Complications in Post-mastectomy Immediate Breast Reconstruction: A Ten-year Analysis of Outcomes

Single-Stage Latissimus-Implant Breast Reconstruction Is Safe and Reliable: A Single Surgeon Series of 207 Flaps

BACKGROUND

The latissimus dorsi flap (LDF) is a historical workhorse and contemporary salvage mainstay for breast reconstruction. There is still debate regarding timing and staging, with some authors advocating for staged reconstruction using tissue expanders. We present a single-surgeon experience with LDF breast reconstruction and compare the results of single-stage reconstruction versus staged approaches.

METHODS

Patients undergoing LDF breast reconstruction from 2008 to 2021 with a single surgeon (R.S.) were included. Charts were reviewed for demographics, indications, number and type of planned stages, and outcomes. Acute and chronic complications and revisions were compared between indication and staging groups.

RESULTS

A total of 156 patients underwent LDF breast reconstruction, of which 111 flaps (53.1%) were bilateral. One hundred seventy-nine (85.6%) flaps were for primary reconstruction, and 30 (14.4%) flaps were for salvage of a previous breast reconstruction. Fourteen (6.7%) flaps were 1-stage LDF alone, 189 (90.4%) were 1-stage LDF with implant, 1 (0.5%) was 2-stage LDF with implant, and 5 (2.4%) were 2-stage LDF with tissue expander then implant. The mean follow-up was 44.9 months (range, 1-164 months). The most common complication was capsular contracture (29%). Overall complication rates were similar between primary and salvage reconstruction (35.8% vs 43.3%, P = 0.426), as was needed for revision (39.1% vs 40.0%, P = 0.926). There was a significant difference in complication rate (P = 0.021) but not revision rate (P = 0.133) between staging groups: 1-stage LDF alone, 7.1%, 14.3%; 1-stage LDF with implant, 40.2%, 41.8%; 2-stage LDF with implant, 0.0%, 0.0%; and 2-stage LDF with expander then implant, 0.0%, 20.0%. After removing capsular contracture, there was no difference in complication rates.

CONCLUSIONS

Single-staged LDF/implant reconstruction remains a safe and reliable surgical option for both primary and salvage breast reconstruction. High rates of capsular contracture should prompt the deployment of techniques to reduce its incidence.

Factors associated with emergency free flap reoperation in postmastectomy breast reconstruction: A population-based cohort study

BACKGROUND

Reoperation shortly after free flap breast reconstruction is a substantial event with impacts on patients and healthcare utilization. The objective of the study was to evaluate the factors associated with the return to the operating room in free flap breast reconstruction patients.

METHODS

This retrospective cohort study included patients who underwent postmastectomy free flap breast reconstruction from 2005 to 2020 in Ontario, Canada. Patient records were identified from a prospectively maintained administrative database stored at the Institute for Clinical Evaluation Sciences. The outcome of interest was emergency return to the operating room within a week of primary autologous breast reconstruction. Univariate and multivariable logistic regression models were used to assess independent factors associated with emergency reoperation.

RESULTS

We evaluated 2290 patients who underwent autologous breast reconstruction with free tissue transfer. Overall, 167 patients (7.29%) underwent emergency surgery within 7 days. Most reoperations (86%) occurred within the first 3 days. The odds of reoperation were higher for patients from the lower-income quintiles (quintile 5 vs. quintile 1: adjusted odds ratio [aOR] 2.14, 95% confidence interval [CI] 1.27-3.60, p = 0.004) and in nonteaching hospitals (aOR 1.73, 95% CI 1.09-2.72, p = 0.019). Age, Charlson Comorbidity Index, diabetes, reconstruction timing, geographical location, and rurality were not associated with free flap takeback.

CONCLUSION

In a universal health care system, patients from the lowest income quintile and patients who underwent reconstruction at nonteaching hospitals were at increased odds of reoperation. Increased efforts are needed to mitigate the disparities and improve outcomes across all demographics.

