Long-term Implications of Cosmetic Breast Surgeries on Subsequent Breast Reconstruction

Abstract

Background

Cosmetic breast surgeries such as augmentation, mastopexy, and reduction are common aesthetic medical procedures for enhancing physical appearance. Despite their popularity, the influence of these surgeries on subsequent breast reconstruction for cancer patients remains underexplored.

Objectives

In this study we sought to investigate the effects of previous cosmetic breast surgeries on the outcomes of breast reconstruction.

Methods

A retrospective chart review was conducted from January 2011 to May 2023. This analysis compared patients with histories of implant augmentation, breast reduction, mastopexy, and augmentation mastopexy with those receiving reconstruction without any cosmetic surgery history. Demographics, comorbidities, complications, revisions, and BREAST-Q surveys were collected. Statistical analysis was performed with SPSS, with significance set at P < .05.

Results

The study included 124 patients (50 autologous, 74 implant) with a history of cosmetic breast surgery (102 implant augmentations, 17 breast reductions, 5 mastopexies, and 9 augmentation mastopexies). They were analyzed in comparison with 1307 patients (683 autologous, 624 implant) without previous cosmetic breast surgery. Patients with previous cosmetic surgeries showed a higher incidence of hematoma with tissue expander placement. A preference for implant-based reconstruction was more common among patients with an augmentation history (P < .001), whereas autologous reconstruction was more common in those with a history of breast reduction (P = .047). Patients with a history of breast augmentation had on average significantly more breast revisions (P < .05).

Conclusions

In this study we demonstrate a significantly higher hematoma rate and number of revisions in patients with previous cosmetic breast surgery when compared to patients without a history of cosmetic surgery. Furthermore, we suggest that types of cosmetic breast surgery influence the decision-making process regarding implant vs autologous reconstruction.

Level of Evidence: 4

The landscape of plastic surgery has evolved significantly, with cosmetic breast surgeries now representing a substantial component of aesthetic procedures. Surgeries such as breast augmentation, mastopexy, and breast reduction have witnessed a surge in popularity, offering patients not only an enhancement in physical appearance but also a boost in psychological well-being.^1-6 Despite the widespread acceptance and success of these cosmetic interventions, their potential influence on subsequent breast reconstruction, especially for patients with breast cancer, has remained largely underexplored.^7,8

Breast cancer is a pervasive diagnosis affecting millions of individuals worldwide, often necessitating surgical interventions such as mastectomy as part of the treatment protocol.⁹ For these patients, the decision to undergo breast reconstruction is deeply intertwined with physical and emotional well-being, because it plays a pivotal role in restoring a sense of wholeness and self-esteem following cancer treatment.¹⁰ The landscape of breast reconstruction is expansive, encompassing a wide variety of surgical approaches, including autologous tissue reconstruction, implant-based reconstruction, and hybrid techniques.^2,11,12 Autologous tissue reconstruction offers a natural and long-lasting solution, while implant-based reconstruction provides a less invasive alternative.¹³ Understanding how previous cosmetic breast surgery may influence the decision-making and outcomes of subsequent breast reconstruction is important.

In this study we evaluate the implications of cosmetic breast augmentation, mastopexy, and breast reduction on breast reconstruction for breast cancer patients, with a particular focus on the various types of reconstruction. The goal was to equip patients and healthcare providers with evidence-based insights that can guide decision-making and optimize clinical practices. While insurance would consider some breast reduction cases to be reconstructive, we include breast reduction under the umbrella of cosmetic surgeries to explore its aesthetic implications and influence on subsequent reconstructive outcomes.⁴

