Comment on: Breast satisfaction and health-related quality of life following total mastectomy, breast-conserving surgery, or immediate breast reconstruction in Japanese patients with breast cancer: multicentre cross-sectional controlled study (Reborn)

Correspondence to: Janhavi Venkataraman (email: Janhavi.Venkataraman@hcahealthcare.co.uk; janhavivraman@gmail.com)

The London Breast Institute

Princess Grace Hospital

42-52 Nottingham Place

London W1U 5NY, UK

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BJS Open, https://doi.org/10.1093/bjsopen/zraf094, published 11 September 2025

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We read with great interest the article by Seki et al. evaluating breast satisfaction and health-related quality of life (HR-QoL) following different surgical approaches in Japanese patients with breast cancer1. The authors are to be commended for conducting a large multicentre study in this important field.

We would like to highlight several limitations.

First, women in Japan generally have smaller breast volumes and a very low incidence of ptosis2. These anatomical characteristics allow many patients to achieve favourable aesthetic outcomes with implant-based reconstruction, which may partly explain why implant and autologous reconstructions demonstrated comparable HR-QoL in this cohort. However, these findings may not be generalisable to populations with different breast biometrics and cultural expectations.

Second, the study also did not provide detailed information on specific implant-based reconstruction techniques, such as nipple-sparing versus non–nipple-sparing mastectomy, single-stage versus two-stage reconstruction, prepectoral versus subpectoral implant placement, or use of acellular dermal matrix. These factors are well known to influence capsular contracture, shoulder dysfunction, and psychosocial and physical well-being, and their omission limits interpretation of the reported outcomes3.

It should additionally be emphasized that breast-conserving surgery followed by radiotherapy confers superior oncological outcomes compared with mastectomy, as demonstrated by recent clinical evidence, and should therefore be regarded as the preferred option whenever clinically feasible3.

Finally, as acknowledged by the authors, the cross-sectional design and imbalances in baseline characteristics (such as age, disease stage, and adjuvant therapy) limit causal inference.

Future research should employ prospective, longitudinal, and ideally comparative designs that stratify outcomes by reconstruction technique and include populations with more diverse breast biometrics. Such efforts would provide a more nuanced and generalisable understanding of how surgical choices affect long-term HR-QoL.

In summary, the study by Seki et al. represents an important contribution to the literature, but further research addressing methodological and anatomical considerations is essential to guide individualized surgical counselling worldwide.