Clinical outcomes and aesthetic results of reverse sequence endoscopic versus traditional bilateral nipple-sparing mastectomy with immediate implant-based breast reconstruction-an analysis of initial 116 patients from single institution

Background

Endoscopic or robotic surgeries can minimize and hide the scars compared to conventional breast reconstruction but are considered unsuitable for bilateral procedures due to the extended operation time. This study explored a novel time-shortening endoscopic technique, namely reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with bilateral implant-based breast reconstruction (BIBR), and compared it with conventional open surgery in clinical and cosmetic outcomes.

Methods

We retrospectively analyzed patients who underwent BIBR in the West China Hospital from January 2017 to June 2022. Patient characteristics, operation time, postoperative complications, breast satisfaction, and Scar-Q scores were compared between endoscopic and conventional open groups.

Results

Among 116 patients, 76 underwent R-E-NSM with BIBRs (R-E-BIBR group), and 40 underwent conventional open BIBRs (C-O-BIBR group). The demographics and clinical data were similar primarily (P > 0.05). Compared with the C-O-BIBR group, the R-E-BIBR group had lower rates of total (32.5% versus 6.6%, P < 0.001), major (13.8% versus 2.0%, P < 0.001) and minor (23.8% versus 3.9%, P < 0.001) complications. The operation time between the two groups is not statistically significant (290.2 ± 95.2 mins versus 271.9 ± 95.3 mins, P = 0.327). The Harris scale scored breast satisfaction, and the excellent rate of the C-O-BIBR group was 32.5% while the R-E-BIBR group was 58.0% (P < 0.001). The mean Scar-Q scores were 35.17± 9.6 in the C-O-BIBR group and 81.32 ± 12.3 in the R-E-BIBR group, respectively (P < 0.001).

Conclusion

The innovative R-E-NSM with implant-based breast reconstruction makes up for the long operation time of previous endoscopic surgeries and has significant advantages in reducing complication rates and improving the cosmetic results of the postoperative breasts.

Level of Evidence

Level III, Retrospective study.

How low can we go: Achieving postoperative day 1 discharge after deep inferior epigastric perforator, a safe and feasible goal

BACKGROUND

Although rare reports describe discharge to be possible within 48 hours for patients undergoing autologous breast reconstruction, average length of stay remains around 3 days. This study aimed to demonstrate that patients can be safely discharged within 1 day after deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

A retrospective review was performed of patients who underwent free flap breast reconstruction by a single surgeon from November 2021 to May 2024. Demographics, operative details, opioid ingestion, length of stay, and postoperative complications were reviewed to assess safety of discharge in 24 hours.

RESULTS

One hundred sixty-four DIEP flaps were performed on 119 patients. Average length of stay was 1.5 days (SD 0.7 days), with 67 (56.3%) patients discharged on postoperative day 1 (POD1) and 52 (43.7%) discharged after POD1. Of those discharged on POD1, 13 (19.4%) went home in <24 hours. Comparing patients discharged on POD1 to those discharged after POD1, there were statistically significant differences in reconstruction laterality (76.1% vs 44.2% unilateral, p<0.001), operative time (341.0 vs 439.1 minutes, p<0.001), and opioid ingestion on POD1 (4.2 IV morphine milligram equivalents [MME] vs 11.3 MME, p<0.001). Common complications included abdominal wound dehiscence (10.1%), abdominal seroma (5.0%), breast wound dehiscence (4.9%), and breast mastectomy flap necrosis (3.0%). Seventy-six (63.9%) patients had no complications. Overall success rate of flap reconstruction was 100%.

CONCLUSION

Collaboration among surgery, anesthesia, and dedicated nursing teams allow 23-hour observation or outpatient DIEP reconstruction to be safe and feasible. By attaining equivalency with implant-based reconstruction, access to flap reconstruction can be extended to more patients.

Frailty and Malnutrition in Surgical Outcomes of Elderly Breast Cancer Patients

INTRODUCTION

We evaluate the impact of frailty and malnutrition on breast cancer surgery outcomes in older adults using the ACS 5-factor modified frailty index (MFI) and Global Leadership Initiative on Malnutrition (GLIM) definition.

