Effect of Patient Age on Outcomes in Breast Reconstruction: Results from a Multicenter Prospective Study

Is Immediate Breast Reconstruction an Option for Elderly Women? A Comparative Study Between Elderly and Younger Population

OBJECTIVE

To evaluate the incidence of postoperative complications (POC) in elderly patients (EP) compared to younger patients (YP) following immediate breast reconstruction (IBR) after total mastectomy (TM).

METHODS

This retrospective study included patients treated at the Institut Universitaire of Cancer of Toulouse-Oncopole (IUCT-O) between January 2014 and May 2022. The primary outcome was the incidence of POC within 30 days postoperatively. Secondary outcomes included the delay before initiation of adjuvant treatments and re-hospitalization rates.

RESULTS

Elderly patients had a significantly higher rate of POC compared to younger patients, affecting 27.9% of EP and only 14.8% of YP. However, the severity of complications does not differ significantly between YP and EP (69.1% of major POC for YP and 64.7% for EP, P = .6680). Rates of re-hospitalization within 30 days between the 2 groups are similar (67.3% for YP and 61.8% for EP, P = .5962). Most importantly, these complications are not responsible for a delay in initiating adjuvant treatment compared with the younger population. Age ≥ 70 years and obesity (BMI ≥ 30) were identified as independent risk factors for POC.

CONCLUSION

Despite a higher rate of POC, immediate breast reconstruction can be considered for elderly patients, but these patients should be carefully selected and assessed preoperatively to limit the risk of POC.

Influence of age on patient decision regret following breast reconstruction: a multicenter collaborative study in Japan

BACKGROUND

In recent years, the age range of patients undergoing breast reconstruction has expanded. Establishment of the influence of the age of a patient with breast cancer on the level of regret after breast reconstruction could assist in decision-making across age groups at the time of choice of options for breast cancer surgery.

OBJECTIVES

The objective of the study is to investigate the current age distribution of patients undergoing treatment for breast cancer in Japan through a multicenter collaborative study, and to examine the impact of age on post-surgical decision regret, analyzed by type of surgical procedure.

METHODS

A multicenter observational retrospective study was conducted in 576 patients who were diagnosed with breast cancer pathologically and underwent mastectomy (Bt), breast-conserving surgery (Bc) or breast reconstruction (Br). Demographic and outcome data were collected and the level of regret concerning the surgical decision was surveyed using the Decision Regret Scale (DRS) across the different patient groups.

RESULTS

The average age of the Bt group was significantly higher than those in the Bc and Br groups. The level of regret was slightly but significantly higher in the Br group compared to the other groups. Regression analysis of the relationship between age and DRS scores indicated that reconstruction is associated with an increase of about 5 points in the DRS score. This analysis also revealed that the DRS score slightly increases with advancing age, regardless of the surgical method.

CONCLUSIONS

In reconstruction cases, addition of new surgical procedures may lead to more complications, which might have slightly increased regret; however, the increase was not significant. Thus, although more cautious surgical criteria are desirable for older patients, age alone should not be a deterrent to opting for breast reconstruction.

Postmastectomy Breast Reconstruction in Patients with Non-Metastatic Breast Cancer: A Systematic Review

Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed-with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results.

Autologous and implant based immediate breast reconstructive trends following unilateral modified radical and radical mastectomy: a SEER database analysis

Longitudinal trends in breast reconstruction after modified radical mastectomy remain under described. This study aims to assess procedural trends in autologous reconstruction (AR) and implant-based reconstruction (IBR), to analyse demographic shifts in these patients, and to examine differences in oncologic management. This retrospective study utilizes the Surveillance, Epidemiology, and End Results (SEER) database to investigate trends in immediate breast reconstruction from 2000 to 2020 following unilateral modified radical and radical mastectomy. Demographic and oncologic variables were collected, and reconstruction types were categorised as IBR, AR, or a combination. Subgroup analyses compared IBR and AR patients, and demographic changes between the 2000-2010 and 2010-2020 cohorts were examined. Chi-square tests in R studio were used for statistical analysis. Of the 25,649 patients, 51.8% underwent IBR and 48.2% AR. AR patients were typically younger, more frequently Black, had higher incomes, and were less likely to live in rural areas compared to IBR patients. A shift from AR to IBR was observed, with AR decreasing from 41.8% in 2000 to 24.5% in 2020. Significant demographic changes in AR patients included increased age, higher proportions of Black and Asian patients, reduced income, and increased non-marital status. Oncologic management differed, as AR patients were less likely to have received chemotherapy and radiation prior to their reconstruction, and experienced longer reconstruction times compared to IBR patients. This study highlights a decline in AR and rising IBR popularity, and reveals evolving patient characteristics. Understanding these trends is crucial for equitable access and informed decision-making in breast cancer reconstructive care.

Quality of Life after Alloplastic versus Autologous Breast Reconstruction: The Influence of Patient Characteristics on Outcomes

Objective

Quality of life (QoL) following autologous breast reconstruction has been found to be higher compared to alloplastic breast reconstruction. However, evaluating QoL is complex as it is influenced by various factors, including patient characteristics and treatment types. Previous studies comparing QoL between reconstruction techniques have not sufficiently addressed baseline differences between patient groups, some of which contribute to indication bias. Using an alternative approach to identify the confounders, this study aimed to evaluate which factors affect the patient satisfaction and QoL after alloplastic or autologous reconstruction, with follow-up extending up to 3 years post-surgery.

Method

QoL and satisfaction were measured using the Breast-Q preoperatively and after breast reconstruction (post-BR) at 6 weeks, 6 months, 1 year, and 3 years. General and mental health were measured using the SF-36 and the HADS. A generalized linear mixed model was utilized to assess which factors confound the relationship between reconstruction technique and Breast-Q scores.

Results

Factors contributing to the disparity in Breast-Q scores between autologous and alloplastic breast reconstruction varied across Breast-Q subscales. Autologous breast reconstruction patients consistently reported higher "Satisfaction with Breasts" and "Physical Well-being," while the minimal important differences in "Psychosocial" and "Sexual Well-being" were lost after adjustment for confounding factors.

Conclusion

This study confirms that even when adjusted for confounders, scores on two QoL subscales autologous breast reconstruction patients score significantly higher over time. Although autologous reconstruction remained superior regarding "Satisfaction with Breasts," scores decreased in autologous reconstruction patients when they were depressed at baseline, underwent radiotherapy, had a history of breast cancer, or faced major complications.

Impact of Prepectoral Implant Placement and Radiation Modalities (Protons/Photons/Dosimetry) in Mastectomy Patients Undergoing Immediate Single Stage Direct-to-Implant Breast Reconstruction

PURPOSE

For patients with breast cancer receiving mastectomy with direct-to-implant (DTI) immediate breast reconstruction, placing the implant in the prepectoral or subpectoral plane remains debatable, especially in settings of postmastectomy radiation therapy (PMRT).

METHODS AND MATERIALS

We reviewed 3039 patients who underwent mastectomy and reconstruction at our institution between 2005 and 2020. Patients receiving DTI with and without PMRT were included. PMRT was delivered either with a photon (3-dimensional-conformal or volumetric arc therapy) or proton therapy, mainly with pencil-beam-scanning. All patients received conventional fractionation (50-50.4 Gy in 25-28 fractions). Primary endpoints were reconstruction complications defined as infection/necrosis requiring debridement; capsular contracture requiring capsulotomy; absolute reconstruction failure entailing permanent removal of the implant without replacement (ie, no salvage reconstruction); and overall reconstruction failure (removal of the implant for any complication with and without salvage reconstruction). Different subgroup analyses were done.

RESULTS

A total of 815 patients met inclusion criteria, with an overall median follow-up of 6.2 years. We found that there is no significant difference between prepectoral versus subpectoral for infection/necrosis (odds ratio [OR], 1.5; P = .3); capsular contracture (OR, 0.97; P = .9); absolute reconstruction failure (OR, 1.9; P = .12); and overall reconstruction failure (OR, 1.2; P = .5). Findings were confirmed using both logistic regression, time-to-event analysis, and multivariable analyses for the entire cohort and subgroups with and without PMRT. There was no significant difference between protons and photons in terms of infection/necrosis (OR, 1.6; P = .4) and absolute reconstruction failure (OR, 1.2; P = .7), but there were significantly higher risks for capsular contracture with protons (OR, 4.4; P < .001) and overall reconstruction failure compared with photons (OR, 2.0; P = .05). We did not find a significant correlation pattern between different dosimetry factors (the average dose, the maximum dose, and volume in cubic centimeter) in either the reconstructed chest wall target or the skin structure, about reconstruction complications, whether for proton or photon patients.

CONCLUSIONS

For patients receiving single-stage DTI reconstruction with and without PMRT, prepectoral implant placement had similar rates of complications and reconstruction failure compared with subpectoral reconstruction. Protons compared with photons did not increase the risk of infection/necrosis but significantly increased capsular contracture risks.

Factors affecting upper limb functional recovery after mastectomy with immediate breast reconstruction: a prospective study

BACKGROUND

Little is known about the differences in postoperative shoulder function following two common approaches for immediate breast reconstruction (IBR): abdominal-based breast reconstruction and implant-based breast reconstruction (ABR and IMBR). It was hypothesized that postoperative upper limb function would differ between the ABR and IMBR due to incomplete detachment of the pectoral muscles.

