Anna Paganini, Susanne Meyer, Håkan Hallberg, Emma Hansson

Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4133–4143Received 8 April 2022; accepted 16 August 2022




Biological or synthetic meshes are commonly used in implant-based immediate breast reconstruction (IBR).1 They were introduced as an adjunct in secondary esthetic breast surgery and later established in breast reconstructions after breast cancer to give a better control of the reconstructed breast footprint, decrease the risk for capsular contracture, and allow for single-stage reconstruction with a fixed volume implant.2 However, scientific studies have thus far failed to support some of the benefits,3 and meshes seem to give rise to more complications than traditional muscle-cover,1,3,4 although the frequencies vary considerably depending on the type of mesh used.5 Complications seem to be lower for synthetic than biological meshes.3, 6
The frequency of complications is only one of the outcomes that are important when breast reconstruction technique is chosen. The BRAVO study7 has developed a core outcome set, which comprises major complications, unplanned surgery, donor site morbidity, normality, quality of life, and women’s cosmetic satisfaction (important for both professionals and patients); implant- and flap-related complications (important for professionals alone); and self-esteem, emotional well-being, and physical well-being (important for patients alone).7 The outcomes normality, quality of life, women’s cosmetic satisfaction self-esteem, emotional well-being, and physical well-being can be measured with patient-reported outcome measurements (PROMs).8 The dimensions measured with PROMs are complex concepts influenced by body image, social networks, psychological factors,9, 10, 11 and attitudes to the care given,12 in addition to by body mass index (BMI),13 tobacco use,14,15 and other diseases.16 Therefore, the measurement of PROMs is infested with confounders, and it is difficult to single out one factor, such as type of mesh, to compare.
The aim of this study was to compare PROMs in IBR with a synthetic mesh and a biological mesh, in a randomized controlled trial, using the compared materials in the same patient, thereby eliminating patient-related confounders. We hypothesize that the biological mesh has better stretch properties and therefore gives rise to reconstructed breasts that appear more natural and are softer, and thereby more appealing, to the patient.

Satisfaction with biological and synthetic mesh breasts

One mesh type was not clearly superior to the other regarding patient-reported satisfaction of individual items of the satisfaction with breast/s domain of BREAST-Q. A majority of the participants were equally satisfied/dissatisfied with the synthetic and the biological mesh sides regarding size of bra, softness, natural part of body, appearance compared with preoperatively, and palpable wrinkles, and about half of the patients regarding shape of bra, natural appearance, feel to touch, and visible wrinkles (Figure 2, Table 5). The aspect in which the most participants experience a difference between the synthetic and the biological mesh breast was a natural appearance, visible wrinkles, and feel to touch (Table 5, Figure 2). Among the participants who experienced differences between the two sides, more participants were more satisfied with the biological mesh regarding natural appearance and appearance compared with preoperatively. A few biological mesh breasts had bottoming out (Table 2). Among participants who experienced a difference between the two breasts, a predominance was more satisfied with the synthetic mesh size of bra and natural part of body (Table 5, Figure 2). Half of the participants who experienced a difference between the synthetic and the biological mesh were more satisfied with the synthetic mesh and half with the biological mesh regarding feel to touch, softness, and palpable wrinkles (Table 5, Figure 2).