METHODS

Single institution retrospective review of a prospective database of the older adult (>60 years old) breast cancer surgery patients (2000-2016); cases stratified into groups as per MFI (0-2) and GLIM. Characteristics, 90-day post-op events, and 5-year follow-up data were analyzed to report survival and complication outcomes.

RESULTS

Among 436 patients at diagnosis, 213 (48.9%) were >80 years old. 377 (86.5%) were alive at 5 years. 274 (62.8%) had MFI > 0, and 69 (15.8%) had malnutrition. Patients ≥ 80, MFI > 0, and PR-negative tumors had worse 5-year survival. There was no survival difference in patients >80 with/without malnutrition (HR = 1.01, p = 0.971), and there was no difference in mastectomy or lumpectomy (p = 0.560) between patients ≥ 80 or patients younger than 80; however, 94% of immediate reconstruction were in pts < 80. On multivariate regression, complications were associated with age < 80, readmission, MFI > 0, and history of HTN; serious complications were associated with age < 80, readmission, anticoagulation, and not receiving endocrine therapy.

CONCLUSION

MFI showed a significant predictive value for 5-year survival for patients ≥ 80 and should be part of the preoperative evaluation.

Direct-to-implant and tissue expander-based immediate breast reconstruction in Chinese women: A comparison of surgical complications and patient-reported outcomes

BACKGROUND

Direct-to-implant (DTI) breast reconstruction restores patient body image immediately after mastectomy but may increase postoperative complications compared to tissue expander (TE)-based breast reconstruction. Few studies have compared the surgical complications and patient-reported outcomes (PROs) of DTI and TE breast reconstructions in Asian women.

METHOD

This study compared postoperative complications and PROs between DTI and TE breast reconstruction in Chinese women and explores the risk factors of postoperative complications and the influencing factors of PROs. A retrospective chart review of patients undergoing immediate breast reconstruction between 2008 and 2022 was conducted, and BREAST-Q questionnaires of the breast reconstruction module were distributed to eligible patients. Multivariate regression models were used to explore risk factors for postoperative complications and factors that influence BREAST-Q scores.

RESULTS

DTI was associated with lower rates of major complications and implant loss but had no significant influence on patient satisfaction or quality of life. Age and axillary lymph node dissection were important complication risk factors for both DTI and TE. The application of acellular dermal matrix significantly increased the risk of seroma or hematoma. In the DTI group, capsular contracture significantly reduced patient satisfaction with breast scores.

CONCLUSION

DTI dual-plane breast reconstruction does not increase complication rates in appropriately selected Chinese patients. In DTI patients, the management of capsular contracture is crucial for improving patient satisfaction.

Oncoplastic Surgery with Volume Replacement versus Mastectomy with Implant-Based Breast Reconstruction: Early Postoperative Complications in Patients with Breast Cancer

BACKGROUND

 Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-day postoperative complications between these two techniques.

METHODS

 We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications.

RESULTS

 A cohort of 8,403 breast cancer patients was analyzed. A total of 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years (p < 0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, p < 0.001), exhibited a higher body mass index (31.73 vs. 26.93, p < 0.001), had a greater prevalence of diabetes mellitus (11.0 vs. 5.0%, p < 0.001). They also had a higher ASA classification (2.33 vs. 2.15, p < 0.001), shorter operative time (173.39 vs. 216.20 minutes, p < 0.001), and a higher proportion of outpatient procedures (83.7 vs. 39.5%, p < 0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients (4.2 vs. 10.9%, p < 0.001), including lower rates of surgical complications (2.2 vs. 8.0%, p < 0.001) and wound complications (1.9 vs. 4.8%, p = 0.005) compared with MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications.

CONCLUSION

 OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared with MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.

Bilobed lateral artery perforator-based flap for partial breast reconstruction - Technique description and results from a ten-year cohort

INTRODUCTION

We present a new technique, the bilobed lateral artery perforator-based flap, for breast-conserving surgery of large central tumors or nearby, combining Zymany's bilobed flap and a Lateral Intercostal Perforator (LICAP) flap, and its 10-year outcomes.

