ORIGINAL ARTICLE

Long-Term Complications and Patient-Reported Outcomes

After Alloplastic Breast Reconstruction
Chia-Chun Lee, MD,a Cherng-Kang Perng, MD, PhD,a,b Hsu Ma, MD, PhD,a,b,c Szu-Hsien Wu, MD,a,b
Fu-Yin Hsiao, MD,a,b Ling-Ming Tseng, MD, PhD,b,d,e Yi-Fang Tsai, MD, PhD,b,d,e Yen-Shu Lin, MD,b,d,e
Pei-Ju Lien,b,d,e,f and Chin-Jung Feng, MDa,b,e,g

used, ultimate goals include obtaining an aesthetic breast while maximiz-

Background: The most widely used method for breast reconstruction in Taiwan
ing oncologic safety and minimizing reconstructive complications.2
is alloplastic breast reconstruction, and traditionally, it can be categorized into im-
Alloplastic breast reconstruction is the most widely used method
mediate or delayed, single-stage or 2-stage procedures. We evaluated clinical out-
in Taiwan, and traditionally, it can be categorized into immediate or de-
comes and analyzed patients' self-reported satisfaction and quality of life after
layed, single-stage or 2-stage procedures. The advantages of single-stage
alloplastic breast reconstruction based on a previous preliminary study.
reconstruction include quicker restoration of breast mound, in contrast to
Patient and Methods: The patients who underwent primary alloplastic breast re-
traditional 2-stage techniques, and avoidance of numerous office visits
construction after mastectomy were recruited in 2006 to 2020 at a single institute
required for the expansion process. However, single-stage implant
in Taiwan. The assessment of clinical outcomes was conducted by retrospective chart
reconstructions may have additional risks according to the quality of
review and risk analysis. The patients also completed the BREAST-Q, a condition-
the mastectomy flaps.3 Several studies have demonstrated complica-
specific patient-reported outcome measure, at least 6 months after treatment.
tions after implant use, implying that long-term outcomes may be less
Results: A total of 237 patients with 247 reconstructed breasts were enrolled in
than optimal, regardless of whether single-stage or 2-stage procedures
this study. The demographics showed that 205 (83%) were reconstructed using
are used.4–6 In our previous preliminary study, complications after
a 2-stage tissue expander-based procedure and 42 (17%) were 1-stage direct-to-
implant-based breast reconstruction are attributed to both patient-related
implant reconstructions. The mean follow-up time was 79.5 months. The clinical
and operative-related factors, which also interact.7
assessment revealed that the overall complication rate was 34%, with infection
On the other hand, patient-reported outcomes (PROs) after im-
being the most common (21 patients; 8%). According to risk analysis, smoking
plant reconstruction have been frequently discussed and evaluated in
(odds ratio, 7.626; 95% confidence interval, 1.56–37.30; P = 0.012), and
the literature. The development of the BREAST-Q—a validated PRO
nipple-sparing mastectomy (odds ratio, 3.281; 95% confidence interval, 1.54–
instrument—have helped to address this issue. Recently, the 1-year
6.99; P = 0.002) were significant risk factors for overall complications. The ques-
PROs of the Mastectomy Reconstruction Outcomes Consortium (MROC)
tionnaire response rate was 38% (94 of 247), at least 6 months after treatment.
study found that women who chose autologous reconstruction were more
The total mean score was 69.78.
satisfied with their breasts and reported greater psychosocial and sexual
Conclusions: At a single institute in Taiwan from 2006 to 2020, alloplastic breast
well-being than did women who chose implant-based breast recon-
reconstruction, either single- or 2-stage, have acceptable complication rate and
struction.1,8 Other studies also reported that patients with autologous
good postoperative satisfaction based on patient-reported outcomes. Both patient-
breast reconstruction had greater postoperative satisfaction than those
and surgery-related factors presented as significant risk factors. Precise patient
with implant-based reconstruction.9
selection and comprehensive discussion between the patient and physician may
Based on previous preliminary study, this study enrolled more
play the important role to achieve optimal aesthetic outcomes.
patients to analyze the risk factors for complications after alloplastic
Key Words: breast reconstruction, breast implant, patient-reported outcomes breast reconstruction in longer follow-up period. Furthermore, we inves-
(Ann Plast Surg 2022;88: S78–S84)
tigated patient's satisfaction and QoL by the BREAST-Q questionnaire.

