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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

Rapid Response:

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

Minimal invasive surgery - Implant mesh based breast reconstruction would be the right choice in the right patient: we need strict regulations of new surgical products

I read with interest the article by Potter et al (1) and the need for high quality evidence. First of all it must be emphasised that a variety of Oncoplastic and Reconstructive surgery are available and offered to breast cancer patients. However only approximately 40% of patients choose and undergo breast reconstruction which varies from simple mesh implant based breast reconstruction to complex micro-vascular surgery.

It is well known that Implant based breast reconstruction can be different types including: use of expander or definitive implants which can be placed in different anatomical planes including submuscular or subcutaneous. It must be emphasised that different techniques are adopted based on patient choice, oncological needs and surgeons expertise. Hence it would be difficult to incorporate “ one size fits all into surgical practice” but the techniques can be standardised.

Advances in materials and technology have enabled to carry out prepectoral mesh implant based breast reconstruction. This has led the way forward to enable “Minimal Invasive surgery” with least morbidity to patients, restoration of body image and preservation of normal chest wall anatomy. Hence this technique would be suitable in appropriately selected patients.

However we also do know that there are a variety of meshes available in the market. In the United kingdom and Europe new products related to medical devices need to be CE marked (2). The new meshes are marketed after acquiring CE marking and unfortunately these products are marketed into clinical use without evidence of high quality data and long- term results. Hence it important that the new products including breast implants and meshes are vigorously tested, evaluated robustly before available in the common market. It is also vital to work synergistically with the industry to promote innovation and advances in surgery.

However we must understand that science and technology are evolving rapidly and it is important to adapt innovative ways with caution until we have high quality evidence and patients need to be fully informed.

What you need to know?
• Implant mesh based reconstruction is a suitable option in selected patients
• Different techniques – available depending on patient choice, oncological needs and surgeons expertise
• Patients must ensure they have adequate information about their surgery, surgeons outcome and any products that would be used in their surgery

For the future
• It is the responsibility of the Government, Health industry and National health service to work in partnership to promote innovation but ensure high quality data are available before any product (mesh/implants) are available in the UK market.

1. Potter S, Mackenzie M, Blazeby J. Does the addition of mesh improve outcome in implant based breast reconstruction after mastectomy for breast cancer. BMJ 2018: 36-38.

2. Green M, Vidya R. Innovation in the need for high-quality evidence and evaluation: time to share global data and experience. Journal of the Royal Society of Medicine 2018; 111(6): 188

Competing interests: No competing interests

08 July 2018
Raghavan Vidya
Consultant Oncoplastic Surgeon and Honorary Senior Lecturer Birmingham University
Royal Wolverhampton NHS Trust
Breast Department, Royal Wolverhampton NHS Trust, Wolverhampton, WV10 0QP