Mike: Hello, I’m Mike Clarke, Podcast Editor for the Cochrane Library. Women undergoing mastectomy for breast cancer treatment or risk reduction can choose among different options for breast reconstruction. In this podcast, the lead author of a new Cochrane review from October 2024, Nicola Rocco, breast oncoplastic surgeon and assistant professor at the University Hospital Federico II of Naples (Italy) discusses its findings for the comparison of implants and autologous tissue for breast reconstruction following mastectomy, with one of his c0-authors, Corrado Rispoli, from Monaldi Hospital in Naples.

Corrado: Hello Nicola, could you begin by telling us about the need for a systematic review comparing implants and autologous tissue for breast reconstruction following mastectomy?

Nicola: Thanks Corrado. Well, women who decide to undergo breast reconstruction after mastectomy deserve full details on the potential harms and benefits associated with their reconstructive pathway, if they are to make a truly informed decision in a proper shared decision-making process. This needs to be evidence-based but there was no systematic review available to us, as breast oncoplastic surgeons, providing up-to-date data from research into clinical and patient-reported outcomes in this clinical scenario, which we could use in our discussions with patients.

Corrado: So, what in particular were you hoping to cover in your Cochrane review?

Nicola: We wanted to assess the effects of different types of reconstructive technique in women undergoing breast reconstruction following a mastectomy. Specifically, we compared the use of the woman’s own tissues, called an autologous tissue-based approach, versus implants. We looked at the effects on quality of life, short-term and long-term complications, and loco-regional recurrence. We also hoped to be able to provide data on the need for re-interventions, and the length of the operation and post-operative stay.

Corrado: And what did you find?

Nicola: There are 36 studies in the review, which included more than 57,000 women from all over the world. Unfortunately, though, although this is the best available evidence, the quality of these studies and the overall evidence they provide is largely unsatisfactory. With that caution in mind, we found that use of women’s own tissues was associated with better post-operative quality of life and implants seem to carry an increased risk of long-term complications. The two reconstructive techniques were comparable for short-term complications and re-intervention rates.

Corrado: So how will the review’s findings change your approach in your daily clinical and surgical practice?

Nicola: Well, the findings seem to go in the direction of better outcomes with the use of the woman’s own tissues. However, because the quality of the evidence is low and because a scenario based totally on this is not reasonable or feasible, considering the direct costs, the operative times and the major impact on the woman’s body. Therefore, a selective approach towards breast reconstruction is probably the most appropriate solution. This would balance between the benefits and harms of autologous tissues, which might be favourable for some groups of patients but not for others.

Corrado: And, are you able to be precise about those groups?

Nicola: Unfortunately, no. At the moment the studies available for our review cannot help us in this refining of our approach towards breast reconstruction. It has not been possible to identify subgroups of patients in whom an autologous tissue-based approach is preferable to an implant-based approach.

Corrado: How might these limitations be overcome, to help to refine decision making about breast reconstruction?

Nicola: One solution might large studies which allow surgeons to use their preferred reconstruction option in a flexible way and, then to analyse the women’s outcomes in ways that balance out the differences between the types of women receiving the different options.

Corrado: Thank you, Nicola. If people would like to read the review, how can they get hold of it?

Nicola: Thanks Corrado. It’s available online at Cochrane library dot com with a search for “autologous tissue flaps for breast reconstruction”.