MATERIALS AND METHODS

We studied 37 patients with malignant breast tumors near or involving the central skin, without ptosis or desire to correct it, who avoided mastectomy with this modified bilobed flap from 2013 to 2022. The same surgeon operated on them in different institutions. This research project was approved by our ethical committee (n. 2.322.212).

RESULTS

The mean age was 57.17 (±12.60) years. The mean specimen weight was 74.32 (±25.84)g, and the mean tumor size was 40.35 (±15.81) mm. Fourteen (37.84 %) tumors were larger than 5 cm and one was multicentric. Thirty-two (86.49 %) patients had invasive ductal carcinomas. Nipple areola complex was removed in 19 (51.35 %) cases due to clinical involvement, and immediately reconstructed in two cases with contralateral free grafting. Twenty-one (56.76 %) patients received neoadjuvant chemotherapy. Three (8.11 %) patients had immediate contralateral mastopexy. Radiotherapy was indicated in all cases. There were 3 (8.11 %) minor complications, one positive margin, and no surgical revisions. In a mean follow-up of 39.97 (±29.43) months, there were no local recurrences, 2 metastasis, and one death. Satisfaction and aesthetic results were good or excellent in most cases.

CONCLUSIONS

The new technique enabled breast conservation, with high rates of free margins, high levels of satisfaction, few complications in women with large central tumors on small breasts with limited ptosis.

Implants versus autologous tissue flaps for breast reconstruction following mastectomy

BACKGROUND

Women who have a mastectomy for breast cancer treatment or risk reduction may be offered different options for breast reconstruction, including use of implants or the woman's own tissue (autologous tissue flaps). The choice of technique depends on factors such as the woman's preferences, breast characteristics, preoperative imaging, comorbidities, smoking habits, prior chest or breast irradiation, and planned adjuvant therapies.

OBJECTIVES

To assess the effects of implants versus autologous tissue flaps for postmastectomy breast reconstruction on women's quality of life, satisfaction, and short- and long-term surgical complications.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registries in July 2022.

SELECTION CRITERIA

We included studies that compared implant-based reconstruction with autologous tissue-based reconstruction following mastectomy for breast cancer treatment or risk reduction. The minimum eligible sample size was 100 participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data using standard Cochrane procedures. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Thirty-five non-randomised studies with 57,555 participants met our inclusion criteria. There were nine prospective cohort studies and 26 retrospective cohort studies. We judged 26 studies at serious overall risk of bias and the remaining studies at moderate overall risk of bias. Some studies measured quality of life and satisfaction using the BREAST-Q (scale of 0 to 100, higher is better). Implants may reduce postoperative psychosocial well-being compared with autologous tissue flaps (mean difference (MD) -4.26 points, 95% confidence interval (CI) -4.91 to -3.61; I² = 0%; 6 studies, 3335 participants; low-certainty evidence). Implants may reduce or have little to no effect on postoperative physical well-being compared with autologous tissue flaps, but the evidence is very uncertain (MD -1.92 points, 95% CI -4.44 to 0.60; I² = 87%; 6 studies, 3335 participants; very low-certainty evidence). Implants may reduce postoperative sexual well-being compared with autologous reconstruction (MD -6.63 points, 95% CI -7.55 to -5.72; I² = 0; 6 studies, 3335 participants; low-certainty evidence). Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the breast, but the evidence is very uncertain (MD -8.17 points, 95% CI -11.41 to -4.92; I² = 90%; 6 studies, 3335 participants; very low-certainty evidence). This outcome refers to a woman's satisfaction with breast size, bra fit, appearance in the mirror (clothed or unclothed), and how the breast feels to touch. Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the reconstruction (MD -5.96 points, 95% CI -10.24 to -1.68; I² = 62%; 4 studies, 1196 participants; low-certainty evidence). This outcome refers to whether the aesthetic outcome has met the woman's expectations, the impact surgery has had on her life, and whether she thinks she made the right decision to have the reconstruction. Implants may reduce or have little to no effect on the risk of short-term complications compared with autologous tissue flaps, but the evidence is very uncertain (risk ratio (RR) 0.80, 95% CI 0.63 to 1.03; I² = 91%; 22 studies, 34,244 participants; very low-certainty evidence). Implants may increase long-term complications compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.56, 95% CI 1.09 to 2.22; I² = 94%; 17 studies, 26,930 participants; very low-certainty evidence). Implants may have little to no effect on the need for reintervention compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.23, 95% CI 0.91 to 1.68; I² = 93%; 15 studies, 14,171 participants; very low-certainty evidence). Implants may reduce the duration of surgery compared with autologous tissue flaps, but the evidence is very uncertain (MD -125.04 minutes, 95% CI -131.41 to -118.67; I² = 0; 2 studies, 836 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review show that autologous tissue-based reconstruction compared with implant-based reconstruction may improve participant-reported outcomes such as psychosocial well-being, sexual well-being, and satisfaction with the reconstruction. There is also very uncertain evidence to suggest that autologous tissue-based reconstruction increases satisfaction with the breast and reduces the risk of long-term complications compared with implants. Implant-based reconstruction may be a shorter procedure, but the evidence is very uncertain. Despite the growing demand for breast reconstruction, the best technique has not been adequately studied in randomised controlled trials (RCTs), and the evidence provided by non-randomised studies is often unsatisfactory. There is no superior breast reconstruction technique for all women. Future research should focus on the definition of decisional drivers to guide an evidence-based shared decision-making process in reconstructive breast surgery.

Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy

BACKGROUND

Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM).

METHODS

A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance.

RESULTS

Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications.

CONCLUSIONS

Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

Monitoring for Breast Cancer Recurrence Following Goldilocks Breast Reconstruction

BACKGROUND

The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, there is concern that imbrication of these skin flaps may predispose to fat necrosis and make detection of local breast cancer recurrence more difficult. Goldilocks patients follow a traditional postmastectomy screening pathway that includes clinical examination for locoregional recurrence, but it is unclear if this is sufficient. We evaluate our Goldilocks reconstruction case series to determine rates of diagnostic imaging, biopsy, and locoregional and distant recurrence.

METHODS

Sixty-six patients (94 breasts) undergoing Goldilocks breast reconstruction were retrospectively reviewed. Any diagnostic postoperative imaging/biopsies performed and that confirmed local or distant breast cancer recurrence were noted.

RESULTS

Average time of follow-up was 45 months. Most patients in this cohort had stage 0 (27.3%) or stage I (40.9%) breast cancer. There were a total of 11 (11.7%) concerning breast masses identified. Seven (7.4%) masses were biopsied, of which 5 were benign and 2 were invasive cancer recurrence. Four masses (4.3%) underwent diagnostic imaging only, all with benign findings. Five patients in this series were found to have either distant disease or a second primary cancer in the nonoperative contralateral breast.

CONCLUSIONS

Rates of local recurrence following Goldilocks are not higher than expected after other types of postmastectomy reconstruction. Clinical monitoring successfully detected local recurrence in all affected patients in this series. More definite guidelines around the routine screening of Goldilocks mastectomy patients may aid in early detection of local breast cancer recurrence.

The volume-outcome relationship in free-flap reconstruction: A nationwide study based on the Clinical Database

BACKGROUND

The association between successful reconstructive surgery with a free flap and hospital volume has not been well established. This study was designed to retrospectively analyze the outcome of free-flap surgery registered in a nationwide surgical registration system in Japan to clarify the relationship between free-flap survival and facilities' average annual number of free-flap surgeries.

METHODS

We analyzed data from 19,482 free flaps performed during 2017-2020 at 407 facilities throughout Japan. After adjusting for sex, age, and disease classification that differ between the groups, we examined the differences in the flap survival rates among the different facilities in terms of the average number of free-flap surgeries performed annually.