B reast cancer affects 1 in 8 women during their lifetimes. Although

most women survive breast cancer after mastectomy, many must
struggle with the long-term sequelae of surgery on body image, psycho-
logical health, and quality of life (QoL).1 Breast reconstruction, using
either implant or autologous tissue, can help restore body image and al-
leviate distress associated with mastectomy. Regardless of the technique
Received November 17, 2021, and accepted for publication, after revision November
28, 2021.
a
Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans
General Hospital; bSchool of Medicine, National Yang Ming Chiao Tung University;
c
Department of Surgery, National Defense Medical Center; dDivision of General
Surgery, Department of Surgery, and eComprehensive Breast Health Center & Division
of General Surgery, Department of Surgery, Taipei Veterans General Hospital;
f
Department of Nursing, Yuanpei University of Medical Technology; and gInstitute
of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
Conflicts of interest and sources of funding: none declared.
Reprints: Chin-Jung Feng, MD, Division of Plastic and Reconstructive Surgery,
Department of Surgery, Taipei Veterans General Hospital, No. 201, Section 2,
Shih-Pai Rd, Taipei 112, Taiwan. E-mail: s19001013@ym.edu.tw.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/22/8801–0S78
DOI: 10.1097/SAP.0000000000003114
PATIENTS AND METHODS
This retrospective study was approved by the institutional review
board of Taipei Veteran General Hospital, a tertiary academic medical
center in Taipei City, Taiwan (TPEVGH IRB No. 2019-05-004 AC).
All patients in this study were women who were older than 18 years, un-
derwent immediate or delayed implant-based breast reconstruction after
therapeutic or prophylactic mastectomy at our hospital, and completed
the treatment course according to the Veterans General Hospital guide-
lines between 2006 and 2020. Exclusion criteria included secondary
breast reconstruction, follow-up time less than 1-year after reconstruc-
tion, failure of final permanent prosthesis placement, and combined
implant-based and autologous reconstruction (Fig. 1).
Demographic and clinical characteristics of patients were col-
lected, including age, body mass index (BMI), medical history, laterality
(ie, unilateral vs bilateral), indication for mastectomy (ie, therapeutic vs
prophylactic), mastectomy type (ie, nipple-sparing versus skin-sparing),
timing of reconstruction (ie, immediate vs delayed), smoking status
(ie, nonsmoker, previous smoker, or current smoker), surgical variables
(ie, mastectomy incision, reconstruction stage, implant profile, and use
of porcine small intestine submucosa mesh), radiation therapy (ie, none,
before mastectomy, after mastectomy, or after reconstruction), and