PURPOSE

This study aimed to investigate the factors for shoulder function recovery post-IBR and compare recovery outcomes between ABR and IMBR.

METHODS

This single-center prospective follow-up study included 60 patients who underwent IBR for 4 months postoperatively. Patients were invited to complete functional measurements 1 and 4 months postoperatively. The primary outcome was improvement in upper limb disability based on the Q-DASH score. Secondary outcomes were functional shoulder recovery markers: shoulder flexibility, strength, movement accuracy, scapular alignment, body schema accuracy, and neuropathic pain. Repeated-measures analyzes of variance and linear regression were performed.

RESULTS

Within-group differences were found for most variables (p < .05) except for neuropathic pain (p = .929). However, there was no overall main group effect (p > .05). Multivariate regression analysis established significant models for ABR and IMBR (R2 = 0.430, p = .002 and R2 = 0.442, p < .001, respectively). However, the variables included in the model showed between-group differences.

CONCLUSION

Postoperative shoulder function was comparable between the two IBR approaches. However, different factors were associated with improved upper limb disability between ABR and IMBR. Acute rehabilitation focused on resolving muscle tightness and pain may help mitigate upper limb disabilities following IBR.Trial registration number: KCT 0006501.

Normative BREAST-Q Scores in Sub-Saharan African Women: Interpreting the Impact of Mastectomy and Reconstruction

Background

Breast cancer is a leading cause of mortality among women in sub-Saharan Africa (SSA). As such, optimizing outcomes for treatment and reconstruction is a global health priority. Currently, normative data for interpreting BREAST-Q results are limited to high-income countries. This study seeks to evaluate baseline breast-related quality of life in SSA women without breast cancer and compare it with previously published normative values.

Methods

Women in Ghana, Nigeria, and Ethiopia 18 years of age and older with no history of breast cancer or breast surgery were recruited to complete the BREAST-Q preoperative mastectomy module. Multivariable regression was performed to identify correlations between sociodemographic variables and BREAST-Q scores. Comparisons were made between normative data previously published in high-income countries and within individual SSA populations.

Results

Normative BREAST-Q scores were obtained from a total of 453 women (169 Ghanaian, 210 Nigerian, and 74 Ethiopian) with a mean age of 26 ± 7 years and body mass index of 26 ± 6 kg/m2. Scores were as follows: satisfaction with breasts, 64 ± 26; psychosocial well-being, 63 ± 23; sexual well-being, 57 ± 26; and physical well-being, 68 ± 16. Compared with scores published in the United States, SSA women scored higher in breast satisfaction and lower in psychosocial and physical well-being. Significant differences in scores were also found among countries in SSA.

Conclusions

This study establishes normative values for the BREAST-Q mastectomy module in a group of women in SSA without breast cancer and found significant variability globally and among countries within the same region.

Patient-reported outcomes 3 and 18 months after mastectomy and immediate prepectoral implant-based breast reconstruction in the UK Pre-BRA prospective multicentre cohort study

INTRODUCTION

Prepectoral techniques are becoming standard of care for implant-based breast reconstruction due to reduced impact on chest wall function and improved patient satisfaction. Evidence to support these benefits, however, is lacking. Here, patient-reported outcomes (PROs) of prepectoral breast reconstruction (PPBR) in the Pre-BRA cohort are reported.

METHODS

Women undergoing PPBR after mastectomy for breast cancer or risk reduction between July 2019 and December 2020 were recruited. Participants completed the BREAST-Q preoperatively and at 3 and 18 months following surgery together with a single item evaluating overall satisfaction at 18 months. Women completing at least one BREAST-Q scale at any timepoint were eligible for inclusion. Questionnaires were scored according to the developers' instructions and scores compared over time. Exploratory analysis, adjusting for baseline scores was performed to explore factors impacting PROs.

RESULTS

In total 338 of 343 (98.5%) women undergoing PPBR at 40 UK centres were included in the analysis. Compared with baseline scores, women reported statistically significant and clinically meaningful decreases in both 'Physical' and 'Sexual well-being' at 3 and 18 months. Adjusting for baseline, at 18 months, those experiencing implant loss or having surgery for malignancy reported lower scores in all BREAST-Q domains. Overall, two-thirds of women (167/251) rated the outcome of their reconstruction as 'excellent/very good', but experiencing major complications, implant loss, and being dissatisfied with wrinkling/rippling in the reconstructed breast were associated with reduced satisfaction.

CONCLUSIONS

PPBR impacts postoperative physical well-being and PROs are variable. These findings should be discussed with patients to support informed decision-making based on realistic expectations of outcome.

STUDY REGISTRATION

ISRCTN11898000.

Satisfaction with Breasts following Autologous Reconstruction: Assessing Associated Factors and the Impact of Revisions

BACKGROUND

Autologous breast reconstruction (ABR) may confer higher patient-reported outcomes than implant breast reconstruction, but an in-depth examination of factors associated with satisfaction after ABR is lacking. The authors aimed to determine independent predictors of 1-year satisfaction with breasts after ABR and assess the importance of elective procedures on satisfaction.

METHODS

A retrospective analysis of patients who underwent abdominally based ABR between 2010 and 2021 and completed the BREAST-Q Satisfaction with Breasts module at 1 year was performed. Elective procedures consisted of breast revision and nipple-areola complex reconstruction.

RESULTS

A total of 959 patients were included. Satisfaction with Breasts score improved from 53 (interquartile range [IQR], 44 to 64) preoperatively to 64 (IQR, 53 to 78) at 1 year postoperatively ( P < 0.001). Factors significantly associated with decreased postoperative score included lower preoperative scores (β = 0.19 [95% CI, 0.08 to 0.31]; P = 0.001), older age (β = -0.17 [95% CI, -0.34 to -0.01]; P = 0.042), Asian race (versus White, β = -6.7 [95% CI, -12 to -1.7]; P = 0.008), and a history of psychiatric diagnoses (β = -3.4 [95% CI, -6.2 to -0.66]; P = 0.015). Patients who received radiation therapy (β = -5.6 [95% CI, -9.0 to -2.3]; P = 0.001) or had mastectomy skin flap/nipple necrosis (β = -3.8 [95% CI, -7.6 to -0.06]; P = 0.046) also had significantly decreased scores. Satisfaction with Breasts scores improved significantly after breast revision procedures (from 54 [IQR, 42 to 65] to 65 [IQR, 54 to 78]; P < 0.001), and nipple-areola complex reconstruction (from 58 [IQR, 47 to 71] to 67 [IQR, 57 to 82]; P < 0.001).

CONCLUSIONS

Multiple independent patient and treatment level factors are associated with lower 1-year Satisfaction with Breasts scores following ABR. Elective procedures have the potential to improve satisfaction. Understanding these findings is imperative for optimizing clinical decision-making and managing expectations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Comparative analysis of comorbidity indexes in implant-based breast reconstruction

INTRODUCTION

Recent studies have used comorbidity indexes to stratify postsurgical complication risk across multiple surgical fields, including plastic surgery. However, such studies are lacking in implant-based breast reconstruction (IBBR). Understanding how comorbidity scores affect postsurgical outcomes in IBBR can help identify patients who may require additional medical surveillance after surgery.

METHODS

We conducted a retrospective analysis of adult female patients who underwent IBBR between January 2017 and December 2022 using the Merative™ Marketscan® Research Databases. ICD-10 diagnosis codes were used to calculate patients' scores on four different comorbidity indexes. Chi-squared tests were performed for demographic analysis, and multivariable logistic regression controlling for demographic and surgical variables, was conducted to determine associations between comorbidity indexes and adverse outcomes.

RESULTS

Among 16,287 IBBR patients, 3145 (19.3%) experienced a complication within 90 days. On regression analysis, the Modified Frailty Index 5-Item (mFI-5) demonstrated the strongest associations with complications (odds ratio=1.25 [1.18, 1.32]), compared to the Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Modified Frailty Index 11-Item. Further regression analysis revealed that four out of the five mFI-5 comorbidities were independent risk factors for postsurgical complications.

CONCLUSION

This study highlights important associations between comorbidity indexes and adverse postoperative outcomes in IBBR. mFI-5 demonstrated superior performance in postoperative risk stratification compared to the other indexes analyzed. These findings suggest that using mFI-5 in clinical settings may help identify high comorbidity patients who may benefit from additional monitoring and prophylactic measures. Further research is needed to understand how to mitigate the increased postoperative complication risk in these patients.

Age Impacts Clinical and Patient-Reported Outcomes following Postmastectomy Breast Reconstruction

BACKGROUND

Although the current literature indicates that age should not be a deterring factor in postmastectomy breast reconstruction, the true impact of increasing age on postoperative outcomes remains unknown. The purpose of this study is to understand the impact of age on complications and patient-reported outcomes (PROs) using the BREAST-Q longitudinally 5 years after postmastectomy breast reconstruction.

METHODS

The authors conducted a retrospective analysis of patients who underwent autologous (ABR) or implant-based reconstruction (IBR). Age was studied as both a categorical and a continuous variable. Outcome measures included complications and BREAST-Q scores preoperatively, at 6 months, and 1 to 5 years postoperatively.

