155/820). The rate of open access was 82.60% (677/820), and that of endoscopic access was 17.40% (143/820), which indicates that endoscopic breast reconstruction is still in the initial exploratory stage in China. In terms of the choice of immediate IBBR surgical modality, the results revealed that the patient’s N-stage, history of radiotherapy, (anticipated) adjuvant radiotherapy, mastectomy type, and axillary surgery type were significantly correlated with decision-making regarding the procedure type for immediate IBBR surgery (P <0.001, P = 0.027, P = 0.001, P <0.001, and P <0.001, respectively). There was no statistically significant difference between the two immediate IBBR procedure types in terms of patient age, whether they received neoadjuvant chemotherapy or whether they planned to receive adjuvant chemotherapy [Supplementary Table 1, https://links.lww.com/CM9/C693]. These findings indicate that operators may be more inclined to choose immediate two-stage IBBR in patients requiring radiotherapy or in whom the nipple–areola complex cannot be preserved, whereas factors such as patient age, neoadjuvant chemotherapy, and adjuvant chemotherapy have less impact. The results showed that Chinese doctors preferred anatomically textured silicone breast prostheses for breast reconstruction because of their natural appearance and feel, which occupied 655 out of 735 breast prostheses, and the median volume was 245 (180–300) mL. In addition, the application of acellular dermal matrix patches and titanium-coated polypropylene mesh is becoming increasingly common, particularly for enhancing aesthetic outcomes and providing additional support during the reconstruction process. The remaining implantation-related parameters are shown in Supplementary Table 2, https://links.lww.com/CM9/C693. A total of 723 patients were included in the complication analysis. Fifty-one patients experienced reconstruction-related complications (7.05%, 51/723), 17 patients underwent unplanned revision surgery (2.35%, 17/723), and 7 patients experienced implant loss (0.97%, 7/723), which is lower than that reported previously.[2,3] This may be related to the shorter follow-up period, as well as the irregularity, incompleteness, and untimeliness of recording the postoperative follow-up data, which led to bias in the research results. Allergy history (P = 0.029), hypertension (P = 0.024), lymph node stage (P = 0.034), axillary surgery type (P = 0.016), and adjuvant radiotherapy (anticipated) (P = 0.022) were significantly correlated with the occurrence of complications. There were no statistically significant associations between complications and the implant placement level or implant covering material (P >0.05) [Table 1], and subpectoral breast reconstruction is the main form in China (61.13%, 442/723). Multivariable logistic regression revealed that allergy history (odds ratio [OR], 2.696; 95% confidence interval [CI], 1.239–5.868; P = 0.012) and postoperative radiotherapy (OR, 1.984; 95% CI, 1.054–3.734; P = 0.034) were independent risk factors for reconstruction-related complications. Table 1 - Univariable analysis of factors associated with reconstruction-related complications in breast cancer patients undergoing immediate implant-based breast reconstruction. Factors No complications (n = 672) Complications (n = 51) χ 2 P Age 42.42 ± 8.45 43.00 ± 8.63 1.645 0.619 <40 years 260 (38.7) 20 (39.2) 40–49 years 279 (41.5) 19 (37.3) 50–59 years 118 (17.6) 12 (23.5) ≥60 years 15 (2.2) 0 (0) Allergy history 4.783 0.029 Yes 48 (7.7) 9 (17.6) No 574 (92.3) 42 (82.4) BMI (kg/m2) 4.398 0.208 <18.5 33 (4.9) 4 (7.8) 18.5–23.9 432 (64.3) 26 (51.0) 24.0–27.9 170 (25.3) 18 (35.3) ≥28.0 37 (5.5) 3 (5.9) T stage 3.502 0.295 IS 130 (19.3) 13 (25.5) 1 267 (39.7) 17 (33.3) 2 257 (38.2) 18 (35.3) 3 18 (2.7) 3 (5.9) N stage 8.037 0.034 0 463 (68.9) 29 (56.9) 1 163 (24.3) 16 (31.4) 2 39 (5.8) 3 (5.9) 3 7 (1.0) 3 (5.9) Mastectomy type 1.275 0.340 NSM 551 (82.0) 45 (88.2) SSM 121 (18.0) 6 (11.8) Axillary surgery type 8.001 0.016 SLNB 480 (71.4) 28 (54.9) LLND 37 (5.5) 7 (13.7) ALND 155 (23.1) 16 (31.4) Hypertension 5.318 0.024 Yes 112 (16.7) 15 (29.4) No 560 (83.3) 36 (70.6) Smoking 3.122 0.092 Yes 