Systematic review and meta-analysis of revision surgery after immediate implant-based breast reconstruction: Re-implantation or converting to free tissue transfer?

Abstract

Immediate breast reconstruction contributes to comprehensive breast cancer care. Implant-based reconstruction (IBR) accounts for most reconstructive procedures. However, many patients undergo subsequent implant exchange or autologous conversion to optimize breast stability and patient satisfaction. This review aimed to characterize surgical complications, explore patient-reported outcomes, and identify factors related to decision-making for each revision type. In this systematic review and meta-analysis (CR420251070741), MEDLINE, Embase, CINAHL, Web of Science, Scopus, and CENTRAL were searched from inception to February 19, 2025, for studies reporting complications, BREAST-Q scores, or decision-making factors for implant exchange or autologous revision after IBR. Methodological quality was assessed using the Newcastle-Ottawa Quality Assessment for Cohort Studies tool. The primary outcome was the pooled complication rate for each procedure (meta-analysis of proportions). The mean BREAST-Q scores and patient decision-making factors were secondarily reviewed. Nineteen studies were included, encompassing 597 implant exchange patients and 702 autologous revision patients. The complication rates for implant exchange and autologous revision were 31.00% (95% confidence interval [CI], 10.00-64.00; 95% prediction interval [PI], 0.00-98.00) and 37.00% (95% CI, 24.00-51.00; 95% PI, 7.00-82.00), respectively. The decision-making factors for autologous revision were poor cosmesis (n=170), capsular contracture (n=147), and pain (n=95). The mean psychosocial and sexual well-being scores were higher after implant exchange versus autologous revision, whereas the mean satisfaction with BREAST-Q scores showed the opposite effect. Determinants and outcomes varied among revision procedures. Although these findings may help to contextualize the risks and benefits of revision, direct comparison studies between implant exchange and autologous conversion after IBR are warranted before clinical implementation.