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Annals of Plastic Surgery • Volume 88, Supplement 1, March 2022
FIGURE 1. Flowchart of the study design.
chemotherapy. All surgical plans were reviewed and performed by the
multidisciplinary team, including 3 senior breast surgeons and 5 plastic
surgeons.
Clinical outcomes were defined as overall (any) complications.
Infection, seroma, capsular contracture, implant malposition, wound
complications, hematoma, implant rupture, and implant explantation were
evaluated, respectively, according to medical records. Infection was further
defined as minor or major infection. Minor infection was treated by oral an-
tibiotics under the outpatient setting, whereas major infection needed fur-
ther intravenous antibiotics under hospitalization or surgical debridement.
Seroma was also divided into early or late seroma by diagnosed at less than
12 months or more than 12 months. Only Baker grade 3 or 4 capsular con-
tracture was defined as complication. Wound complications were defined
as skin flap necrosis due to noninfectious etiology or any poor wound
healing. At last, nipple complications were also analyzed (ie, partial or total
necrosis) if the nipple-sparing mastectomy was performed.
Patient-reported outcomes were assessed via the BREAST-Q (re-
construction module) Version 2.0 survey. It is a condition-specific PRO
instrument that measures breast-related QoL and satisfaction in patients
undergoing breast reconstruction; details of its validation have been
published elsewhere.10,11 Six domains were independently calculated,
including psychosocial well-being, physical well-being: chest, sexual
well-being, satisfaction with breasts, satisfaction with implants, and sat-
isfaction with care. Each domain score was obtained by adding the re-
sponse items together and then converting the raw sum scale score to
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Alloplastic Breast Reconstruction
a score ranging from 0 to 100. Higher scores indicated greater satisfac-
tion or QoL. All patients received surveys under an outpatient setting at
least 6 months after completion of breast reconstruction and adjuvant
therapy. Patients who had reconstruction failure at any stage were ex-
cluded from the survey.
All data were analyzed by statistical database (IBM SPSS Version
25.0; IBM Corp, Armonk, New York). To assess the association between
risk factors and complications, univariate and multivariate analyses were
performed with logistic regression model. P values <0.05 were statistical
significance.
RESULTS
A total of 237 patients with 247 breasts were finally enrolled in
this cohort from 2006 to 2020. The mean follow-up time was 79.5 months.
The patients of demographic characteristics revealed that the average age
was 45 years and the average BMI was 22.1 kg/m2. Eleven patients (4%)
had a history of diabetes, and 13 patients (5%) had a history of smoking.
Bilateral breast reconstructions were performed in 10 patients (4%). Four-
teen patients (5%) had a history of radiotherapy before reconstruction, and
20 patients (8%) received postmastectomy radiotherapy. Thirty patients
(12%) and 96 patients (38%) received neoadjuvant and adjuvant chemo-
therapy, respectively. About the timing of reconstructions, 234 (95%) were
immediate, and 13 (5%) were delayed. About the reconstruction type, 205
(83%) were 2-stage tissue expander-implant technique, but only 42 (17%)
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Chia-Chun et al Annals of Plastic Surgery • Volume 88, Supplement 1, March 2022

