Issues, considerations, and trends in bilateral breast reconstruction

BACKGROUND:: Indications for bilateral mastectomy, including contralateral and bilateral prophylactic mastectomy, continue to evolve. Increased demand for bilateral breast reconstruction warrants evaluation of both oncologic imperatives and outcomes specific to bilateral reconstructions. METHODS:: Bilateral autologous and implant-based breast reconstructions from 1990 to 2005 were analyzed and compared with cases of unilateral reconstruction. RESULTS:: A total of 3518 cases of breast reconstruction (from 1990 to 2005) were analyzed. The majority of patients (n = 2285) underwent unilateral reconstruction using abdominal free flaps (61 percent), implants alone (23 percent), latissimus flaps with or without implants (9 percent), and pedicled transverse rectus abdominis musculocutaneous flaps (5 percent). Bilateral reconstructions were primarily immediate (70 percent) for unilateral cancer with contralateral prophylactic mastectomy (69 percent). Bilateral reconstruction was achieved with implants (57 percent), free flaps (35 percent), latissimus flaps with or without implants (4 percent), and pedicled transverse rectus abdominis musculocutaneous flaps (1 percent). Flap loss rate was comparable in unilateral and bilateral groups (1.4 percent and 1.2 percent, respectively). Bilateral reconstruction increased 36 percent after 2000. From 2000 to 2005, the majority of unilateral cases were reconstructed with flaps (68 percent; implants, 32 percent), whereas the majority of bilateral cases were reconstructed with implants (62 percent; flaps, 38 percent). Perioperative complications were higher in bilateral compared with unilateral reconstructions and in autologous compared with implant reconstructions. Free flap failure rates of 1.5 percent contrasted with early (3 percent) and long-term (>5 years) implant failure rates (8 percent). CONCLUSIONS:: Autologous tissues provide optimal replacement after mastectomy but carry the potential for donor-site morbidity. Implant reconstructions, although demonstrating less initial morbidity, appear to deteriorate over time. Aesthetic reconstruction of bilateral breasts imposes specific challenges that warrant further study into strategies for maximizing outcomes.