RESULTS

The total overall necrosis rate was 2.8%. Of all procedures, 14.9%, 12.9%, 33.4%, and 38.8% were performed at facilities with an average number of free-flap procedures <10, 10-19, 20-49, and ≥ 50 per year, respectively, and the respective rates of total necrosis were 6.0%, 3.8%, 2.1%, and 1.7%, respectively. The odds ratios and 95% confidence intervals of flap necrosis for facilities with ≥ 50 cases per year relative to those <10 were 2.70 (1.98-3.68) for nonbreast reconstruction cases and 5.72 (2.77-11.8) for breast reconstruction cases.

CONCLUSION

This analysis of a nationwide plastic surgery database showed that free-flap surgeries in institutions with a low average annual number of free-flap surgeries had a higher risk of total necrosis. Measures should be taken to either aggregate cases into high-volume centers or improve management at low-volume centers.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications

BACKGROUND

The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery.

METHODS

The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively.

RESULTS

A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org .

CONCLUSIONS

The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

Explaining risks and benefits of loco-regional treatments to patients

Treatment for early-stage breast cancer is complex, requiring multidisciplinary care with a multitude of treatment options available for each patient. Coupled with the rising importance of shared decision-making, patient-physician conversations are progressively more complicated. These conversations require frank disclosure of risks and benefits of the different treatment modalities in a way that is individualized for each patient and simple to understand. In most patients, breast conserving therapy with radiation should be presented as the gold-standard local treatment given similar long-term and improved quality of life outcomes. De-escalation is currently at the forefront of research in loco-regional treatments, and further investigations are required to best determine the optimal patient populations for reduced sentinel lymph node sampling, omission of sentinel lymph node biopsy altogether and omission of radiation treatment. For future trials, better endpoints need to be established considering patient-centered outcomes as well as recurrence.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data

BACKGROUND

 While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality.

METHODS

 The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed.

RESULTS

 A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified.

CONCLUSION

 Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

"My body, my choice": A qualitative study of women's mastectomy with flat closure experiences

This qualitative study aimed to describe and explore the pre and post-mastectomy experiences of women choosing flat closure after a breast cancer diagnosis. Aesthetic flat closure creates a flat contoured chest wall after a mastectomy. There is limited research on women's flat closure experiences. To fill this gap, we interviewed 19 women (Mage = 53, range 31-72) with breast cancer who underwent a bilateral mastectomy with flat closure, examining decision-making, mirror-viewing, and flat closure experiences. Using a hermeneutic phenomenological design, we generated seven themes. Broadly, women choosing flat closure experienced pressure from their clinicians to undergo breast reconstruction. We found flat closure information to be consistently lacking. Mirror-viewing experiences of women obtaining suboptimal flat closure outcomes led to shattered expectations, mirror avoidance, psychological distress, and body image disturbances. Women negotiated their new reality by discovering ways to feel comfortable with their flat bodies. Regardless of surgical outcome, decision satisfaction was high. These findings illustrate the importance of bodily autonomy and supportive healthcare environments for women making flat closure decisions. Providing comprehensive information on all surgical options and addressing post-operative expectations can improve women's decision-making and mirror-viewing experiences and assist women in adapting to their new body image.

Analysis of Patient-Reported Outcomes After Breast Reconstruction: A Retrospective Study

OBJECTIVE

This study aimed to investigate the effects of surgical timing, procedure, and age, on complication rates, health-related quality of life, and postoperative satisfaction, in patients who underwent breast reconstruction.

METHODS

The data of 80 patients who underwent breast reconstruction surgery between August 2004 and June 2018 were reviewed. Patients were grouped according to surgical timing, procedure, and age. The evaluation indicators included complications and BREAST-Q scores. The statistical methods used included the Mann-Whitney U test and analyses of variance and covariance.

