Reply: Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation.

Abstract

We thank the authors for their thoughtful reading of our article1 and their comments. We fully agree with the authors that the timing of patient-reported outcome (PRO) measures may introduce some confounding. However, most retrospective cohort studies assessing PROs have this limitation because surveys may not be collected at standardized time points as is often the case with prospective studies. Whereas the time from reconstruction to survey completion in our study was not statistically different between the study groups,1 the authors propose that “according to [their] clinical experience,” implant-based reconstruction (IBR) and free flap breast reconstruction (FFBR) patients have different times to achievement of a relatively “stable status,” that is, 1 year for IBR and 6 months for FFBR. This opinion, to our knowledge, is unsubstantiated and has not been reported in the literature. We urge the authors to evaluate and report their data to provide scientific evidence, so that plastic surgeons can learn from their experiences. Furthermore, the authors propose that the results’ accuracy could have been compromised by not excluding patients who completed the PRO measures within 1 year of surgery. They state that excluding patients with a short postoperative period or delaying survey completion until a sufficiently long postoperative period has elapsed would yield more convincing results. However, in our study, the median time from the second reconstruction to survey completion for FFBR was 4.9 years (interquartile range, 1.8 to 9.2 years), and that for IBR was 7.3 years (interquartile range, 4.9 to 8.8 years).1 More importantly, the shortest time from second reconstruction to survey completion in our study was 1.2 years. Therefore, all surveys were completed more than 1 year after surgery, eliminating the need to exclude any PRO surveys. The authors question whether and, if so, when a patient should receive an immediate IBR rather than a delayed IBR following explantation owing to infection. They also pose the question of which factors should be considered when deciding between an immediate and a delayed IBR. We specifically state in our article that we do not generally advocate immediate IBR but rather secondary IBR under all circumstances until further research proves otherwise. An exception might be when the infection diagnosis is questionable preoperatively or is significantly challenged based on operative findings. Another less common but possible indication would be if the infection diagnosis is, at best, questionable, and the device is thought to be at high risk for exposure in the near future, which may necessitate subsequent immediate surgery. Of note, however, is that the selection criteria in our study were based on the discretion of individual surgeons, over which we had no control. We hypothesized that surgeons most likely considered the severity of the infection and whether they believed each patient had a true infection. We strongly recommend FFBR in patients at increased risk for infection, explantation, or reconstructive failure. If IBR is used, the default should always be delayed IBR, with primary immediate IBR performed only under exceptional circumstances. A diagnosis of device infection that is not clear preoperatively or even intraoperatively is not uncommon. Our study was designed to elucidate the outcomes of various options to manage patients who need explantation owing to infection. Based on this information, surgeons, and patients can determine the best option for individual patients through shared decision-making. On the basis of our outcome data alone, one could consider FFBR for every patient who undergoes explantation owing to infection. However, FFBR and IBR have significant differences, including in their complication profiles, donor-site morbidity, and hospitalization and recovery times. Something that should be emphasized is that patients who underwent initial IBR did so for certain reasons. After careful preoperative discussion between the patient and surgeon, the decision to perform an initial IBR was made. Obviously, many factors went into that decision. Some patients are not good candidates for, or would never agree to undergo, FFBR. Also, the situation regarding device explantation for infection is very different from that regarding the initial reconstruction. However, patients and surgeons should also revisit the factors considered when the initial IBR was chosen. The discussion and decision about which reconstructive option (if any) should be performed following device explantation owing to infection are important, requiring more shared decision-making. We hope that our study sheds some light on outcomes for various reconstructive options when in this situation, so that more informed discussions between surgeons and patients can occur. We anticipate that this will result in improved outcomes for each patient. DISCLOSURE The authors have no relevant financial interests or conflicts of interest to report.