RESULTS

A total of 4730 patients were included, of which 1536 (32.5%) underwent ABR and 3194 (67.5%) underwent IBR. Older age was significantly associated with increased risk of developing mastectomy skin flap/nipple necrosis, infection, and seroma. Older age was negatively correlated with Satisfaction with Breasts (β = -0.06 [95% CI, -0.12 to -0.01]; P = 0.033) and positively correlated with Psychosocial Well-being (β = 0.14 [95% CI, 0.09 to 0.20]; P < 0.001). Older age was not correlated with Physical Well-being of the Chest (β = -0.03 [95% CI, 0.08 to 0.02]; P = 0.2) or Sexual Well-being (β = -0.04 [95% CI, -0.12 to 0.02]; P = 0.2). Subgroup analyses of ABR and IBR patients demonstrated different complications and PRO profiles.

CONCLUSIONS

The authors' analysis of the impact of age on surgical outcomes and PROs suggests that complication rates increase with age, and older age is negatively correlated with Satisfaction with Breasts but positively correlated with Psychosocial Well-being. Overall, older patients should be informed about the potential associated risks and anticipated PROs.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

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.

Bilateral Lumbar Artery Perforator Flaps for Breast Reconstruction: A Perforator Classification System

BACKGROUND

Autologous breast reconstruction is continually evolving, with focus on the ideal donor site. This study presents 108 consecutive simultaneous lumbar artery perforator (LAP) flaps and a perforator classification system.

METHODS

A retrospective review of all LAP flaps was completed, and appropriate data were recorded. All simultaneous bilateral LAP flaps were included, and perforator patterns were assessed using CT angiography (CTA).

RESULTS

Fifty-four patients (108 flaps) were included in the final review. The mean patient age was 50.7 years, and the mean body mass index was 26.6. Mean ischemia times for all flaps and grafts were 130 ± 64.5 and 300.6 ± 97.3 minutes, respectively. The average pedicle length was 4.6 ± 1.5 cm, and the average composite graft length was 6.2 ± 1.7 cm. Donor-site complications consisted of seromas (10 patients [19%]), hematomas (6 patients [11%]), procedural wounds (4 patients [8%]), and infections (2 patients [4%]). The total flap loss rate was 2.8%. Perforators were classified into categories based on pedicle pattern, lumbar spine level, and clusters, all in relation to posterior iliac bone as seen per CTA. Vascular pedicle patterns were categorized as type 1 (43.9%), 2 (45.6%), 3 (8.8%), or 4 (1.8%). Perforators were dissected at lumbar spine level L3 in 51.8% of patients, L4 in 46.5%, and L5 in 1.8%.

CONCLUSIONS

The authors present a CTA-directed anatomic perforator classification system to assist in preoperative planning, dissection, and choice of the composite graft best suited for particular perforator patterns or calibers. Simultaneous LAP flaps can be performed successfully with excellent outcomes in cases unsuitable for other flaps.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Non-linear relationship between TyG index and the risk of prediabetes in young people: a 5-year retrospective cohort study in Chinese young adults

Objective

Given the limited evidence on the relationship between the triglyceride-glucose (TyG) index and the risk of prediabetes among young adults, our study aimed to investigate the potential impact of the TyG index on the future development of prediabetes in young individuals.

Methods

This retrospective cohort study included 125,327 healthy adults aged 20 to 45 years. We utilized Cox proportional hazards regression models, combined with cubic spline functions and smooth curve fitting, to assess the relationship between baseline TyG index and the risk of prediabetes among young adults, exploring its non-linear association. A series of sensitivity analyses and subgroup analyses were conducted to ensure the robustness of our findings.

Results

After adjusting for covariates, the study found a positive correlation between the TyG index and the risk of prediabetes (HR=1.81, 95%CI: 1.54-2.13, p<0.0001). The risk of prediabetes increased progressively across quartiles of the TyG index (Q1 to Q4), with Q4 showing a significantly higher risk compared to Q1 (adjusted HR=2.33, 95% CI=1.72-3.16). Moreover, a non-linear relationship was identified between the TyG index and the risk of prediabetes, with an inflection point at 9.39. To the left of the inflection point, the HR was 2.04 (95% CI: 1.69 to 2.46), while to the right, the HR was 0.89 (95% CI: 0.48 to 1.65).

Conclusion

Our study reveals a non-linear relationship and a saturation effect between the TyG index and the development of prediabetes among young individuals in China, with an inflection point at 9.39. Understanding this non-linear relationship can assist clinicians in identifying young individuals at high risk and implementing targeted interventions to reduce their risk of progressing to diabetes.

Breast cancer patients' postoperative outcomes in nipple-sparing mastectomy and reconstruction with subpectoral implant placement: a single center experience

Background

The continuous increase in the rate of nipple sparing mastectomy (NSM), the development of several reconstructive techniques and the following introduction of acellular derma matrix (ADM) has revolutionized implant-based breast reconstruction. This study aimed to investigate postoperative complications, health-related quality of life (HRQoL) and patients' satisfaction in patients undergoing NSM and breast reconstruction with or without ADM.

Methods

Enrolled patients were divided into three groups: immediate breast reconstruction (IBR) with definitive implant and ADM (Group A), IBR only with definitive prosthesis (Group B), and two-stage breast reconstruction (Group C). The postoperative complications, BREAST-Q outcomes and reoperations were compared.

Results

A total of 105 BC patients were enrolled and a total of 139 post-mastectomy breast reconstructions were performed. Seroma was the most prevalent complication observed: 8.3% in Group A, 2.9% in Group B and 5.7% in Group C. Postoperative infection occurred in two patients of Group A (5.6%), one patient of Group B (2.9%) and one of Group C (2.9%). Group A reported larger drain volume (1,125±243.5 cc), longer drain period (13.2±2.8 days), and the lowest incidence of capsular contracture (5.6%). The BREAST-Q patient-reported outcome measures document that all patients aged ≥50 years presented a higher score in "Satisfaction with breast" (P<0.001) and "Satisfaction with outcome" domains (P<0.05). Performing a bilateral breast reconstruction was associated to higher scores in "Physical wellbeing chest domain" (P<0.05). In addition, patients in Group A and Group B reported higher score in "Satisfaction with the breast" domain (P<0.001) but only in Group B we reported a higher score in "Satisfaction with outcome" (P<0.001).

Conclusions

Subpectoral IBR results in manageable complications and greater personal satisfaction. The ADM could improve breast reconstruction reducing the rate of capsular contracture. The prepectoral placement of ADM could minimize complications and optimize aesthetic results.

Reducing Disparities: Regional Anesthesia Blocks for Mastectomy with Reconstruction Within Standardized Regional Anesthesia Pathways

BACKGROUND

Recent data suggest disparities in receipt of regional anesthesia prior to breast reconstruction. We aimed to understand factors associated with block receipt for mastectomy with immediate tissue expander (TE) reconstruction in a high-volume ambulatory surgery practice with standardized regional anesthesia pathways.

PATIENTS AND METHODS

Patients who underwent mastectomy with immediate TE reconstruction from 2017 to 2022 were included. All patients were considered eligible for and were offered preoperative nerve blocks as part of routine anesthesia care. Interpreters were used for non-English speaking patients. Patients who declined a block were compared with those who opted for the procedure.

RESULTS

Of 4213 patients who underwent mastectomy with immediate TE reconstruction, 91% accepted and 9% declined a nerve block. On univariate analyses, patients with the lowest rate of block refusal were white, non-Hispanic, English speakers, patients with commercial insurance, and patients undergoing bilateral reconstruction. The rate of block refusal went down from 12 in 2017 to 6% in 2022. Multivariable logistic regression demonstrated that older age (p = 0.011), Hispanic ethnicity (versus non-Hispanic; p = 0.049), Medicaid status (versus commercial insurance; p < 0.001), unilateral surgery (versus bilateral; p = 0.045), and reconstruction in earlier study years (versus 2022; 2017, p < 0.001; 2018, p < 0.001; 2019, p = 0.001; 2020, p = 0.006) were associated with block refusal.

CONCLUSIONS

An established preoperative regional anesthesia program with blocks offered to all patients undergoing mastectomy with TE reconstruction can result in decreased racial disparities. However, continued differences in age, ethnicity, and insurance status justify future efforts to enhance preoperative educational efforts that address patient hesitancies in these subpopulations.

A Randomized Controlled Trial of the Implementation of BREASTChoice , a Multilevel Breast Reconstruction Decision Support Tool With Personalized Risk Prediction

OBJECTIVE

To implement the BREASTChoice decision tool into the electronic health record and evaluate its effectiveness.

BACKGROUND

BREASTChoice , is a multilevel decision tool that: 1) educates patients about breast reconstruction; 2) estimates personalized risk of complications; 3) clarifies patient preferences; and 4) informs clinicians about patients' risk and preferences.

METHODS

A multisite randomized controlled trial enrolled adult women with stage 0-III breast malignancy undergoing mastectomy. Participants were randomized to BREASTChoice or a control website. A survey assessed knowledge, preferences, decisional conflict, shared decision-making, preferred treatment, and usability. We conducted intent-to-treat (ITT), per-protocol (PP) analyses (those randomized to BREASTChoice who accessed the tool), and stratified analyses.