METHODS

After Institutional Review Board (IRB) approval from UT Southwestern Medical Center (Dallas, TX) was obtained, a retrospective chart review of all patients with a recorded history of cosmetic breast surgery before any autologous or implant-based breast reconstruction between January 2011 and May 2023 was performed. All patient care was managed by the 2 senior authors (N.T.H. and S.S.T.) at a single academic institution. Three separate analyses were completed in this study. Patients with a history of cosmetic breast surgery, including implant augmentation, breast reduction, mastopexy, and augmentation mastopexy, were analyzed in comparison with patients who did not undergo any cosmetic breast surgery. Augmentation mastopexy was then combined with implant augmentation and analyzed separately from breast reduction patients, compared with patients with no history of cosmetic breast surgery. Last, augmentation and augmentation mastopexy patients were analyzed in comparison with breast reduction patients. For each analysis, patients were further separated by reconstruction type to be analyzed within an autologous-based reconstruction group and implant-based reconstruction group. Specific flap types were analyzed within the autologous-based reconstruction group. To standardize the reconstruction process, all patients included in this study underwent tissue expander placement. Any data recorded separately by sidedness (right vs left) were combined into a single variable. Data including patient demographics, comorbidities, smoking history, cancer treatments, complications, and revisions were analyzed.

BREAST-Q surveys were sent to all patients seen for breast reconstruction by N.T.H. and S.S.T. at consistent time points.¹⁴ All completed responses were included in the study regardless of timing. Patient-reported postoperative satisfaction with breasts, psychosocial well-being, physical well-being: chest, physical well-being: abdomen, sexual well-being, satisfaction with information, satisfaction with surgeon, and satisfaction with office staff were tabulated and compared between groups. All data were collected retrospectively and managed with REDCap electronic data capture tools.¹⁵ Statistical analysis was completed with SPSS statistical software.¹⁶ Pearson's chi-square test was applied to compare categorical variables across groups, and an independent samples t test compared continuous variables across groups.¹⁷  P values less than .05 were considered statistically significant.

RESULTS

A total of 124 patients (50 autologous, 74 implant) with a history of cosmetic breast surgery were included. The average age of patients was 52 (±10.2) years. The group comprised 102 implant augmentations, 17 breast reductions, 5 mastopexies, and 9 augmentation mastopexies. This group was compared with 1307 patients (683 autologous, 624 implant) with no history of previous cosmetic breast surgery. The average age of patients was 53 (±11.0). Patient demographics were compared (Table 1). On average, patients with a history of previous cosmetic breast surgery (P < .001) or previous breast augmentation (P < .001) had a significantly lower BMI than patients without a history of previous cosmetic breast surgery. Analysis of tissue expander complications revealed a significantly higher hematoma rate in those patients with a history of previous cosmetic surgery (P < .001) (Table 2).

With regard to reconstruction choice, a significantly higher proportion of patients with a history of previous cosmetic breast surgery (P = .011) and augmentation only (P < .001) pursued implant-based reconstruction, while a significantly higher proportion of patients with a history of breast reduction (0.047) pursued autologous-based reconstruction. Of note, a significantly higher proportion of patients with a previous history of cosmetic breast surgery (P = .002, < .001) and breast augmentation (P = .005, < .001) chose either profunda artery perforator (PAP) or lumbar artery perforator (LAP) autologous surgeries, respectively. On average, patients with a history of previous cosmetic breast surgery (P = .003) or breast augmentation (P = .002) who pursued autologous-based reconstruction had significantly more breast revisions (Table 3). Additionally, patients with a history of previous cosmetic breast surgery (P = .040, .004) or breast augmentation (P = .042, .010) who pursued implant-based reconstruction had on average significantly more breast revisions and total number of operating room visits for breast reconstruction, respectively (Table 4).

The demographics of patients with a history of breast augmentation were compared to those with a history of breast reduction (Supplemental Table 1, available online at www.aestheticsurgeryjournal.com). On average, the BMI of patients with a history of breast augmentation was lower than that of patients with a history of breast reduction (P = .007). There were no differences in tissue expander complications between groups (Supplemental Table 2, available online at www.aestheticsurgeryjournal.com). A significantly higher proportion of patients with a history of breast augmentation pursued implant-based reconstruction, while a significantly higher proportion of patients with a history of breast reduction pursued autologous-based reconstruction (Supplemental Tables 3, 4, available online at www.aestheticsurgeryjournal.com).

