Recommendation Difficult to Understand

Gerber and colleagues first emphasize that autologous and heterologous breast reconstruction are procedures that “complement rather than oppose each other ”, only to later recommend implant-based reconstruction (1). In this form, it is difficult to understand this recommendation. Implants are not superior to autologous reconstruction, they only find more widespread use.

Gerber et al. document acute complication rates following reconstruction involving implants of up to 15.3% (1). Over the long term, revision surgery, such as implant removal and/or implant replacement or switching to autologous tissue, may be required to treat painful and aesthetically unacceptable capsular fibrosis. In a registry-based study, an overall complication rate of 76.4% and a revision surgery rate of 40.6% was found 8 years after implant-based breast reconstruction (2).

The database of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC, Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen; www.mammarekonstruktion.de) found for 1600 DIEP flap breast reconstructions a loss rate of 1.41%; this complication rate is significantly lower than that of implant-based reconstruction. Operating times are longer for autologous tissue-based reconstruction, but the long-term outcome is generally more favorable.

Anaplastic large-cell lymphoma is another complication of implant-based reconstruction (3). While its clinical significance remains uncertain, it already has to be addressed in the informed consent discussion.

The authors suggest to postpone reconstruction in patients scheduled for radiotherapy. However, this is not necessary. In Table 3, they report the same evidence level for autologous reconstruction before and after radiotherapy (2a); consequently, the procedure can be performed before radiotherapy, too. All more recent studies show that microsurgical flap breast reconstruction is not associated with an increased rate of radiotherapy-related complications (4).

The Clinical Practice Guideline on Breast Cancer (S3) requires that at the beginning of treatment patients must be informed about all available treatment options, including microsurgical procedures. Non-directive advice should be given in cooperation with the plastic surgeon. In many Centers for Breast Diseases, this collaboration has already been practiced successfully (as demonstrated by the authors) to achieve the best oncological and aesthetic results for our patients.