RESULTS

The incidence of complications was 15.0% (12/80). The complication rates were similar in each group ( P > 0.05). The postsurgical scores of patient satisfaction with breast, psychosocial well-being, and sexual well-being were higher than the presurgical scores ( P < 0.05). The postoperative psychosocial and sexual well-being scores of patients in the immediate group were higher than those in the delayed group ( P < 0.05). The satisfaction with the outcome in the abdominal flap group was higher than that in the other group, whereas the sexual well-being score of the abdominal flap group was lower than that of the other group ( P < 0.05). The scores of the postoperative physical well-being of the chest and abdomen in the younger group were higher than that in the older group ( P < 0.05).

CONCLUSIONS

Breast reconstruction can significantly improve patients' health-related quality of life and satisfaction. Immediate breast reconstruction can reduce the adverse psychological and physical effects that breast loss exerts on patients, leading to better postoperative satisfaction. Patients who underwent breast reconstruction with abdominal flaps had higher postoperative satisfaction. Breast reconstruction in elderly patients was associated with considerable postoperative satisfaction.

Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients

BACKGROUND

The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR.

METHODS

A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research.

RESULTS

Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010).

CONCLUSIONS

The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.

The Impact of Diabetes Mellitus on Breast Reconstruction Outcomes and Complications: A Systematic Literature Review and Meta-analysis

INTRODUCTION

As the incidence of breast cancer and diabetes rises, so does the number of patients with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at a higher risk for post-operative complications. The current study examined the effects of diabetes on BR wound outcomes and overall complications post-operatively.

METHODS

This study followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We conducted a systematic search and meta-analysis for published articles on the effects of DM on BR in January 2022 using the PubMed, MEDLINE, and Cochrane databases. Diabetes, breast reconstruction, and complications were used as keywords.

RESULTS

Forty-three studies were included in the qualitative synthesis, and five provided data to be included in the meta-analysis published between 2006 and 2020. A total of 19,731 patients (9.07%) had diabetes, whereas 197,812 patients had no diabetes. The results of the pooled outcomes revealed no differences in the risk of total flap loss (p = 0.892) and wound infection (p = 0.579,). Nevertheless, the risk of wound dehiscence was significantly higher among patients with diabetes than their non-diabetic counterparts (p < 0.0001).

CONCLUSION

Diabetic patients undergoing BR have a significantly higher risk of wound dehiscence. As a result of the adverse effects of diabetes status on BR outcomes, patients need to be counseled about optimizing their diabetes management before surgery. Because of the heterogeneity in our results, prospective randomized studies are needed to shed light on the consequences of diabetes mellitus in BR surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical and demographic predictors of free flap salvage after takeback: A systematic review

BACKGROUND

Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage.

METHODS

A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis.

RESULTS

The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure.

CONCLUSIONS

Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.

Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis

BACKGROUND

As rates of breast cancer and type II diabetes increase, so does the number of women with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at increased risk of postoperative complications. This meta-analysis seeks to evaluate the post-operative outcomes of women with diabetes who underwent BR following mastectomy.

METHOD

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, PUBMED, and MEDLINE electronic databases were searched from inception to November 1, 2020 for studies published in English. Outcomes evaluated were overall complications, surgical complications, and longer hospital stay. Subgroup analysis investigated outcomes, such as implant/flap failure, infection, and necrosis.

RESULTS

Sixty-five studies met our inclusion criteria and 38 provided data to be included in the meta-analysis. A total of 151,585 patients were included, of which 9299 had diabetes. Women with diabetes were more likely to experience overall complications (11.6% vs 5.6%; p<0.0001) and surgical complications (7.7% vs 3.3%; p<0.0001), and were more likely to have a prolonged hospital stay (p = 0.04) than women without diabetes. Subgroup analysis showed that implant loss (2.5% vs 1.6%; p = 0.0003), infection (6.8% vs 2.5%; p<0.0001) and necrosis (23.8% vs 6.5; p = 0.001) were significantly higher in women with diabetes.

CONCLUSIONS

This study provides evidence that diabetes mellitus increases the risk of complications in patients with breast cancer undergoing BR after mastectomy. Prospective studies are required to establish whether diabetes that is well-controlled prior to reconstruction, including diabetes that is paired with adjuvant radiation therapy, reduces the perioperative risks.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis

For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer.