All BREAST-Q responses for preoperative and postoperative reconstruction were analyzed for each group and directly compared with the cohort of patients with no history of cosmetic breast surgery. Response rates were 11% for preoperative reconstruction surveys and 43% for postoperative reconstruction surveys (Figure 1). Postoperative BREAST-Q surveys were sent out at 3-month, 6-month, 12-month, 18-month, and 24-month intervals. The average postoperative response time was 15.4 months. Patients with a history of breast augmentation or augmentation mastopexy had a significantly higher preoperative breast satisfaction and chest physical well-being score when compared with no history of cosmetic surgery patients (Supplemental Table 5, available online at www.aestheticsurgeryjournal.com). When comparing all patients with a history of cosmetic breast surgery to those with no history of cosmetic breast surgery, there was a significantly higher postoperative chest physical well-being score and postoperative sexual well-being score (Table 5). Clinical significance was confirmed by a 4-point change in BREAST-Q response scores.¹⁸ Of note, patients with a history of breast augmentation or reduction were found to have higher BREAST-Q scores of clinical significance for preoperative breast satisfaction, psychosocial well-being, and chest physical well-being, while only patients with a history of breast augmentation had a higher BREAST-Q score for sexual well-being. Postoperative BREAST-Q responses of clinical significance demonstrated patients with a history of breast augmentation or reduction with higher BREAST-Q scores for postoperative breast satisfaction, chest physical well-being, and sexual well-being. Patients with a history of breast reduction had a higher sexual well-being response score of clinical significance.

DISCUSSION

The findings of this study offer new insights into the nuanced relationship between previous cosmetic breast surgeries and subsequent breast reconstruction outcomes, highlighting several important considerations for surgeons and patients. First, the significantly lower BMI observed in patients with a history of cosmetic breast surgery, especially those who underwent augmentation, suggests that these individuals may present distinct anatomical and physiological profiles compared with those without this history. This underscores the need for personalized preoperative assessment and counseling. Due to the low BMI of these patients, it was not surprising that they more often opted for LAP and PAP flaps instead of DIEP (deep inferior epigastric perforator) flaps. Many studies have shown good outcomes in low BMI patients with alternative flaps to the DIEP flap due to inadequate abdominal tissue.^19-23 We chose to exclusively include tissue expander patients to standardize our reconstructive process, as it aligned with our breast surgeons’ preferences, primarily opting for 2-stage implant or delayed autologous reconstructions, because expanders offered better control over mastectomy skin and facilitated optimal results with fat grafting.² Immediate autologous reconstruction is avoided in many cancer cases due to concerns about radiation effects on flaps.²⁴

Moreover, the choice of reconstruction modality appears to be influenced by previous cosmetic procedures, with a predilection for implant-based reconstruction observed in patients with previous breast augmentation and a tendency toward autologous-based methods in those with a history of reduction. These preferences may reflect underlying patient desires, be impacted by the patient anatomy, or be a result of cosmetic changes following the previous breast surgeries. It is possible that tissue availability and quality may be a decisive factor driving decision-making.^21,25 For instance, those with a history of breast augmentation might not have adequate donor sites to recreate the augmented appearance of their breast.

Complications, such as an elevated incidence of tissue expander hematoma in patients with previous cosmetic breast surgery, may stem from the complexities of altered anatomical planes or scar tissue formation. These factors can complicate the mastectomy and expander phase of the reconstructive process. The incidence of neoadjuvant chemotherapy was statistically significantly higher in patients who underwent augmentation or augmentation mastopexy. This discrepancy may be attributed to the inability to match the cohorts accurately, which represents a limitation of this study. Additionally, the increased rate of tissue expander infections in patients with a history of augmentation is potentially explained by the higher prevalence of neoadjuvant chemotherapy in these patients.