66 (9.8) 9 (17.6) No 606 (90.2) 42 (82.4) Diabetes 1.463 0.237 Yes 69 (10.3) 8 (15.7) No 603 (89.7) 43 (84.3) Previous radiotherapy – 0.445 Yes 7 (1.0) 1 (2.0) No 665 (99.0) 50 (98.0) Neoadjuvant chemotherapy 0.357 0.573 Yes 114 (17.0) 7 (13.7) No 558 (83.0) 44 (86.3) Adjuvant chemotherapy (anticipated) 1.230 0.310 Yes 328 (48.8) 29 (56.9) No 344 (51.2) 22 (43.1) Adjuvant radiotherapy (anticipated) 5.622 0.022 Yes 174 (25.9) 21 (41.2) No 498 (74.1) 30 (58.8) Reconstruction procedure 1.537 0.454 Immediate one-stage IBBR 562 (83.6) 40 (78.4) Immediate two-stage IBBR (First stage) 52 (7.7) 6 (11.8) Immediate two-stage IBBR (Second stage) 58 (8.6) 5 (9.8) Surgical access 3.062 0.096 Open 539 (80.2) 46 (90.2) Endoscopic 133 (19.8) 5 (9.8) Implant placement level 3.417 0.173 Prepectoral 248 (36.7) 14 (27.5) Subpectoral 405 (59.9) 37 (72.5) Under the pectoralis major muscle fascia 23 (3.4) 0 (0.0) Implant covering material 1.077 0.576 Pure prosthesis/tissue expander 153 (22.8) 11 (21.6) Acellular dermal matrix 142 (21.1) 8 (15.7) Titanium-coated polypropylene mesh 377 (56.1) 32 (62.7) Intraoperative local antibiotic use 3.136 0.086 Yes 521 (77.6) 34 (66.7) No 151 (22.4) 17 (33.3) Prophylactic systemic antibiotics perioperatively 1.438 0.262 Yes 548 (81.5) 45 (88.2) No 124 (18.5) 6 (11.8) Postoperative use of hemostatic drugs 1.665 0.261 Yes 128 (19.0) 6 (11.8) No 544 (81.0) 45 (88.2) Use of corset after surgery 0.060 0.836 Yes 575 (85.6) 43 (84.3) No 97 (14.4) 8 (15.7) Data are presented as mean ± SD or n (%). ALND: Axillary lymph node dissection; BMI: Body mass index; IBBR: Implant-based breast reconstruction; LLND: Low-level lymph node dissection; NSM: Nipple-sparing mastectomy; SLNB: Sentinel lymph node biopsy; SSM: Skin-sparing mastectomy With respect to the aesthetic assessment of the reconstructed breasts, of the 32 hospitals included in the survey, only 18 hospitals retained images or measurement data preoperatively, and 16 hospitals routinely assessed breast reconstruction outcomes. To conclude, when performing immediate IBBR, operators need to predict and prevent complications based on the patient’s individual risk factors to improve the rate and management of breast reconstruction after mastectomy. Postoperative follow-up and aesthetic assessment should be more standardized. Acknowledgements The authors acknowledge the Chinese Society of Breast Surgery, including Jianghua Ou, The Affiliated Tumor Hospital of Xinjiang Medical University; Erwei Song, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University; Rui Ling, Xijing Hospital of Airforce Medical University; Ailin Song, Lanzhou University Second Hospital; Chuan Wang, Fujian Medical University Union Hospital; Jun Jiang, The First Hospital Affiliated with AMU (Southwest Hospital); Shu Wang, Peking University People’s Hospital; Zhenzhen Liu, Henan Cancer Hospital; Xuening Duan, Yinhua Liu, Peking University First Hospital; Wei Zhu, Zhongshan Hospital of Fudan University; Shui Wang, Jiangsu Province Hospital; Lili Tang, Xiangya Hospital Central South University; Dahua Mao, Affiliated Wudang Hospital of Guizhou Medical University; Peifen Fu, Bajin Wei, The First Affiliated Hospital of Zhejiang University; Jinghua Zhang, Tangshan People’s Hospital; Xiang Qu, Beijing Friendship Hospital of Capital Medical University; Zuowei Zhao, The Second Hospital of Dalian Medical University; Jiandong Wang, Chinese PLA General Hospital; Zhongwei Cao, Inner Mongolia People’s Hospital; Hua Kang, Xuanwu Hospital Capital Medical University; Yun-Jiang Liu, The Fourth Hospital of Hebei Medical University; Ke Liu, Jilin Cancer Hospital; Zhi-Min Fan, The First Hospital of Jilin University; ZhiGang Yu, The Second Hospital of Shandong University; Xing-Song Yu, Shandong Provincial Hospital; Jian Huang, The Second Affiliated Hospital of Zhejiang University School of Medicine; Hong-Chuan Jiang, Beijing ChaoYang Hospital Capital Medical University; Yi Zhao, Shengjing Hospital of China Medical University; YongHui Liu, The Second Affiliated Hospital of Nanchang University; Ke-Qin Wu, Obstetrics & Gynecology Hospital of Fudan University; and Qiang Zou, Huashan Hospital of Fudan University. Conflicts of interest None.