Methods

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.

Results

We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4-8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1-10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5-4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions.

Conclusions

Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

Repair of Breast Defect by Transfer of a Contralateral Internal Mammary Artery Perforator Flap

This is a case report of a patient with a borderline phyllodes tumor in the left breast. Seventeen months after the resection of the phyllodes tumor from the patient’s left breast, the tumor occurred again 5 months ago in the surgical region. A large defect was generated after the extended resection of the left breast mass, and it was repaired with a contralateral internal mammary artery perforator flap. After the operation, bilateral breast symmetry was good, and the patient was satisfied with the shape of the breast. Postoperative follow-up was performed for 15 months, and no local recurrence was observed.

Higher body mass index is a more important risk factor than sarcopenia for complications in deep inferior epigastric perforator reconstruction

BACKGROUND

In recent years, breast reconstruction using autologous tissue after breast cancer surgery has become a common procedure. This study investigated the association between the occurrence of complications in breast reconstruction using deep inferior epigastric perforator (DIEP) flaps and patient risk factors among Asian women.

METHODS

This study included cases of breast reconstruction using DIEP flaps performed at our institution. We retrospectively investigated the relationship between preoperative and operative patient factors and postoperative complications by collecting data from medical records. Sarcopenia was also evaluated by calculating psoas muscle index from the area of the iliopsoas muscle at the level of the third lumbar vertebra using images from preoperative computed tomography. Postoperative complications were compared between a low-body mass index (BMI) group and a high-BMI group, defined using BMI values of <25 kg/m² and ≥25 kg/m², respectively.

RESULTS

A total of 129 cases of breast reconstruction using DIEP flaps were included in this analysis. The frequency of postoperative complications was significantly higher in the high-BMI group, including for skin flap necrosis of the breast (p = 0.03), recipient-site infection (p = 0.03), and donor-site seroma (p = 0.003). Moreover, abdominal circumference correlated significantly with recipient-site infection (p = 0.01) and donor-site seroma (p = 0.002). Sarcopenia did not show significant correlations with any complications.

CONCLUSION

BMI was identified as a risk factor for the occurrence of postoperative complications in breast reconstruction using the DIEP flap, but sarcopenia was not.

Effect of surgical complications on outcomes in breast cancer patients treated with mastectomy and immediate reconstruction

BACKGROUND

Operative complications affect recurrence in non-breast malignancies. Rising rates of mastectomy with immediate reconstruction and their increased post-operative complications fuel concerns for poorer outcome in breast cancer (BC). We sought to determine the effect of complications on recurrence in BC patients.

METHODS

A single-institution retrospective review was conducted of incident BC treated with mastectomy and immediate reconstruction. Overall survival and recurrence were compared between patients with complications to those without.

RESULTS

Of 201 patients (350 mastectomies, 86 nipple-sparing), 62 (30.8%) had a surgical complication. Patients with complications were older, but groups were similar for type of reconstruction, tobacco use, hormone receptor status, HER2, lymphovascular invasion, and pathologic stage (all p > 0.05). Twenty-two complications (10.9%) were infection, 5 (2.5%) dehiscence, 14 flap necrosis (7%), 21 hematomas (10.4%), and 8 nipple necroses (9%). Recurrence occurred in 18 (8.9%) patients: 4 local, 2 regional, and 12 distant. After 8.9 years of median follow-up, patients with complications trended towards higher recurrence (hazard ratio (HR) 2.23, log-rank p = 0.08, Cox regression p = 0.05), particularly with nipple necrosis (HR 3.28, log-rank p = 0.09, regression p = 0.06). Patients with other complications had similar recurrence-free survival to those without (all p > 0.05). Higher stage (HR 13.66, log-rank p = 0.03) and adjuvant radiation (HR 2.78, log-rank p = 0.04) cases were more likely to recur. Patients with complications had similar overall survival to those without (log-rank p > 0.05).

CONCLUSION

BC patients with surgical complications do not have lower overall survival. This finding may be due to the improved prognosis compared to non-breast malignancies.