An Analysis of the Motivating and Risk Factors for Conversion from Implant-Based to Total Autologous Breast Reconstruction

Background: Problems with implant-based breast reconstructions can lead to patient dissatisfaction and a request for total autologous reconstruction. This 12-year study aimed to determine the rate of conversion from implant-based to autologous reconstruction, to identify potential risk factors, compare the rate of conversion in implant-only and latissimus dorsi/implant reconstructions, and assess patient satisfaction following conversion. Methods: Implant-based reconstructions performed between 2000 and 2008 were reviewed. The cohort was then followed prospectively until 2012. Results: One hundred thirty-nine implant-based reconstructions were performed in 118 patients. Sixty-nine patients underwent latissimus dorsi/-implant (80 breasts) and 49 underwent implant-only reconstructions (59 breasts). Twenty-one underwent bilateral reconstructions following risk-reduction surgery. Sixteen percent (19 of 118) of patients and 14 percent of breasts (19 of 139) underwent conversion to autologous tissue. None of the 21 bilateral cases converted (hazard ratio, 4.6; p < 0.05). Median time to conversion was 64 months (range, 18 to 142 months). The main motivating factors for conversion included poor aesthetic result (36.8 percent), capsular contracture (31.6 percent), change in weight (21.1 percent), and implant infection/extrusion (10.5 percent). Implant-only reconstructions were more likely to convert (hazard ratio, 3.6; p < 0.05) and at an earlier stage (p < 0.05) than latissimus dorsi/implant reconstructions. Neither radiotherapy (p = 0.68) nor capsular contracture (p = 0.94) significantly increased the risk of conversion. The BREAST-Q demonstrated high patient satisfaction after conversion. Conclusions: Autologous tissue conversion offers a definitive means of improving the quality of the result, patient satisfaction, and quality of life in troublesome implant-based breast reconstructions. Latissimus dorsi coverage of implants and bilateral reconstructions appear to be protective.