Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction

The long-term cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate post-mastectomy breast reconstruction with various types of implants have been analyzed prospectively over a 9-year period. Of these patients, 334 wh o completed their reconstruction were suitable for evaluation of their cosm etic outcome. The early complication rate (< 2 months) was 9.2 percent, wit h an explanation rate of 1.7 percent. The late complication rate (> 2 month s) was 23 percent, with a pathological capsular contracture rate of 11 perc ent at 2 years and 15 percent at 5 years and an implant removal rate of 7 p ercent. The revisional surgery rate was 30.2 percent. The cosmetic results were assessed prospectively using an objective five-po int global scale. Every patient was scored at each visit once surgery was c ompleted. The overall cosmetic outcome deteriorated in a linear fashion, fr om an initial acceptable result of 86 percent 2 years after patients comple ted their reconstruction to only 54 percent at 5 years. This decline in cos metic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient, or the type of mastectomy incision employed. Radiotherapy was not a significant factor because only 28 patient s were irradiated. Upon Cox model analysis, pathological capsular contractu re was the only factor that contributed significantly to a poor cosmetic ou tcome in which p < 0.0001 (relative risk 6.3). Despite a high revisional su rgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of th e patients without capsular contracture who demonstrated deterioration in t heir cosmetic scores, it became clear that a possible reason for their poor results was late asymmetry produced by the failure of both breasts to unde rgo symmetrical ptosis with aging.