Notably, the analysis indicates that individuals with a history of cosmetic breast surgery, particularly those who underwent augmentation, tend to undergo more breast revisional surgeries and have a higher overall number of operating room visits for breast reconstruction. Others have reported similar findings.²⁶ Moreover, the patterns observed suggest that previous cosmetic surgeries might influence patient expectations and perceptions of acceptable outcomes, potentially lowering their threshold for pursuing surgical revisions. These findings highlight the intricate balance between surgical strategy and patient expectations, emphasizing the need for a comprehensive, patient-centered approach in managing breast reconstruction for individuals. Understanding the psychological profile of patients who have previously undergone cosmetic breast procedures is crucial when they face reconstructive surgery. These patients often have high aesthetic expectations and are accustomed to surgical results that enhance their appearance. It is essential for surgeons to manage these expectations realistically, discussing potential risks and complications in detail. This paper provides a framework for these discussions, providing guidance to aligning patient expectations with likely outcomes, thereby reducing dissatisfaction and the potential for challenging postoperative periods.

While patients with a history of breast augmentation or augmentation mastopexy reported significantly higher preoperative breast satisfaction and chest physical well-being compared to those without any cosmetic surgery history, there was no such difference noted with a breast reduction history preoperatively. This suggests that the type of previous cosmetic breast surgery can have different effects on a patient's baseline satisfaction and perception of physical well-being. Postoperatively, however, there was a notable improvement in chest physical and sexual well-being across patients with any history of cosmetic breast surgery compared to those without, supporting the hypothesis that previous cosmetic interventions can yield enduring positive effects on physical and sexual well-being after mastectomy and breast reconstruction.²⁷ Numerous studies in the literature have demonstrated significant improvements in patient satisfaction and quality of life following cosmetic breast surgeries. These improvements, measured with the BREAST-Q survey tool, have been consistently observed across various follow-up periods.^{28, 29} Our findings add a new dimension to the discourse, demonstrating that previous cosmetic breast surgeries ultimately enhance patient-reported satisfaction and well-being scores without detracting from postreconstruction quality of life.

Previous studies have investigated the considerations of previous cosmetic breast surgeries in subsequent breast reconstruction; however, they primarily focused on implant-based reconstruction.^26,30,31 In contrast, our study includes both implant-based and microsurgical reconstruction techniques for patients with a history of cosmetic breast surgery. Specifically, in our study we examine DIEP, LAP, and PAP flaps, which have not been reported in the previous literature for this patient population requiring breast reconstruction after breast cancer. This represents a pivotal advancement in comprehending the complexities and outcomes of breast reconstruction following cosmetic breast surgeries. Despite its contributions, additional research is needed to address the limitations of this study. Notably, the retrospective design and reliance on subjective responses from the BREAST-Q survey introduce potential biases that may have affected our findings. One of the main strengths of our study was the large sample size and the comprehensive data collection on patient satisfaction and surgical outcomes. However, a notable weakness was the lack of matched cohorts, because the number of patients with a history of cosmetic surgery was significantly smaller than those without. This discrepancy may introduce bias and affect the generalizability of our findings. Future investigation must adopt longitudinal approaches to holistically grasp the long-term effects of previous cosmetic breast surgeries on reconstruction outcomes, specifically in evaluating long-term outcomes, patient satisfaction, and quality of life after reconstruction. Such research is crucial for developing a more nuanced understanding of how preexisting cosmetic procedures influence the reconstructive journey, thereby informing best practices and optimizing patient care.

CONCLUSIONS

In conclusion, this research identifies the interplay between breast reconstruction and previous cosmetic breast surgeries, highlighting the paramount importance of a personalized, history-informed approach. Our findings illuminate not only the necessity of integrating a patient's complete surgical history into postmastectomy reconstruction planning but also how specific types of previous cosmetic breast procedures critically influence the selection of reconstruction techniques. This detailed exploration reveals that while previous surgeries can enhance reconstruction outcomes, they also elevate the risk of complications, increase the likelihood of surgical revisions, and lead to more frequent operating room visits. Therefore, recognizing the influence of past cosmetic breast surgeries on the decision-making processes is essential to tailoring reconstruction strategies that optimize outcomes and navigate the complexities of patient care with informed precision.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes