Annelotte van Bommel

109 Clinicians’ opinion on immediate breast reconstruction except for patients aged over 75 years, which was more frequently reported by plastic surgeons compared to surgical oncologists. A possible explanation for this finding may be the assumption that older patients prefer not to undergo IBR. Another reason may be that older patients generally have more comorbidities and are therefore less eligible for IBR, specifically for more complex autologous reconstructions with potentially higher risk of complications. Smoking was considered an important contra-indication for all types of breast reconstruction by all physicians due to associated complications. In case of autologous reconstruction smoking leads to an increased risk of fat necrosis and wound healing problems, also of the donorsite, 30 and in implant reconstruction an increased risk of implant loss due to wound healing problems and infections was found. 29,31 It is therefore recommended to stop smoking 4–6 weeks prior to surgery. 32 As expected, morbid obesity affected the decision-making process for all reconstructive techniques. 18,19,26 It is well-known from plastic surgery literature that obesity leads to an increased risk of complications of the breast reconstruction itself, 29,31,33 and therefore it was not a surprise plastic surgeons more frequently regarded obesity as a contra-indication compared to surgical oncologists. Besides BMI, plastic surgeons tended to report large breast size (>cup D) more frequently as contra-indication compared to surgical oncologists. Larger breast volume is associated with an increased risk of complications as skin flap morbidity, implant loss and reoperations. 34–36 Comorbidities have been frequently reported in literature as contra-indications for IBR. 18,19,30,31,37 Plastic surgeons specifically reported cardiac and pulmonary comorbidities as contra-indications for autologous reconstruction because of the lengthy operative procedure with prolonged general anesthesia time leading to an increased risk of postoperative medical complications in these patients. Previous cardiac surgery has been suggested tobe apredictor ofmajor surgical complications. 30 Oncological related contra-indications Consistent with previous literature, 18 advanced tumor stage (cT3) and tumor positive nodes (cN2) were important contra-indications according to both groups. 6