Conceptual Considerations In Breast Reconstruction

Patient-Reported Outcomes Following Breast Reconstruction Surgery and Therapeutic Mammoplasty: Prospective Evaluation 1 Year Post-Surgery with BREAST-Q Questionnaire

Breast Cancer (BC) treatment leads to mutilation and destruction of breast shape with negative effects on body image and self-esteem.One of the main goals of reconstructive and oncoplastic breast surgery is to satisfy patients and improve their quality of life (QoL).Therefore, it is important to assess the patient experience post-surgery by means of patient-reported outcome measures (PROMs) that focus on the patient's perception of the surgery and surgical care, as well as psychosocial well-being and physical functioning. The objective of the current study was to identify predictors of patient satisfaction such as breast appearance including implant type in a selective sample of women who underwent breast reconstruction surgery using implants. Participants in this prospective study were women, (age 26-75 years) that were newly diagnosed with breast carcinoma. All consecutive patients who underwent breast reconstruction between January 2013 and October 2014 were asked to complete the BREAST-Q questionnaire 1 year after surgery. 120 patients underwent unilateral breast reconstruction using implant. While 38 patients underwent reconstruction with opposite breast reduction symmertization, 27 patients underwent therapeutic mammoplasty. The response rate for BREAST-Q questionnaire completion was 98 % with 147 out of 150 study participants completed the questionnaire. From the data collected from 147 patients, the responses could be distributed into 4 distinct groups based on the reconstruction outcomes namely "very much satisfied" (93 %) or "definitely and mostly satisfied" (94 %) or "satisfied" with the outcome (88 %) or "definitely agree on having reconstruction rather than the alternative of having no breast "(91 %).The results showed significant improvement in all four areas that were evaluated after surgery namely satisfaction with the appearance of the breasts, psychosocial, sexual and physical well-being. While the reconstruction surgery had an overall positive impact on quality of life it was observed that in patients that did not undergo breast reconstruction psychological issues related to sexuality were observed. Many newly diagnosed BC patients do not opt for these new surgical procedures due to psychological trauma or lack of information. Based on these observations, we propose that Breast Cancer Management protocols should also include additional counselling support for the newly diagnosed BC patients on the option of breast reconstruction along with conventional medical treatment counselling by the Oncosurgeon.

Satisfaction with and psychological impact of immediate and deferred breast reconstruction

BACKGROUND

The present work assesses the effect of immediate breast reconstruction (IBR), deferred breast reconstruction (DBR), and no breast reconstruction on the psychological impact.

PATIENTS AND METHODS

Standard questionnaires were used to determine the psychological impact suffered by patients who underwent IBR, DBR and no reconstruction, their degree of satisfaction with the results achieved, and their postprocedure opinions regarding reconstruction options.

RESULTS

A total of 526 women underwent mastectomy. The response rate to the questionnaires was 71.67%. A significantly greater proportion of the women who underwent no reconstruction suffered psychological problems than those who underwent reconstruction of some type (P = 0.01). Some 94.77% of the women who underwent IBR maintained a postprocedure preference for this option; in contrast, some 87.27% of the DBR and 56.14% of the no-reconstruction patients declared a postprocedure preference for IBR. In all, 63.49% of the women who underwent reconstruction were moderately very satisfied with the aesthetic results achieved, while only 22.80% of the no-reconstruction patients declared such satisfaction (P = 0.0001).

CONCLUSIONS

The women who underwent no breast reconstruction suffered more emotional problems than those who underwent a reconstruction procedure. In general, all groups reported a postprocedure preference for IBR in their questionnaire answers. The aesthetic results achieved by IBR seem to be those best accepted.

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.

The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors

The purpose of this study was to identify important sociodemographic factors affecting the utilization of immediate and early delayed postmastectomy breast reconstruction in the United States. Using the Surveillance, Epidemiology, and End Results (SEER) program, all cases of mastectomy-treated breast cancer that were reported to a SEER registry in 1998 were identified. Data were limited to reconstructions within the first 4 months postmastectomy, and logistic regression was used to analyze the effects of sociodemographic variables on reconstruction rates. Of the 10,406 mastectomy-treated breast cancer patients, 1607 (15 percent) underwent reconstruction within the first 4 months postmastectomy. Compared with women 45 to 54 years old, those 35 to 44 years old were significantly more likely to have breast reconstruction (OR = 1.52, p < 0.001), but women 55 to 64, 65 to 74, and 75 years and older were significantly less likely to have reconstruction (OR = 0.42, p < 0.001; OR = 0.16, p < 0.001; OR = 0.04, p < 0.001, respectively). Compared with Caucasian women, African American, Hispanic, and Asian women were significantly less likely to have reconstruction (OR = 0.48, p < 0.001; OR = 0.45, p < 0.001; OR = 0.29, p < 0.001, respectively). In addition, a four-fold difference in reconstruction rates existed in high-use versus low-use regions. With regard to the type of reconstruction, patients younger than 35 and 65 to 74 years old were significantly less likely to receive autogenous tissue reconstruction compared with women 45 to 54 years old (OR = 0.47, p = 0.047; OR p = 0.61, p = 0.031, respectively). However, African Americans were significantly more likely to receive autogenous tissue reconstructions compared with Caucasians (OR = 2.03, p = 0.021). According to these data, the utilization of immediate and early delayed breast reconstruction in the United States is low and is significantly influenced by patients' age, race, and geographic location. Further research is needed to evaluate the impact of provider bias, patient preference, and barriers to care on the utilization of breast reconstruction in the United States.

Multidisciplinary care for patients with breast cancer

Breast cancer management requires a multidisciplinary approach that is tailored to the patient's stage at presentation, desire for breast conservation or reconstruction, estimation of risk of recurrence, and assessment of the benefits and toxicities of potential adjuvant therapies. At the Lahey Clinic Medical Center, breast surgeons, plastic surgeons, radiation oncologists, and medical oncologists staff the Breast Cancer Treatment Clinic, and work closely together to formulate treatment plans that will optimize the likelihood for cure with an acceptable cosmetic result. This involves careful preoperative work-up, surgical axillary staging, breast irradiation in the setting of breast conservation, and selection of chemotherapy or hormonal therapy if appropriate. Newer aspects of breast cancer care, including sentinal lymph node biopsy, postmastectomy radiation therapy, expanded use of hormonal therapy in younger women, new agents and chemotherapy combinations, and autogenous reconstruction techniques, have become an essential part of the multidisciplinary clinic approach.