Intended for healthcare professionals

Practice Uncertainties

Does the addition of mesh improve outcomes in implant based breast reconstruction after mastectomy for breast cancer?

BMJ 2018; 362 doi: (Published 06 July 2018) Cite this as: BMJ 2018;362:k2607
  1. Shelley Potter, NIHR clinician scientist and, consultant senior lecturer in oncoplastic breast surgery1,
  2. Mairead MacKenzie, patient advocate2,
  3. Jane M Blazeby, professor of surgery3
  1. 1Centre for Surgical Research, Bristol Medical School, Bristol, UK, and Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
  2. 2Independent Cancer Patients’ Voice, London, UK
  3. 3Bristol Medical School, Bristol, UK
  1. Correspondence to S Potter shelley.potter{at}

What you need to know

  • The use of biological and synthetic meshes in implant based breast reconstruction has become standard care, but there is limited high quality evidence to support their safety or effectiveness.

  • Discuss with your patient the benefits and risks of using either types of mesh, including the lack of high quality long term comparative data, single stage compared with two-stage procedures, complications, and the need to consider the surgeon’s experience in the technique.

  • Encourage patients who opt for mesh based implant reconstruction to be involved in research studies contributing to evidence on long term outcomes

Of the 55 000 women diagnosed with breast cancer1 each year in the UK, more than 40% require a mastectomy2 as primary surgical treatment. To optimise quality of life and outcomes, the National Institute for Health and Care Excellence (NICE) recommends offering immediate breast reconstruction.3 In the UK4 and US,5 implant based breast reconstruction (IBBR) is the most commonly performed technique.

The implant is usually placed in a pocket under the pectoralis major muscle. This generally requires a two-stage approach as the pocket is not large enough to accommodate a fixed volume implant. A tissue expander is placed as a first stage and it is expanded by injecting fluid percutaneously until the desired size is achieved. The expander is then replaced by a fixed volume implant at a second operation. This technique is safe,6 but time consuming and uncomfortable. It is possible to use combined expander implants (“permanent expanders”) as a one-stage approach to avoid a second operation, but the results may be unsatisfactory.7

The introduction of biological and synthetic meshes in the early 2000s to augment the submuscular pocket has had a major impact on the practice of IBBR. The mesh can be used as a sling between the lower …

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