were 1-stage direct-to-implant reconstructions. In addition, nipple-sparing

mastectomy was performed in 68 (28%) reconstructions. Among which, TABLE 1. Clinical and Demographic Characteristics of the Study
34 (50%) had periareolar or periareolar with extension incisions and Cohort With Alloplastic Breast Reconstruction
the remaining half 34 (50%) had nonperiareolar incisions. Allergan
(63%; Allergan, Inc, Irvine, California) was the most commonly used im- Patient Demographics n (%)
plant brand; silicone filled (87%), round (80%), and textured (64%) were Total patients 237
the most common implant profiles, respectively. Twenty-two (9%) recon- Total breasts 247
structions used porcine small intestinal submucosal (SIS) mesh for im- Age, mean, y 45
plant coverage. The mean implant size was 343.6 mL. Table 1 revealed
BMI, mean, kg/m2 22.1
the demographics of our cohort.
The assessment of clinical outcomes revealed that the overall DM
complication rate was 34% with 84 reconstructions. Infection was the No 236 (96)
most common postoperative complication (21 reconstructions; 8%), Yes 11 (4)
which included minor infection in 3 reconstructions (1%) and major in- Smoking
fection in 18 reconstructions (7%), respectively. The second most com- No 233 (94)
mon complication was seroma (15 reconstructions; 6%), then followed Yes 13 (5)
by capsular contracture (13 reconstructions; 5%) and malposition (13 Radiotherapy
reconstructions; 5%). The reconstruction failure rate was 2% with 6 im- Preoperative treatment 14 (5)
plant explantations (Fig. 2). Postoperative treatment 20 (8)
In multivariable logistic regression analysis, smoking (odds ratio
Chemotherapy
[OR], 7.626; 95% confidence interval [CI], 1.56–37.30; P = 0.012), and
nipple-sparing mastectomy (OR, 3.281; 95% CI, 1.54–6.99; P = 0.002) Preoperative treatment 30 (12)
were significant risk factors for any complication. Higher BMI (OR, Postoperative treatment 96 (38)
1.088; 95% CI, 1.0–1.18; P = 0.045) and direct-to-implant procedures Timing of reconstruction
(OR, 2.858; 95% CI, 1.45–5.63; P = 0.002) were potential risk factors Immediate 234 (95)
for overall complication in univariable regression analysis, but were not Delayed 13 (5)
significant in the multivariate analysis. Diabetes (OR, 6.986; 95% CI, Reconstruction
1.63–29.89; P = 0.009), smoking (OR, 7.544; 95% CI, 1.55–36.69; Direct to implant 42 (17)
P = 0.001), and early seroma (OR, 5.314; 95% CI, 1.02–27.63; Tissue expander-implant 205 (83)
P = 0.047) were independent risk factors for infection. In terms of Mastectomy type
seroma, direct-to-implant (OR, 3.849; 95% CI, 1.22–12.11; P = 0.021)
Non–nipple-sparing mastectomy 179 (72)
was an independent risk factor. Seroma (OR, 10.81; 95% CI, 2.48–
47.11; P = 0.002), postmastectomy radiotherapy (OR, 5.95; 95% CI, Nipple-sparing mastectomy 68 (28)
1.03–34.35; P = 0.046), and direct-to-implant (OR, 5.164; 95% CI, Incision location (for nipple-sparing mastectomy)
1.19–22.49; P = 0.029) were independent risk factors for capsular con- Periareolar (or with extension) 34 (50)
tracture. Early seroma (OR, 23.75; 95% CI, 5.97–94.44; P < 0.001) in Nonperiareolar 34 (50)
particular was a potential risk factor concerning capsular contracture in Breast implant brand
univariate analysis. In nipple-sparing mastectomy procedures, nipple Allergan 156 (63)
complications occurred in 15 (22%) reconstructions. Smoking (OR, Mentor 70 (28)
9.9; 95% CI, 1.63–60.06; P = 0.013) and periareolar incisions (OR, Motiva 13 (5)
5.342; 95% CI, 1.19–23.92; P = 0.028) were independent risk factors Breast implant surface
for nipple complications (Tables 2; 3).
Smooth 85 (34)
Ninety-four patients responded to the BREAST-Q questionnaire,
with a response rate of 38%. After a minimum of 6 months after com- Textured 157 (64)
pletion of treatment, patients' psychosocial well-being (68.05) scored Breast implant shape
similar to physical well-being: chest (67.52), but were both higher than Round 198 (80)
their sexual well-being (53.63; Table 4). Satisfaction with breasts had a Anatomical 46 (19)
mean score of 57.11, whereas satisfaction with implants had a mean Breast implant filler
score of 5.85 (maximum score of 8 in the BREAST-Q questionnaire). Saline 28 (11)
The total mean score of all domains was 69.78. Silicone 219 (87)
Here, we present a case of a 41-year-old woman with right breast SIS mesh
ductal carcinoma in situ, who underwent nipple-sparing mastectomy, No 225 (91)
sentinel lymph node biopsy, and further immediate breast reconstruc-
Yes 22 (9)
tion with direct-to-implant technique (Fig. 3). We also present another
case of a 53-year-old woman with right breast ductal carcinoma in situ. Implant size, mean, mL 343.6
Two-stage breast reconstruction and contralateral breast augmentation Follow-up time, mean, mo 79.5
were performed after skin-sparing mastectomy (Fig. 4). They were both BMI, body mass index; DM, Diabetes Mellitus; SIS mesh, porcine small in-
satisfied with aesthetic results at the 12-month follow-up with no post- testinal submucosal mesh.
operative complications.