RESULTS

23/25 eligible clinicians enrolled. 369/761 (48%) contacted patients enrolled and were randomized. Patients' average age was 51 years; 15% were older than 65. BREASTChoice participants had higher knowledge than control participants (ITT: mean 70.6 vs. 67.4, P =0.08; PP: mean 71.4 vs. 67.4, P =0.03), especially when stratified by site (ITT: P =0.04, PP: P =0.01), age (ITT: P =0.04, PP: P =0.02), and race (ITT: P =0.04, PP: P =0.01). BREASTChoice did not improve decisional conflict, match between preferences and treatment, or shared decision-making. In PP analyses, fewer high-risk patients using BREASTChoice chose reconstruction. BREASTChoice had high usability.

CONCLUSIONS

BREASTChoice is a novel decision tool incorporating risk prediction, patient education, and clinician engagement. Patients using BREASTChoice had higher knowledge; older adults and those from racially minoritized backgrounds especially benefitted. There was no impact on other decision outcomes. Future studies should overcome implementation barriers and specifically examine decision outcomes among high-risk patients.

Preoperative depression and anxiety associated with younger age and receipt of immediate breast reconstruction

BACKGROUND

As survivorship for breast cancer continues to improve, emphasis of care falls upon improving patients' quality of life. Understanding physical and mental health in the preoperative period is needed to aid surgical decision making and improve patient experience.

METHODS

Consecutive patients awaiting total mastectomy (TM), TM with immediate breast reconstruction (IBR) and breast conserving surgery (BCS) were prospectively recruited. Scores for PHQ-9, GAD-7, Breast-Q, EQ5D(5L), PEG were collected preoperatively. Association was measured with multivariate analyses.

RESULTS

477 participants (374 BSC, 46 ​TM, 84 IBR) were included. Younger patients and those choosing IBR reported worse depression and anxiety symptoms. Clinical tumor features did not affect patient reported outcomes. Higher Breast-Q scores were seen with BCS and lower scores with TM.

CONCLUSIONS

Patients scheduled for IBR and younger patients reported worse symptoms of depression and anxiety, regardless of clinical features. This will help with surgical decision making and identify patients in need for additional perioperative supports.

Patterns of breast reconstruction and the influence of a surgical multidisciplinary clinic

BACKGROUND

Of the 40% of breast cancer patients who have a mastectomy as part of their surgical treatment, only approximately 29% have a breast reconstruction. In 2016, Alfred Health established a multidisciplinary surgical clinic with breast and plastic surgeons, aiming to improve interdisciplinary collaboration. This study aimed to assess the provision of breast reconstruction at an Australian tertiary public hospital and examine whether the multidisciplinary surgical clinic have improved our reconstructive service provision.

METHODS

A retrospective cohort study of patients who underwent mastectomy at Alfred Health between October 2011 and September 2021 was conducted. Patients were divided into before and after groups, treated during the 5-year period before and after establishing the multidisciplinary clinic respectively. Demographic data, operative details, histopathology, and treatments were compared.

RESULTS

Over the 10-year period, 423 mastectomies were performed for 351 patients. Of those, 153 patients underwent breast reconstruction, providing an overall reconstruction rate of 43.6%. There was a statistically significant increase in the breast reconstruction rate from 36.5% before to 53.4% after the creation of the multidisciplinary surgical clinic. Patient factors such as age and tumour receptor status did not differ significantly between the groups.

CONCLUSION

The establishment of a surgical multidisciplinary clinic has led to a statistically significant increase in the rate of breast reconstruction from 36.5% to 53.4%, leading to improved healthcare provision for our patients. Factors identified to be associated with increased uptake in the reconstruction service include younger age and node negative disease.

Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) outcomes in the elderly have not been well characterized. The goal of this study was to evaluate NSM outcomes in patients over age 60.

PATIENTS AND METHODS

A single-institution retrospective cohort study was performed for NSM patients over the age of 60 from January 2004 to January 2022. Demographic, intraoperative, and postoperative variables were collected.

RESULTS

We identified 136 women who underwent a total of 200 NSMs at a mean age 65.2 years and with mean body mass index of 25. Most (56%) had invasive breast cancer, requiring neoadjuvant chemotherapy in 15%, and 17.5% had radiation prior to NSM. A total of 91% had immediate tissue expander placement. The infection rate was 19%, with 11.5% requiring expander explantation in the follow-up period. In binomial logistic regression analysis, prior radiation increased the odds of any complication by 2.9 (OR 2.93, CI 1.30-6.58, p = 0.009) and increased the odds of infection by 5.7 (OR 5.70, CI 1.95-16.66, p = 0.001), but no associations were seen for other covariates including age, comorbidities, prior chemotherapy, or presence of invasive disease. Diabetes increased the odds of wound breakdown specifically by 9.0 (OR 8.97, CI 2.01-39.92, p = 0.004). Local recurrence was 3% in mean 3.4-year follow-up.

CONCLUSIONS

Our data support NSM in patients over the age of 60 years with acceptable outcomes within the standard of care. Locoregional recurrence was within the cited range of 0-5%, and only diabetes and prior radiation were associated with reconstructive complications. NSM should thus be offered when appropriate regardless of increased age to achieve oncologic and reconstructive goals.

Long-term patient-reported outcomes of immediate breast reconstruction after mastectomy for breast cancer: population-based cohort study

BACKGROUND

Breast reconstruction is offered to improve quality of life for women after mastectomy for breast cancer, but information regarding the long-term patient-reported outcomes of different reconstruction procedures is currently lacking. The Brighter study aimed to evaluate long-term patient-reported outcomes after immediate breast reconstruction (IBR) in a population-based cohort.

METHODS

Women who underwent mastectomy with IBR for breast cancer in England between 1 January 2008 and 31 March 2009 were identified from National Health Service Hospital Episode Statistics. Surviving women were invited to complete the BREAST-Q, EQ-5D-5L™, and ICECAP-A at least 12 years after the index procedure. Questionnaires were scored according to developers' instructions and compared by IBR type.

RESULTS

Some 1236 women underwent IBR; 343 (27.8 per cent) had 2-stage expander/implant, 630 (51.0 per cent) latissimus dorsi, and 263 (21.3 per cent) abdominal flap reconstructions, with a mean(s.d.) follow-up of 13.3(0.5) years. Women who underwent abdominal flap reconstruction reported higher scores in all BREAST-Q domains than those who had other procedures. These differences remained statistically significant and clinically meaningful after adjusting for age, ethnicity, geographical region, socioeconomic status, smoking, BMI, and complications. The greatest difference was seen in scores for satisfaction with breasts; women who had abdominal flap reconstructions reported scores that were 13.17 (95 per cent c.i. 9.48 to 16.87) points; P < 0.001) higher than those among women who had two-stage expander/implant procedures. Women who underwent latissimus dorsi reconstruction reported significantly more pain/discomfort on the EQ-5D-5L™, but no other differences between procedures were seen.

CONCLUSION

Long-term patient-reported outcomes are significantly better following abdominal flap reconstruction than other traditional procedure types. These findings should be shared with women considering IBR to help them make informed decisions about their surgical options.

Deliberate Practice in DIEP Flap Breast Reconstruction: An Immediate and Sustained Decrease in Morbidity and Operative Time

BACKGROUND

Deep inferior epigastric perforator (DIEP) flaps are nuanced, multistep, complex procedures. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency, and overall outcomes. The authors critically assess the utility of implementing deliberate practice and process mapping as a research tool in the context of morbidity and operative time.

METHODS

Co-surgeons at a university hospital implemented deliberate practice and performed two prospective process analysis studies evaluating critical steps in DIEP flap reconstruction. During the 9-month period (June of 2018 to February of 2019), the flap harvest and microsurgery steps were assessed. During the 8-month period (January to August of 2020), the analysis was expanded to encompass the entire operation. To evaluate the immediate and sustained impact of process analysis, 375 bilateral DIEP flap patients were divided into eight consecutive 9-month intervals completed before, during, and after the two studies. Using risk-adjusted multivariate regressions, morbidity and operative time were compared between groups.

RESULTS

Time intervals completed before the first study had comparable morbidity and operative time. During the first study, there was an immediate 83.8% ( P < 0.001) decreased risk in morbidity. Operative time during the second study decreased by 2.19 hours ( P < 0.001). Morbidity and operative time continued to decrease until the end of data collection [62.1% decreased risk in morbidity ( P = 0.023) and decreased operative time of 2.22 hours ( P < 0.001)].

CONCLUSIONS

Deliberate practice and process analysis are powerful tools. Implementation of these tools can generate immediate and sustained decreases in morbidity and operative time for patients undergoing procedures such as DIEP flap breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

National Trends in "Going Flat" After Mastectomy

INTRODUCTION

The "Going Flat" movement became widely publicized in 2016 and provides information and support to women who choose to forego post-mastectomy breast reconstruction (PMBR). The objectives of this study were to evaluate temporal trends in PMBR to ascertain the potential impact of this movement and assess which factors are associated with going flat.

METHODS

A retrospective cohort analysis was performed using the NCDB of women with non-metastatic breast cancer who underwent mastectomy between 2004 and 2019. Trends in going flat after mastectomy were examined and stratified by age (< 50, 50-69, ≥ 70). A multivariate logistic regression model was used to identify factors associated with going flat.

