Lisa Cassileth, MD, FACS, chief executive officer and founder of The Practice Healthcare, discussed her retrospective study assessing 499 breast reconstructions, published in Aesthetic Surgery Journal Open Forum, which showed non-significantly lower mastectomy skin flap necrosis (MSFN) rates in patients who received upsized implants compared with those who were downsized. Cassileth further defined the hypotheses her team initially considered, including differences in patient age, body mass index (BMI), and breast size between the 2 groups, and explained why those factors did not fully account for the pattern they observed.
Transcript:
CancerNetwork: What were your initial thoughts when you found that MSFN rates were lower in the upsized group compared with the downsized group, and how do you interpret these results?
Cassileth: Well, our first thought was that these are different patient populations. Looking at it, we thought, okay, perhaps it’s a thinner patient [population]…Let’s say your peak cancer diagnosis [age] is 55; our patients are a little younger than that because we also have a lot of prophylactic patients. We have a different group of patients; these patients…tend to be a healthier group than [patients in the rest of the country]. Maybe, over time, if they breastfed, they’ve lost volume, and you see that a lot in women as they age, especially after breastfeeding. They have a net loss of volume over time, especially if their weight stays similar, and they can even become more slender than they were before, with loose skin. The patient is like, “I used to be a C, now I’m a B. Can I just be my old size?” I don’t want to tell that patient no if the answer isn’t no. We thought, oh, this is because it’s a different group of patients. They [have] lower BMI, they’ve kept their weight down, maybe they breastfed, and maybe this is just a healthier group.
It turned out that although that was true, it wasn’t the driving principle. Patients at the same weight had less risk when they upsized vs downsized. We [also] thought, maybe it’s overall breast size. Now, it is true that the bigger the breast, the greater the complication rate. There’s more surface area, more square centimeters of tissue, so there’s more exposed trauma to the body, and some [complications] do go up, seroma especially. Seroma is a complication caused by damage to blood or lymphatic channels from the overall trauma and surface area inside the breast. After we corrected for BMI and breast size, what we found was that it was more than just that.
I don’t have a definitive answer for you, except to say that as a plastic surgeon, you want a hand-and-glove fit between the remaining breast skin and the implant. If a patient is complaining that they’re too loose, using something that fills it out is going to give a better hand-and-glove fit than forcing them into a smaller device and having it drape off them like a Shar-Pei. That isn’t success. Not only does it not look good, but the body doesn’t like folds and wrinkles because they affect blood flow. We just want it smooth and even, with direct [blood flow] everywhere, and that’s better. Not only does it look better, but it’s more anatomically correct for that patient. Now, when you take someone [who has larger breasts] and wants to downsize, not only would you have that additional injury, but you’d also have [tissue] that has to shrink to fit a smaller device. Maybe you’ll get some of that Shar-Pei [effect], or maybe you’re just asking the skin to retract under the weight of that heavier breast. Now, you’re asking the tissue to do more, and that increases the complication rate and the injury risk to the patient.
Reference
Cassileth LB, Killeen KL, York A, Rosen D. Does breast implant size larger than mastectomy specimen size increase the risk of flap necrosis? Aesthet Surg J Open Forum. 2026;8:ojag063. doi:10.1093/asjof/ojag063