However, the implant-related complications, such as infection and cap-

DISCUSSION sular contracture, may affect the aesthetic outcomes and patients' satis-
After the moratorium on silicone breast implants was lifted in the factions. Thus, it is quite important to understand the possible risk fac-
United States in 2006, silicone-filled implants have become the more tors of complications in alloplastic breast reconstruction and then opti-
popular breast implant both for augmentation and reconstruction. mize the clinical outcomes.

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Annals of Plastic Surgery • Volume 88, Supplement 1, March 2022
FIGURE 2. Summary of complications after alloplastic breast reconstruction.
In this study, we revealed the risk factors of complications and
PROs of implant-based breast reconstruction in an Asian population,
based on our preliminary results from 2009 to 2018.7 The complication
rate decreased from 37% to 34% compared with previous study, mostly
involving infections. In multivariate analysis, smoking and nipple-sparing
mastectomy were still identified as significant risk factors for overall
complications. Diabetes mellitus, direct-to-implant procedures, periareolar
incision, postmastectomy radiotherapy, and seroma were significant risk
factors for individual complications. The PRO questionnaire response rate
was 38% and yielded a total mean score of 69.78.
From 2006 to 2020, alloplastic breast reconstruction (either single-
stage or 2-stage) yielded a postoperative overall complication rate of 34%
after a mean follow-up of 79.5 months. Only 2% reconstructive failure with
implant explantation was found, which was slightly higher than previous
preliminary report.7 In the previous MROC data, the 2-year overall compli-
cation rate for 2-stage implant reconstruction was 26.6%, but single-stage
implant reconstruction had higher complication rate with 31.3%.5 In our
study, the 2-stage tissue expander-implant technique was used in 83%
reconstruction, whereas only in 42 (17%), 1-stage direct-to-implant re-
constructions were performed. The overall complication rate of our
study was quite similar to other previous studies, even for a longer
follow-up time.12
Among all complications, infection (8%) was the most common
complication in our study. This finding was also consistent with our
preliminary study.7 The MROC data, a total of 1637 alloplastic breast
reconstruction, showed an infection rate of 10.4% in 2-stage reconstruc-
tions and 15.2% in direct-to-implant procedures. However, some previ-
ous reports demonstrated a lower infection rate in alloplastic breast re-
constructions, ranging from 1% to 7.5%.2,3,13,14 Further multivariate
analysis revealed that patient-related factors, such as a history of diabe-
tes (OR, 6.986; 95% CI, 1.63–29.89; P = 0.009) and smoking (OR,
9.331; 95% CI, 2.54–34.30; P = 0.001), significantly increased the risk
of developing postoperative infection in our cohort. Therefore, the ap-
propriate patient selection of implant-based reconstruction was crucial
to prevent postoperative infection. In addition, early seroma was also
a significant risk factor for infection in our study (OR, 5.314; 95%
CI, 1.02–27.63; P = 0.047). The incidence of seroma after implant-
based reconstruction varies from 0.2% to 20%. Seroma formation is
complicated by ischemic, proinflammatory environment of mastectomy
skin flap; the dead space; and the presence of a foreign body with poten-
tial contamination and biofilm, which could induce further postoperative
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Alloplastic Breast Reconstruction
infection.15 Thus, early detection and prompt management of seroma for-
mation could prevent further implant infection.
In terms of capsular contracture, the mechanism of capsular
contracture is not well known. However, it is theorized to be a local
inflammatory reaction to the foreign body, caused by excessive fibrosis
through collagen production in the tissue surrounding the implant.
Seroma, direct-to-implant and postmastectomy radiotherapy were inde-
pendent risk factors for capsular contracture from our data. Because
seroma was related to the occurrence of infection as mentioned previ-
ously, several studies also found associations between bacterial coloni-
zation and capsular contracture.16 The primary concern with seroma
formation is the propensity to develop the further infection (0.2%–20%)
and implant loss (6.7-fold). In our study, it also disclosed that direct-
to-implant reconstruction may increase the risk of seroma formation.
Seroma formation might result from poor wound healing and skin flap
necrosis, which remains a considerable wound issue after direct-to-
implant reconstruction according to previous report.17 This might be
the reason why direct-to-implant reconstruction was also the indepen-
dent risk factor of capsular contracture. The last but not least, postmas-
tectomy radiotherapy increased the occurrence of capsular contracture
as well. Radiation toxicity induces vascular and soft tissue fibrosis,
which can lead to increased scarring, capsular contracture, a greater risk
of infection and skin necrosis, delayed wound healing, and pain. This
result is consistent with other studies on implant reconstruction followed
by postmastectomy radiotherapy.18 In addition to infection and radio-
therapy, several clinical series have been published addressing the issue
of capsular contracture and surface texturing. Textured surface implants
have been shown to lower the risk of capsular contracture than smooth
surface implants. However, textured surface implants, compared with
smooth surface implants, reduced the occurrence of capsular contrac-
ture without statistical significance in our cohort.
Nipple-sparing mastectomy, even combined with single-stage
direct-to-implant reconstruction, may increase the overall complication
rate and the occurrence of seroma and capsular contracture in our co-
hort. The single-stage implant reconstruction also had a higher rate of
implant malposition and revision from previous studies.17 Thus, the pa-
tient selection plays an important role in single-stage implant recon-
struction. In the nipple-sparing mastectomy setting, nipple necrosis is
the most frequent complication. Some risk factors for nipple necrosis
include smoking, large breast size, obesity, ptosis, old age, breast radi-
ation therapy, periareolar mastectomy incisions, mastectomy, and flap
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Chia-Chun et al Annals of Plastic Surgery • Volume 88, Supplement 1, March 2022