RESULTS

650,983 patients met the inclusion criteria: 244,201 (37.5%) underwent PMBR and 406,782 (62.5%) went flat. Among women < 70, rates of going flat steadily decreased from 2004 to 2015 and then stabilized after 2015, coinciding with the rise of the "Going Flat" movement. In multivariate analysis, non-White race, older age, increasing comorbidities, government provided insurance, treatment at a community program, radiotherapy, and adjuvant chemotherapy were associated with a higher likelihood of going flat (p < 0.001).

CONCLUSION

In the first 2 years after the "Going Flat" movement, the number of women going flat after mastectomy has stabilized in women < 70 for the first time in over a decade. These trends suggest that the social and cultural impact of this movement may have contributed to the stabilization of PMBR rates.

A Scoping Review of the Application of BREAST-Q in Surgical Research

Background

Collection of patient-reported outcome (PRO) data can facilitate cost-effective, evidence-based, and patient-centered care. The BREAST-Q has become the gold standard tool to measure PRO data in breast surgery. The last review of its application indicated that it was underutilized. Considering the evolution in breast surgery, the purpose of this study was to perform a scoping review of BREAST-Q application since 2015 and identify emerging trends and potential persistent gaps to guide patient-centered practice and future research in breast surgery.

Methods

We performed an electronic literature review to identify publications published in English that used the BREAST-Q to assess patient outcomes. We excluded validation studies, review papers, conference abstracts, discussions, comments, and/or responses to previously published papers.

Results

We identified 270 studies that met our inclusion criteria. Specific data was extracted to examine the evolution of the BREAST-Q application and examine clinical trends and research gaps.

Discussion

Despite a significant increase in BREAST-Q studies, gaps in the understanding of the patient experience remain. The BREAST-Q is uniquely designed to measure quality of life and satisfaction with outcome and care. The prospective collection of center-specific data for every type of breast surgery will generate important information for the provision of patient-centered and evidence-based care.

"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.

Efficacy of breast reconstruction in elderly women (>60 years) using deep inferior epigastric perforator flaps: A comparative study

BACKGROUND

The indications for microsurgical breast reconstruction remain debated, particularly concerning the safety of deep inferior epigastric perforator (DIEP) flaps in elderly women. Free tissue transfer still carries a risk of perioperative morbidity and mortality in elderly patients. We conducted this comparative study to clarify this issue.

METHODS

This retrospective cohort study included all unilateral DIEP breast reconstructions performed at a single institution. Patients were divided into two groups based on age: an elderly (60 years or older) and a non-elderly cohort (younger than 60 years). Demographic and comorbidity data were secondary predictor variables. The primary outcomes were complete flap loss, partial flap loss, and the need for flap re-exploration. The secondary outcomes included surgical site occurrences, such as wound healing-related complications, seroma, and others.

RESULTS

We included 214 flaps, 177 in the non-elderly and 37 in the elderly cohort. Elderly women had slightly higher comorbidity rates than those of non-elderly women, although these differences were not statistically significant. BMI was significantly lower in elderly women than in non-elderly women. The incidence of total or partial flap loss did not differ significantly between the two cohorts (2.7% vs 1.1%, p = 0.459% and 0.0% vs 5.1%, p = 0.161), nor did the flap re-exploration (8.1% vs 10.1%, p = 0.937). Similarly, postoperative complication rates did not differ significantly between the two groups (45.9% vs 61.8%, p = 0.074). On logistic regression, being elderly was not a risk factor for complete flap loss, nor for any complications. The overall success rate for the non-elderly cohort was 98.7%, whereas that for the elderly cohort was 97.3%.

CONCLUSIONS

Microsurgical breast reconstruction using DIEP is safe in elderly patients, as it achieves outcomes and complications rates comparable to those observed in a younger population. Patients should not be denied DIEP flaps because of their age alone.

The Rates of Postmastectomy Immediate Breast Reconstruction during the Initial Months of the COVID-19 Pandemic

Background

Coronavirus disease 2019 (COVID-19) pandemic-related changes may have led to changes in immediate breast reconstruction (IBR) rates. We aimed to evaluate these changes before, during, and after the initial wave of COVID-19.

Methods

We retrospectively reviewed women who underwent mastectomy with or without IBR from January 1 to September 30, 2019 and from January 1 to September 30, 2020, and compared demographic, clinical, and surgical variables between defined time periods.

Results

A total of 202 mastectomies were included. Fewer patients underwent IBR during the initial surge of COVID-19 (surge period) compared with the months before (presurge period; 38.46% versus 70.97%, P = 0.0433). When comparing the postsurge period with a year before (postsurge control), fewer patients underwent reconstruction even after the initial surge had passed (53.13% versus 81.25%, P = 0.0007). Those who underwent IBR were older than the year before (59.34 versus 53.06, P = 0.0181). The median number of postoperative visits in the postsurge period was 8.50 (interquartile range: 6-12) compared with 14 (interquartile range: 8-20.50) in the year before (P = 0.0017). The overall incidences of complications and unanticipated resource utilization were also significantly lower in the postsurge period compared with the year before [5.88% versus 30.77% (P = 0.0055), and 14.71% versus 28.85% (P = 0.0103), respectively].

Conclusions

IBR rates were lower even after the initial surge than at the year before. Furthermore, during the pandemic, IBR patients were older, had fewer follow-up visits, and fewer reported complications.

A clinical practice review on process efficiency in autologous breast reconstruction

Autologous breast reconstruction is considered the gold standard technique for breast reconstruction following mastectomy. Thanks to recent refinements the main focus of surgery has shifted from flaps survival and donor site morbidity to optimal aesthetic outcomes and patients' satisfaction. However, prolonged operative time remains a limiting aspect for many patients and surgeons who aim in improving access to care and outcomes. Process mapping is a quality improvement strategy consisting of the creation of a visual representation of a process to recognize errors, minimize waste and optimize outcomes. It has been effectively applied in abdominal based autologous breast reconstruction in nine papers. The process segments and analysis varied between published papers, but all authors focused on intraoperative process mapping and reported reduced operative times. Additional preoperative and postoperative factors have been studied and are commonly applied to further optimize efficiency (such as preoperative CTA, co-surgery model, flap perfusion evaluation, postoperative monitoring, and ERAS protocol). Although shorter operative times are related to decrease surgical morbidity and faster recovery time, and safety, the aesthetic outcome should remain the main focus in autologous breast reconstruction. In fact, the true ultimate aim should be the achievement of high patient satisfaction.

Evaluation of Microvascular Autologous Breast Reconstruction in Patients Older Than 60 Years

BACKGROUND

While free-flap breast reconstruction becomes more common, it is still approached with caution in older patients. Outcomes in the elderly population have not been well characterized, especially with regard to donor-site sequalae. This study compares microvascular autologous breast reconstruction outcomes in patients older and younger 60 years.

METHODS

A single-institution retrospective review was performed for microvascular autologous breast reconstruction from January 2004 through January 2021. Demographic, intraoperative, and postoperative variables, including breast flap and donor-site complications, were evaluated.

RESULTS

Five hundred forty-five breast free flaps were identified, of which 478 (87.8%) were performed on patients younger than 60 years (mean, 46.2 years) and 67 (12.2%) older than 60 years (mean, 64.8 years; P = 0.000). Hyperlipidemia was significantly higher in older patients (19.4% vs 9.6%, P = 0.016). Mean operative time was 46.3 minutes faster in the older cohort ( P = 0.030). There were no significant differences in free-flap loss, venous congestion, takeback, hematoma, seroma, wound healing, or infection. Interestingly, there were significantly more total breast flap complications (28.5% vs 16.4%, P = 0.038) and higher rates of fat necrosis (9.6% vs 1.5%, P = 0.026) in the younger cohort. Significantly more abdominal donor-site complications (43.3% vs 21.3%, P = 0.000) were seen in the older people, with increased wound breakdown ( P = 0.000) and any return to the operating room (20.9% vs 9.8%, P = 0.007). Older patients were also significantly more likely to require surgical correction of an abdominal bulge or hernia (10.4% vs 4%, P = 0.020). The mean follow-up was 1.8 years.

CONCLUSIONS

Our data showed no worsening of individual breast flap outcomes in the older people. However, there were significantly more abdominal complications including surgical correction of abdominal bulge and hernia. This may be related to the inherent qualities of tissue aging and should be taken into consideration for flap selection. These results support autologous breast reconstruction in patients older than 60 years, but patients should be counseled regarding potentially increased abdominal donor-site sequelae.

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.

Outcomes of Third-Attempt Breast Reconstruction following Infection-Associated Failure of Secondary Implant-Based Reconstruction

BACKGROUND

Implant-based reconstruction (IBR) is the most common method of breast reconstruction in the United States. Despite ongoing advancements, periprosthetic infection is a serious problem that often results in device explantation. The objective of this study was to evaluate the outcomes of third-attempt reconstruction in patients in whom secondary implant-based reconstruction failed because of infection.

METHODS

The authors performed a retrospective review of patients who underwent mastectomy followed by IBR from 2000 to 2019. The outcomes of patients in whom secondary IBR failed because of infection and who ultimately underwent third-attempt breast reconstruction were analyzed.

