Discussion: Elective Revisions after Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium.

www.PRSJournal.com 1291 I this article, Nelson et al. report the number of revision and total procedures required to achieve satisfactory postmastectomy breast reconstruction by seven different modalities: direct-to-implant, two-stage tissue expander/implant, pedicled transversus rectus abdominis myocutaneous flap, free transversus rectus abdominis myocutaneous flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, and combination latissimus dorsi flap and implant.1 This represents an important addition to the breast reconstruction literature, and the authors are to be congratulated for their work. A key finding of this article is that complications lead to an increase in both revision and total procedures; 40.2 percent of women who did not experience complications underwent revision procedures versus 67.1 percent of those who did, and an average of 2.2 procedures were required to achieve a stable reconstruction without complications versus 2.6 procedures with complications. These findings are largely in agreement with earlier studies.2–5 The authors defined elective revisions as any operations performed in the operating room under anesthesia, outside of the standard reconstructive algorithm—the index procedure and nipple-areola complex reconstruction. Fat grafting, recontouring or repositioning of flap, and scar revision and/or dog-ear excision were the three most common elective procedures. Several interesting statistically significant clinical and demographic differences were observed between those patients who pursued revisions and those who did not. On the whole, patients who had autologous reconstruction underwent more revisions than those who had prosthetic reconstruction, contrary to previously published data.3 In the complication group, a greater proportion of women who had prophylactic mastectomies opted for revisions than the women who had therapeutic mastectomies. This may be explained by the fact that women who receive prophylactic mastectomies are generally younger6 and perhaps more motivated to achieve a superior aesthetic outcome. Although radiation therapy is well known to lead to an increased incidence of complications,7–10 it was associated with lower rates of revisions. As the authors discuss, this finding is likely both patientand surgeon-related, as patients with more advanced disease and therefore requiring radiation therapy may be more inclined to defer additional elective surgery, especially if the surgeon considers the increased risks of operating in an irradiated field inadvisable. Lastly, patients who were neither white nor black were almost half as likely to undergo revision procedures, although prior research has shown no relationship between ethnicity and choice of reconstruction modality (prosthetic versus autologous).11 The relatively small sample size of this population makes granular subgroup analysis difficult; however, it is an area that deserves further research. When discussing the frequency of elective procedures, it is important to remember the inherently personal nature of these decisions. Unlike postoperative hematoma evacuation or exploration of a flap with arterial or venous insufficiency, fat grafting for superior pole volume deficit or dog-ear excisions are medically unnecessary. Two patients with the same presenting complaint often have vastly different perceptions of the magnitude of the issue and thresholds for pursuing corrective surgery. Patient-reported data on the motivation for choosing (or forgoing) revisions would be valuable. How a surgeon manages the patient