TABLE 2. Associations of Implant-Based Reconstruction Factors With Clinical Outcome—Univariable Analysis

Capsular Nipple Complications

Overall Complication Infection Seroma Contracture (n = 68)
Age 1.013 (0.98–1.04) 1.018 (0.97–1.07) 1.032 (0.98–1.09) 1.046 (0.99–1.11) 1.004 (0.94–1.07)
BMI 1.088 (1.0–1.18)* 1.043 (0.91–1.19) 1.126 (0.98–1.29) 1.081 (0.93–1.26) 1.081 (0.92–1.27)
DM
No Ref Ref Ref Ref Ref
Yes 2.431 (0.72–8.21) 7.361 (1.96–27.66)* — — —
Smoking
No Ref Ref Ref Ref Ref
Yes 12.055 (2.61–55.78)* 12.457 (3.72–41.75)* 3.077 (0.62–15.35) 3.669 (0.72–18.61) 8.333 (1.71–40.63)*
Radiotherapy
Preoperative treatment 2.026 (0.69–5.98) 0.819 (0.10–6.59) — — —
Postoperative treatment 1.658 (0.66–4.18) 2.049 (0.55–7.66) 0.801 (0.10–6.424) 3.829 (0.96–15.24) —
Chemotherapy
Preoperative treatment 0.966 (0.43–2.17) 0.744 (0.16–3.37) — 0.589 (0.07–4.70) —
Postoperative treatment 0.952 (0.55–1.64) 0.965 (0.38–2.42) 0.226 (0.05–1.024) 0.982 (0.31–3.10) 0.473 (0.09–2.38)
Mastectomy type
Non–nipple sparing Ref Ref Ref Ref —
Nipple sparing 3.352 (1.87–5.99)* 0.809 (0.28–2.30) 0.955 (0.29–3.11) 1.696 (0.54–5.38) —
Timing of reconstruction
Immediate Ref Ref Ref Ref —
Delay 0.567 (0.15–2.12) 0.892 (0.11–7.22) — — —
Reconstruction type
Tissue expander-Implant Ref Ref Ref Ref Ref
Direct to implant 2.858 (1.45–5.63)* 1.164 (0.37–3.65) 3.63 (1.22–10.82)* 4.714 (1.50–14.84)* 2.417 (0.73–8.04)
Implant surface
Textured Ref Ref Ref Ref Ref
Smooth 0.863 (0.49–1.51) 0.573 (0.20–1.62) 0.955 (0.32–2.89) 1.692 (0.55–5.21) 0.587 (0.12–3.00)
SIS mesh
No Ref Ref Ref Ref Ref
Yes 1.7 (0.70–4.12) 1.084 (0.24–4.99) 1.631 (0.34–7.74) 0.845 (0.11–6.83) 1.689 (0.51–5.57)
Implant size 1.002 (0.999–1.004) 1.002 (0.99–1.01) 0.998 (0.99–1.0) 1.00 (0.99–1.01) 0.997 (0.99–1.00)
Follow-up time 1.001 (0.999–1.002) — 0.999 (0.99–1.0) 1.002 (1.0–1.003) 0.998 (0.99–1.00)
Seroma —
No — Ref Ref —
Yes — 3.6 (0.91–14.27) 14.0 (3.88–50.58)* —
Early seroma —
No — Ref Ref —
Yes — 6.111 (1.41–26.50)* 23.75 (5.97–94.44)* —
Nipple-sparing mastectomy, incision location
Nonperiareolar — — — Ref
Periareolar — — — 5.636 (1.42–22.36)*
*Statistically significant (P < 0.05).
BMI, body mass index; DM, Diabetes Mellitus; SIS-mesh, porcine small intestinal submucosal mesh.