RESULTS

Of 6093 patients who underwent primary IBR, 13 patients had third-attempt breast reconstruction following infection-related explantation [median age, 52 years (interquartile range, 51 to 56 years); median body mass index, 23 kg/m 2 (interquartile range, 22 to 31 kg/m 2 ); median follow-up, 46 months (interquartile range, 16 to 62 months)]. Nine patients (70%) underwent IBR, two (15%) underwent IBR combined with pedicled latissimus dorsi flap, and two (15%) underwent abdominally based free tissue transfer. Third-attempt breast reconstruction was immediate in 46% of patients and delayed in 54%. The success rate was 78% in the IBR group, with a 23% complication rate. The success rate for autologous breast reconstruction was 100%, with one patient developing venous congestion necessitating return to the operating room.

CONCLUSIONS

Third-attempt breast reconstruction following infection-associated failed secondary IBR is a safe and feasible option. Although the risk of failure is higher than that for primary implant-based reconstruction, a third attempt after secondary IBR infection had a surprisingly high 78% success rate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Determining Breast Implant Prevalence: A Population Study of Italian Chest Radiographs

BACKGROUND

Current breast implant prevalence within the general population remains elusive. An accurate prevalence is critical to serve as the denominator for any assessment of breast implant-related complication. The purpose of this manuscript is to assess this prevalence in women aged 20-70 years in Italy.

MATERIALS AND METHODS

Eight reviewers, demonstrating a mean sensitivity of 87.0% and specificity of 97.0%, were recruited for retrospective identification of implants on chest radiographs from a tertiary academic hospital in a major urban setting. Three final reviewers were selected, and they assessed all eligible chest radiographs collected between January and December 2019. The hospital-based population was compared to epidemiological data at a local, regional and national level to demonstrate homogeneity of age structures using the phi correlation coefficient.

RESULTS

We identified 3,448 chest X-rays which yielded 140 implants, with an overall prevalence of 4.1% for women aged 20-70. Implants were bilateral in 76% of cases and unilateral in 24%. They were placed cosmetically in 47.1% cases and used for reconstruction in 52.9% cases. Phi correlation coefficient found no differences across hospital-based, local, regional and national populations.

CONCLUSION

A validated method was performed to estimate implant prevalence from an academic hospital in a major urban setting at 4.1% and was used to estimate national prevalence in Italy. The implications of this epidemiologic study may reach across national borders for improved understanding of breast implant epidemiology and in predicting the total number of patients within a given population that may be affected by device complications.

LEVEL OF EVIDENCE IV

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 .

Comparison of surgical and patient-reported outcomes between 85 profunda artery perforator flaps and 122 deep inferior epigastric perforator flaps as first choice treatment for breast reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap for breast reconstruction was first published in 2012. Since then, many centers implemented its application as second-line treatment for breast reconstruction in cases where patient characteristics make the deep inferior epigastric perforator (DIEP) flap not feasible to perform. In our center, we established the PAP flap as a first-line procedure for a multitude of reasons for a specific patient population. This study describes perioperative measure, clinical outcomes, and patient-reported outcome measures in comparison to the gold standard, the DIEP flap.

METHODS

In this study, we analyzed all PAP flaps and DIEP flaps performed in a single center between March 2018 and December 2020. We present patient characteristics, surgical technique, perioperative care, surgical outcomes, and complications. The Breast-Q was used to assess patient-reported outcome measures.

RESULTS

A total of 85 PAP flaps and 122 DIEP flaps were performed within 34 months. Average follow-up was 11.6 ± 5.8 months for the PAP group and 11.1 ± 5.8 months for the DIEP group (p = 0.621). Patients' average body mass index was higher in the DIEP flap recipients. Operation time was shorter and ambulation faster in PAP flap recipients. DIEP flap application resulted in higher Breast-Q scores.

CONCLUSIONS

While the PAP flap demonstrated favorable perioperative measures, outcome measures were better with the DIEP flap. The PAP flap is fairly new and demonstrates high potential while still showing a need for refinement compared to the DIEP flap.

Age and Breast Reconstruction

BACKGROUND

Breast reconstruction is frequently offered to cancer patients who undergo mastectomy. Older women tend to have lower rates of reconstruction mostly due to an age-based discretion. We aimed to assess the safety of this surgery in this population.

METHODS

We conducted a single-center retrospective analysis of patients who underwent breast reconstruction following mastectomy between 2015 and 2020 at "Complejo Hospitalario Universitario de Albacete." Patients were classified according to age when the reconstruction process began (group A: < 65 years-group B: > 65 years). Differences in demographics and clinical data were analyzed using Student's t test and Chi-square test. Multivariable logistic regression models were used to estimate odds ratio (OR) and confidence intervals (CIs) for surgical complications according to age group. Propensity-score matching was used as a sensitivity analysis to test consistency among results.

RESULTS

We included 304 women (266: group A-38: group B). Complete reconstruction was achieved in 48.1% of patients in group A vs 10.5% in group B (P < 0.001). After adjusting for potential confounders, age was not associated with an increased risk of surgical complications, neither overall (OR 0.88, 95%CI 0.40-1.95), early (OR 1.35, 95%CI 0.58-3.13) nor late (OR 1.05, 95%CI 0.40-2.81). Radiotherapy and smoking history were significant predictors for complications in every setting.

CONCLUSIONS

In our cohort, age at breast reconstruction is not associated with a higher risk of surgical complications, in contrast to radiotherapy and smoking history. Therefore, age should not be a limiting factor when considering breast reconstruction.

LEVEL OF EVIDENCE IV

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 .

Frailty is the New Age: A Retrospective Study of Modified Frailty Index for Preoperative Risk Assessment in Autologous Breast Reconstruction

BACKGROUND

 Age is a poor predictor of postoperative outcomes in breast reconstruction necessitating new methods for risk-stratifying patients preoperatively. The 5-item modified frailty index (mFI-5) is a validated measure of frailty which assesses patients' global health. The purpose of this study was to compare the effectiveness of mFI-5 and age as independent predictors of 30-day postoperative complications following autologous breast reconstruction.

METHODS

 Patients who underwent autologous breast reconstruction between 2005 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients were stratified based on presence of major, minor, both minor and major, and no complications. Univariate and multivariate logistic regression were performed to determine the predictive power of mFI-5, age, and other preoperative risk factors for development of minor and major 30-day postoperative complications in all patients and stratified by flap type.

RESULTS

 A total of 25,215 patients were included: 20,366 (80.8%) had no complications, 2,009 (8.0%) had minor complications, 1,531 (6.1%) had major complications, and 1,309 (5.2%) had both minor and major complications. Multivariate regression demonstrated age was not a predictor of minor (odds ratio [OR]: 1.0, p = 0.045), major (OR: 1.0, p = 0.367), or both minor and major (OR: 1.0, p = 0.908) postoperative complications. mFI-5 was a significant predictor of minor complications for mFI-5 scores 1 (OR: 1.3, p < 0.001), 2 (OR: 1.8, p < 0.001), and 3 (OR: 2.8, p = 0.043). For major complications, mFI-5 was a significant predictor for scores 1 (OR: 1.2, p = 0.011) and 2 (OR: 1.3, p = 0.03).

CONCLUSION

 Compared with age, mFI-5 scores were better predictors of 30-day postoperative complications following autologous breast reconstruction regardless of flap type. Additionally, higher mFI-5 scores were associated with increased odds of minor and major complications. Our findings indicate that reconstructive breast surgeons should consider using the mFI-5 in lieu of age to risk-stratify patients prior to autologous breast reconstruction surgery.

A retrospective cohort study comparing reconstructive techniques and outcomes in post-mastectomy triple negative breast cancer patients

Background

Up to 42% of all breast cancer patients undergo post-mastectomy reconstruction, however reconstructive techniques have not been widely studied in patients with triple negative breast cancer (TNBC). Reconstructive complications may delay adjuvant treatments; in TNBC, which inherently carries an increased risk of locoregional recurrence, this can greatly affect oncological outcomes. Therefore, we evaluate factors influencing choice of reconstructive techniques following mastectomy in TNBC patients and assess operative and oncologic safety outcomes.

Methods

A single institution retrospective chart review identified TNBC patients who underwent post-mastectomy reconstruction between 2010 to 2020. Clinical characteristics collected included demographics, cancer history, reconstructive techniques [autologous-based reconstruction (ABR) vs. implant-based reconstruction (IBR)] and surgical and oncologic outcomes such as complications, recurrence, and mortality. Factors impacting whether patients underwent ABR versus IBR were assessed, as well as differences in outcomes between the two procedures. Statistical significance was defined as P<0.05.

Results

During the 10-year period, 52.9% (n=127) of all post-mastectomy TNBC patients (n=240) underwent breast reconstruction, most frequently immediately after mastectomy (97.0%). Most patients underwent IBR compared to ABR (82.4% vs. 14.5%). Patients undergoing ABR were older than IBR patients (54.3 vs. 46.4 years; P=0.040) and had a higher body mass index (BMI; 30.0 vs. 26.1 kg/m2; P=0.007). Patients more often pursued ABR if they had a prior breast cancer history (36.8% vs. 16.7%; P=0.041) or experienced TNBC recurrence (26.3% vs. 9.3%; P=0.034), while primary TNBC patients more often opted for IBR. Reconstructive type did not impact complications (ABR 31.6% vs. IBR 16.8%, P=0.131), recurrence (ABR 15.8% vs. IBR 13.0%, P=0.719), or mortality (ABR 0.0% vs. IBR 6.5%, P=0.593) rates.