quality.2 Specifically, periareolar mastectomy incision was found to be a
positive predictor for nipple-areola complex necrosis after nipple-sparing
mastectomy (OR, 22.4). Comparatively, an inframammary fold incision
was a negative predictor for nipple-areola complex necrosis (OR,
0.0006).19 In our cohort, 28% of patients underwent nipple-sparing
mastectomies, with nipple necrosis (partial or total) as the most com-
mon complication (19%). From further risk factor analysis, patients
with smoking history and periareolar incisions may increase the
chances of nipple necrosis by directly cutting off the blood flow of
the nipple-areolar complex.
As for patient satisfaction, the literature on PROs of breast recon-
struction is tremendously broad. Our study revealed that patients with
implant-based reconstruction had acceptable satisfaction in terms of
psychosocial well-being and the appearance of their breasts. In contrast
to our study, many studies compared PRO between alloplastic and au-
tologous breast reconstructions, which disclosed higher satisfaction
with breasts for autologous than alloplastic breast reconstructions.1,8
Eltahir et al20 conducted a systematic review and meta-analysis to com-
pare BREAST-Q measurements between alloplastic and autologous
breast reconstruction.20 Interestingly, when focusing on alloplastic breast
reconstructions, the mean scores of satisfaction with the breast ranged
from 53.8 to 65.5, which was similar to our result (mean [SD], 55.63
[15.8]). It was clear that the similar complication rate resulted in the
similar patient satisfaction compared with our previous studies, although

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Annals of Plastic Surgery • Volume 88, Supplement 1, March 2022 Alloplastic Breast Reconstruction

TABLE 3. Associations of Implant-Based Reconstruction Factors With Clinical Outcomes—Multivariable Analysis

Capsular Nipple Complications

Overall Complication Infection Seroma Contracture (n = 68)
Age — — — 1.03 (0.97–1.10) —
BMI 1.101 (0.99–1.22) — 1.117 (0.97–1.29) — —
DM
No Ref
Yes 2.343 (0.59–9.16) 6.986 (1.63–29.89)* — — —
Smoking
No Ref Ref Ref Ref Ref
Yes 7.626 (1.56–37.30)* 9.331 (2.53–34.30)* 2.182 (0.40–11.80) 2.074 (0.26–16.43) 9.9 (1.632–60.06)*
Radiotherapy
Preoperative treatment 2.357 (0.73–7.60) — — — —
Postoperative treatment — — — 5.95 (1.03–34.35)* —
Mastectomy type
Non–nipple sparing Ref — —
Nipple sparing 3.281 (1.54–6.99)* — — — —
Reconstruction type
Tissue expander-implant Ref — Ref Ref Ref
Direct to implant 1.307 (0.54–3.14) — 3.849 (1.22–12.11)* 5.164 (1.19–22.49)* 2.255 (0.57–8.92)
SIS mesh
No Ref — — — —
Yes — — — — —
Implant size 1.0 (0.997–1.003) — — — —
Follow-up time — — — 1.001 (0.99–1.00) —
Seroma — — —
No — — — Ref —
Yes — — — 10.81 (2.48–47.11) —
Early seroma —
No — Ref — — —
Yes — 5.314 (1.02–27.63)* — — —
Nipple-sparing mastectomy, incision location
Nonperiareolar — — — — Ref
Periareolar — — — — 5.342 (1.19–23.92)*
*Statistically significant (P < 0.05).
BMI, body mass index; DM, Diabetes Mellitus; SIS mesh, porcine small intestinal submucosal mesh.

some cultural differences were present. Susarla et al3 compared patient sat- satisfaction with implants in single-stage reconstruction. Moreover, patients
isfaction between single-stage and 2-stage implant-based reconstructions who had nipple-sparing mastectomy had better satisfaction with breasts
and showed statistically equivalent scores of satisfaction with breasts. How- than those who had had non–nipple-sparing mastectomy (data not shown).
ever, this was slightly different from our results that demonstrated higher These results implied that nipple-sparing mastectomy or the direct-to-implant
technique would not compromise the satisfaction with breasts or im-
plants under appropriate patient selection.
TABLE 4. Summary of PRO Scores on BREAST-Q The limitations of this study included potential selection bias due
to retrospective enrollment and the issue of insurance imbursement. In
PROs Mean ± SD addition, the complication rate may be underestimated because of the
Psychosocial well-being 68.05 ± 16.11 retrospective review of the medical records, relatively small case num-
Physical well-being: chest 67.52 ± 17.49 bers, and short follow-up period. Moreover, some surgical variations
might still exist for different 5 plastic surgeons at our institute. Lastly,
Sexual well-being 53.63 ± 18.29
our response rate of questionnaire was relatively low and lack of preop-
Satisfaction with breasts 57.11 ± 15.43
erative baseline for comparison. The impact of various factors could
Satisfaction with outcome further be analyzed if comparison were provided.
Satisfaction with implants 5.85 ± 1.34
Satisfaction with care CONCLUSIONS
Satisfaction with information 63.17 ± 15.14 At a single institute in Taiwan from 2006 to 2020, alloplastic
Satisfaction with surgeon 79.55 ± 20.58 breast reconstruction, either single or 2-stage, has acceptable complica-
Satisfaction with medical team 83.51 ± 19.60 tion rates and good postoperative satisfactions based on PROs. Optimal
Satisfaction with office staff 84.07 ± 18.79 aesthetic outcomes can be achieved by precise patient selection and
comprehensive discussion between the patient and the physician.

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Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

Chia-Chun et al Annals of Plastic Surgery • Volume 88, Supplement 1, March 2022

FIGURE 3. A 41-year-old woman with right breast ductal carcinoma in situ (upper row). Six-month follow-up after endoscopic-assisted
right nipple-sparing mastectomy and sentinel lymph node biopsy with direct-to-implant breast reconstruction (lower row).

FIGURE 4. A 53-year-old woman with right breast ductal carcinoma in situ (upper row). Six-month follow-up after right non–nipple-
sparing mastectomy and sentinel lymph node biopsy with 2-stage breast reconstruction and contralateral breast augmentation
(lower row).

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