Conclusions

Factors such as age, BMI, and breast cancer history impacted choice of reconstructive technique among TNBC women. No differences in complications, recurrence, or mortality occur in these high-risk patients regardless of reconstructive technique, highlighting that neither ABR nor IBR is superior in regard to surgical and oncologic safety in post-mastectomy TNBC patients.

Evaluation of satisfaction and the quality of life after bilateral breast reconstruction using the BREAST-Q questionnaire

BACKGROUND

The demand of breast reconstruction is growing, the purpose of this study is to evaluate the satisfaction and quality of life of patients who underwent bilateral breast reconstruction.

METHODS

In this cohort retrospective study, patients who underwent bilateral breast reconstruction in our department between September 2009 and December 2019 were asked to complete BREAST-Q questionnaire based on the timing of the reconstruction received following mastectomy, thus dividing them into three groups: (1) bilateral immediate breast reconstruction(BIBR), (2) immediate breast reconstruction in one side and delayed reconstruction on the other side (mixed group), (3) bilateral delayed breast reconstruction(BDBR). Surgical techniques were divided into prosthesthetic (permanent implant and expander), flaps (pedicle or free), mixed technique (associating flap and prosthesis).

RESULTS

Seventy-one out of 94 patients responded to our BREAST-Q questionnaire, with a response rate of 84.5%. A high score is associated with a better result, except in physical well-being where a lower score indicates better outcome. The average score for psychosocial well-being is 63.0 (±17.2) achieving the lowest among the BDBR group. Physical well-being score is 26.0 (±18.6) scoring the highest in BIBR group. Sexual well-being score is 52.2 (±17.4) and seen highest among BDBR group. Satisfaction with breast score is 54.1 (±10.0) and was highest among mixed group.

CONCLUSION

The therapeutic proposal was personalized based on patient profile and choice. The best reconstruction treatment enhancing the quality of life and patient satisfaction remains the option chosen by the patient and whose advantages and disadvantages are accepted by them.

Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis

Breast reconstruction (BR) is a unique surgical procedure that provides patients undergoing mastectomy with significant psychosocial and aesthetic benefits and has also become a crucial part of the treatment pathway for women with breast cancer. Due to methodological inadequacies and the absence of substantial risk factor analysis, no conclusion can be drawn about the correlation between risk variables and post-surgical complications in BR surgery. We aim to identify the potential risk factors associated with postoperative complications.

Methods

We queried MEDLINE and Cochrane CENTRAL from their inception to March 2022, for published randomized controlled trials and observational studies that assessed complications post-reconstruction procedure in breast cancer patients following mastectomy or evaluated at least one of the following outcomes of major or reoperative complications. The results from the studies were presented as odds ratios with 95% confidence intervals and were pooled using a random-effects model.

Results

Our pooled analysis demonstrated a significant correlation with BR postoperative complications and risk factors such as diabetes, hypertension, and obesity. Diabetes and the development of seroma were found to have a significant relationship. Risk variables such as age, radiotherapy, COPD, and smoking had no significant connection with 0-to-30-day readmission and 30-to-90-day readmission.

Conclusion

This meta-analysis shows that risk factors like age, smoking history, high blood pressure, and body mass index (BMI) have a big effect on complications after BR, and patients with risk factors have a high rate of developing infection.

Mortality Rate in Breast Implant Surgery: Is an Additional Procedure Worthwhile to Mitigate BIA-ALCL Risk?

Background

Because of poor knowledge of risks and benefits, prophylactic explantation of high BIA-ALCL risk breast implant (BI) is not indicated. Several surgical risks have been associated with BI surgery, with mortality being the most frightening. Primary aim of this study is to assess mortality rate in patients undergoing breast implant surgery for aesthetic or reconstructive indication.

Materials and Methods

In this retrospective observational cohort study, Breast Implant Surgery Mortality rate (BISM) was calculated as the perioperative mortality rate among 99,690 patients who underwent BI surgery for oncologic and non-oncologic indications. Mean age at first implant placement (A1P), implant lifespan (IL), and women’s life expectancy (WLE) were obtained from a literature review and population database.

Results

BISM rate was 0, and mean A1P was 34 years for breast augmentation, and 50 years for breast reconstruction. Regardless of indication, overall mean A1P can be presumed to be 39 years, while mean BIL was estimated as 9 years and WLE as 85 years.

Conclusion

This study first showed that the BISM risk is 0. This information, and the knowledge that BI patients will undergo one or more revisional procedures if not explantation during their lifetime, may help surgeons in the decision-making process of a pre-emptive substitution or explant in patients at high risk of BIA-ALCL. Our recommendation is that patients with existing macrotextured implants do have a relative indication for explantation and total capsulectomy. The final decision should be shared between patient and surgeon following an evaluation of benefits, surgical risks and comorbidities.

Level of Evidence IV

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.

Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review

BACKGROUND

Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any).

METHODS

MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer.

RESULTS

A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified.

CONCLUSION

Uptake of PMIBR in older women is low with definable (and some correctable) barriers.

A Case for the Use of the 5-Item Modified Frailty Index in Preoperative Risk Assessment for Tissue Expander Placement in Breast Reconstruction

BACKGROUND

Preoperative risk assessment is essential in determining which surgical candidates will have the most to gain from an operation. The 5-item modified frailty index (mFI-5) has been validated as an effective way to determine this risk. This study sought to evaluate the performance of the mFI-5 as a predictor of postoperative complications after tissue expander placement.

METHODS

Patients who underwent placement of a tissue expander were identified using the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project database. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status, diabetes, chronic obstructive pulmonary disease, chronic heart failure, and hypertension), and other factors commonly used to risk stratify (age, body mass index [BMI], American Society of Anesthesiologists (ASA) classification, and history of smoking) were associated with complications.

RESULTS

In 44,728 tissue expander placement cases, the overall complication rate was 10.5% (n = 4674). The mFI-5 score was significantly higher in the group that experienced complications (0.08 vs 0.06, P < 0.001). Compared with the mFI-5 individual components and other common variables used preoperatively to risk stratify patients, univariate analysis demonstrated that mFI-5 had the largest effect size (odds ratio [OR], 5.46; confidence interval [CI], 4.29-6.94; P < 0.001). After controlling for age, BMI, ASA classification, and history of smoking, the mFI-5 still remained the predictor of complications with the largest effect size (OR, 2.25; CI, 1.70-2.97; P < 0.001). In assessing specific complications, the mFI-5 is the independent predictor with the largest significant effect size for surgical dehiscence (OR, 12.76; CI, 5.58-28.18; P < 0.001), surgical site infection (OR, 6.68; CI, 4.53-9.78; P < 0.001), reoperation (OR, 5.23; CI, 3.90-6.99; P < 0.001), and readmission (OR, 4.59; CI, 3.25-6.45; P < 0.001) when compared with age, BMI, ASA class, and/or history of smoking alone.

CONCLUSIONS

The mFI-5 can be used as an effective preoperative predictor of postoperative complications in patients undergoing tissue expander placement. Not only does it have the largest effect size compared with other historical perioperative risk factors, it is more predictive than each of its individual components.

Long-Term Patient Satisfaction and Quality of Life Following Breast Reconstruction Using the BREAST-Q: A Prospective Cohort Study

Background

Breast reconstruction is a promising surgical technique to improve health-related quality of life (HRQoL) in patients with breast cancer. However, the long-term risk factors associated with HRQoL after breast surgery are still unclear. Our aim was to evaluate breast satisfaction and HRQoL following breast reconstruction to identify clinical factors associated with each domain of BREAST-Q in the long-term.

Methods

Patient-reported BREAST-Q outcomes were analyzed 1 and 5 years after breast reconstruction in a single-blinded, prospective study. Multiple regression analysis was performed to identify the risk and protective factors associated with BREAST-Q scores. These scores at 1 and 5 years were also compared across three types of operation: mastectomy only, tissue expander/implant (TE/Imp), and a deep inferior epigastric perforator (DIEP) flap.

Results

Surveys were completed by 141 subjects after 1 year and 131 subjects after 5 years. Compared to mastectomy only, breast reconstruction was significantly associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001), higher body mass index (BMI) resulted in lower “Satisfaction with breasts” (p = 0.004), and a history of psychiatric or neurological medication was significantly associated with “Physical well-being” at 1-year postoperatively (p = 0.02). At 5 years, reconstructive procedures were significantly positively associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p = 0.03; DIEP, p &lt; 0.001), and a bilateral procedure was a significant risk factor for lower “Psychosocial well-being” (p = 0.02).

Conclusions

The results of this study show that breast reconstruction improves “Satisfaction with Breasts” and “Psychosocial well-being” compared to mastectomy. Among all three types of operation, DIEP gave the best scores at 5 years postoperatively. Thus, autologous reconstruction is recommended for promotion of long-term HRQoL after breast surgery.

Current Trends in Breast Reconstruction following Bilateral Prophylactic Mastectomy

Background:

Individuals with genetic susceptibility to breast cancer may pursue bilateral prophylactic mastectomy (BPM) and subsequent breast reconstruction. This study aimed to characterize immediate reconstructive trends following BPM.

Methods:

The ACS-NSQIP database (2010 -2019) was used to examine differences in demographics and operative outcomes based on breast reconstruction technique following BPM and factors predicting reconstruction type.

Results:

Of 1945 patients (mean age, 43.8 ± 11.3 years), implant-based reconstruction (IBR) was most frequently (71.8%) performed following BPM. Patients who underwent IBR (n = 1396) were younger (42.6 years, P < 0.001), more likely to be White (P < 0.05), and more likely to have a BMI less than 25 (P < 0.001). Patients who underwent autologous reconstruction (AR) (n = 186, 45.8 years) were more likely to be Black or African American and have a BMI of 25–30. Patients who underwent mastectomy only (MO) without immediate reconstruction (n = 363) were older (47.6 years), more likely to be Asian, and more likely to have a BMI greater than 35. The MO cohort had the highest frequency of diabetes or smoking history. AR was associated with longer operations, longer lengths of stay, and increased complications. Increasing age and BMI were predictive of AR or MO compared to IBR. Smoking was predictive of MO.

Conclusion:

This is the first large-scale study of genetically susceptible patients who underwent BPM demonstrating a significant relationship between patient demographics, operative outcomes, and immediate reconstruction technique. These results provide valuable insight for surgeons and patients during the shared decision-making process.

Predictive Factors of Satisfaction Following Breast Reconstruction: Do they Influence Patients?

INTRODUCTION

This study aims to analyze whether there is any patient- or treatment-related factor that can influence patients' body perception after mastectomy and autologous or implant-based breast reconstruction.

MATERIALS AND METHODS

This retrospective cohort study included patients who underwent immediate implant-based or DIEP flap breast reconstruction. Predictive factors analyzed included chemotherapy, radiotherapy, hormone therapy, body mass index, age, type of mastectomy, and follow-up length. The BREAST-Q was administered postoperatively almost 2 years from the last surgical procedure. Mean BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. A linear regression model was applied to all BREAST-Q scores with all predictor factors.

RESULTS

In total, 325 patients were enrolled in this study (133 DIEP flap and 192 implant-based reconstructions). The DIEP flap reconstruction group with a previous nipple sparing mastectomy showed the highest scores. Patients with a longer follow-up were less satisfied than the ones with a shorter follow-up, which could be considered as an assessment of the outcome. No significant difference was reported between patients who underwent radiotherapy, chemotherapy or hormone therapy and those who did not. Furthermore, age and BMI had no influence on patient satisfaction.

CONCLUSION

This study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way.

LEVEL OF EVIDENCE IV

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 .

Race and Site of Care Impact Treatment Delays in Older Women with Non-Metastatic Breast Cancer

BACKGROUND

Women ≥ 65 years of age are less likely to receive guideline-concordant breast cancer care. Given existing racial/ethnic disparities, older minority breast cancer patients may be especially prone to inequalities in care. How site of care impacts older breast cancer patients is not well defined. We sought to evaluate the association between race/ethnicity and breast cancer treatment delays in older women treated at minority-serving hospitals (MSHs) versus non-MSHs.

METHODS

Women ≥ 65 years of age treated for non-metastatic breast cancer were identified in the National Cancer Database (2010-2017). Treatment delay was defined as > 90 days from diagnosis to initial treatment. MSHs were defined as the top decile of hospitals serving predominantly Black or Hispanic patients. Multivariable logistic regression models adjusted for patient, tumor, and hospital characteristics were used to determine the odds of treatment delay for women at MSHs versus non-MSHs across racial/ethnic groups.

RESULTS

Overall, 557,816 women were identified among 41 MSHs and 1146 non-MSHs. Average time to treatment was 33.71 days (standard deviation 26.92 days). Older women at MSHs were more likely to experience treatment delays than those at non-MSHs (odds ratio 1.28, 95% confidence interval 1.21-1.36). Regardless of where they received care, minorities were more likely to experience treatment delays than non-Hispanic White women.

CONCLUSIONS

Although 97% of older women treated at Commission on Cancer-accredited hospitals received timely breast cancer care, minorities and those treated at MSHs were more likely to experience treatment delays. Interventions addressing barriers to timely breast cancer care at MSHs may be an effective approach to reducing racial/ethnic disparities.

An Analysis of the Modified Five-Item Frailty Index for Predicting Complications following Free Flap Breast Reconstruction

BACKGROUND

The modified five-item frailty index is a validated and effective tool for assessing risk in surgical candidates. The authors sought to compare the predictive ability of the modified five-item frailty index to established risk factors for complications in free flap breast reconstruction.

METHODS

The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for free flap breast reconstructive procedures. Univariate and multivariate regression analysis models were used to assess how modified five-item frailty index and factors commonly used to risk stratify (age, body mass index, American Society of Anesthesiologists classification, and history of smoking) were associated with complications.

RESULTS

Of the total 10,550 cases, 24.1 percent experienced complications. A high modified five-item frailty index score is associated with a higher overall rate of postoperative complications (p < 0.001). This significant trend was demonstrated in both surgical (p < 0.001) and medical (p < 0.001) complications. When controlling for other risk factors commonly used for risk stratification such as age, body mass index, American Society of Anesthesiologists classification, and history of smoking, the modified five-item frailty index was significantly associated with medical (OR, 1.75; 95 percent CI, 1.37 to 2.22; p = 0.001) and any complications (OR, 1.58; 95 percent CI, 1.29 to 1.93; p < 0.001) and had the largest effect size. Assessing for specific complications, the modified five-item frailty index is the strongest independent predictor of reoperation (OR, 1.41; 95 percent CI, 1.08 to 1.81; p = 0.009).

CONCLUSION

The modified five-item frailty index is a useful predictor of postoperative outcomes in patients undergoing free flap breast reconstruction when compared to other historically considered risk factors for surgical complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Triple negative breast cancer and reconstruction: Predictors of recurrence, complications, and mortality

BACKGROUND

Only 42% of all breast cancer patients undergoing mastectomy elect for breast reconstruction.

OBJECTIVE

We evaluate factors impacting complications, recurrence, and mortality in triple-negative breast cancer (TNBC) patients undergoing reconstruction.

METHODS

Reconstructive TNBC patients at a single institution from 2010 to 2020 were retrospectively reviewed. Patient demographics, cancer characteristics, reconstruction choice, and complications were collected. Statistical significance was defined at p < 0.05.

RESULTS

A total of 131 patients were identified. Average age was 47.8 years, 50.4% were Caucasian and 36.4% were African American. Most patients had invasive ductal carcinoma (90.8%), and most underwent nipple-sparing (41.2%) or skin-sparing (38.9%) mastectomies. Twenty-one patients (16.0%) experienced postoperative complications. Patients with complications tended to be older (52.1 versus 46.9 years, p = 0.052). At mean follow-up of 52.1 months, 14.5% experienced cancer recurrence and 5.3% died. Deceased patients were significantly younger at diagnosis (42.2 versus 48.5 years, p = 0.008) and had a lower BMI compared to surviving patients (21.2 versus 26.9 kg/m2; p = 0.014). Patients younger than age 45 years had higher Ki-67 than those older than 45 years (80.0% versus 60.0%, p = 0.013). Outcomes in autologous- versus implant-based reconstruction were not significantly different.

CONCLUSIONS

In TNBC post-mastectomy reconstruction patients, age and BMI were predictors of mortality while race, smoking history, reconstruction choice, or type of implant-based reconstruction had no significant effect on these outcomes.

SYNOPSIS

The purpose of this study is to evaluate factors that impact complications, recurrence, and mortality in triple negative breast cancer (TNBC) patients undergoing reconstruction. We identified BMI, neoadjuvant chemotherapy, and age as predictors of complications, recurrence, and mortality in TNBC.

Systematic Review of Breast-Q: A Tool to Evaluate Post-Mastectomy Breast Reconstruction

Purpose

The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire’s ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy.

Methods

PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included.

Results

A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including ‘satisfaction with breasts’, “satisfaction with outcome” “psychosocial”, “physical”, and “sexual wellbeing”. Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8–80.0 and 39.0–78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively.

Conclusion

This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.

Pedicled Latissimus Dorsi Kiss Flap for the Reconstruction of Large Chest Wall Defect After Mastectomy

To discover the utility of pedicled latissimus dorsi kiss flap for the reconstruction of chest wall defect after mastectomy. This study was a systemic analysis of 12 female patients with breast tumors who were treated at Affiliated Hospital of Guangdong Medical University from January 2018 to December 2019. Among them, three patients had malignant lobular breast tumors, and nine patients had locally advanced breast cancer. After extensive resection of the primary tumor, the chest wall skin, and soft tissue, a large defect was left in the chest wall of each patient. Based on the design and structure of the kiss flap, two semicircular flaps of equal diameter were designed in the latissimus dorsi region, and their blood supply was retained from the same vascular trunk. Two flaps were transferred to the chest wall through a subcutaneous tunnel, and the incision in the donor area was sutured directly. Finally, two equal semicircle flaps were adjusted to fit the defect and then fixed on the chest wall. Referred to the design of the kiss flap, the area of the latissimus dorsi was increased to cover a larger chest wall defect. We have used this flap to reconstruct chest wall defects on twelve patients. Their age ranged from 24 to 62. The largest defect was 20 × 12 cm, and the smallest defect was 15 × 10 cm in diameter. Postoperative follow-up time was 5–9 months (mean time: 6.2 months): Follow-up observations demonstrated that all the flaps were healed well without edema or extravasation and donor area of all cases was closed well. In addition, no local recurrence or distant metastasis was observed in all patients.