Detailed Analysis of Three Major Breast Reconstructions Using BREAST-Q Responses From 1001 Patients

BACKGROUND

Patient-reported outcomes have become as important as mortality and morbidity in the postoperative evaluation of breast reconstruction surgery. The BREAST-Q is one of the most widely used patient-reported outcomes for breast reconstruction.

OBJECTIVES

A comparative analysis of the scores on each of the BREAST-Q modules could help analyze different reconstruction methods. However, few studies have utilized BREAST-Q for this purpose. The aim of this study was therefore to compare breast reconstruction methods in terms of BREAST-Q module ratings.

METHODS

The authors retrospectively reviewed the data of 1001 patients who had been followed for more than 1 year after breast reconstruction. The 6 BREAST-Q modules were rated on a scale of 0 to 100 and statistically analyzed by multiple regression. In addition, Fisher's exact test was performed after dividing the responses to each question into high- and low-rating groups.

RESULTS

Microvascular abdominal flap reconstruction scored significantly better than implant-based reconstruction on all modules, except psychosocial and sexual well-being. In terms of satisfaction with the breast, latissimus dorsi flap reconstruction was superior to implant-based reconstruction. However, in terms of the reconstruction method, there were no differences in patients' willingness to make the same choice again or whether they regretted having surgery.

CONCLUSIONS

The results highlight the superiority of autologous breast reconstruction. Reconstruction methods should only be performed after a thorough explanation of their characteristics to achieve results that meet patient expectations. The findings are useful for facilitating patient decision-making in breast reconstruction.

LEVEL OF EVIDENCE: 4

Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction

BACKGROUND

The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated.

OBJECTIVE

This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective.

METHODS

A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants.

RESULTS

Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study.

CONCLUSIONS

Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.

Physical well-being recovery trajectories by reconstruction modality in women undergoing mastectomy and breast reconstruction: Significant predictors and health-related quality of life outcomes

OBJECTIVES

We sought to identify trajectories of patient-reported outcomes, specifically physical well-being of the chest (PWBC), in patients who underwent postmastectomy breast reconstruction, and further assessed its significant predictors, and its relationship with health-related quality of life (HRQOL).

METHODS

We used data collected as part of the Mastectomy Reconstruction Outcomes Consortium study within a 2-year follow-up in 2012-2017, with 1422, 1218,1199, and 1417 repeated measures at assessment timepoints of 0,3,12, and 24 months, respectively. We performed latent class growth analysis (LCGA) in the implant group (IMPG) and autologous group (AUTOG) to identify longitudinal change trajectories, and then assessed its significant predictors, and its relationship with HRQOL by conducting multinomial logistic regression.

RESULTS

Of the included 1424 patients, 843 were in IMPG, and 581 were in AUTOG. Both groups experienced reduced PWBC at follow-up. LCGA identified four distinct PWBC trajectories (χ2 = 1019.91, p<0.001): low vs medium high vs medium low vs high baseline PWBC that was restored vs. not-restored after 2 years. In 76.63%(n = 646) of patients in IMPG and 62.99% (n = 366) in AUTOG, PWBC was restored after two years. Patients in IMPG exhibited worse PWBC at 3 months post-surgery than that in AUTOG. Patients with low baseline PWBC that did not improve at 2-year follow up (n = 28, 4.82% for AUTOG) were characterized by radiation following reconstruction and non-white ethnicity. In IMPG, patients with medium low-restored trajectory were more likely to experience improved breast satisfaction, while patients developing high-restored trajectories were less likely to have worsened psychosocial well-being.

CONCLUSION

Although more women in IMPG experienced restored PWBC after 2 years, those in AUTOG exhibited a more favorable postoperative trajectory of change in PWBC. This finding can inform clinical treatment decisions, help manage patient expectations for recovery, and develop rehabilitation interventions contributing to enhancing the postoperative quality of life for breast cancer patients.

Association of the breast reconstruction modality with the development of postmastectomy lymphedema: A long-term follow-up study

BACKGROUND

Whether the breast reconstruction modality could influence the long-term development of post-mastectomy lymphedema has been little investigated. The present study aimed to evaluate the potential association of the breast reconstruction method with the incidence of lymphedema over an extended follow-up period.

METHODS

Patients with breast cancer who underwent immediate reconstruction from 2008 to 2014 were reviewed. They were categorized into three groups according to the reconstruction method: tissue expander/implant, abdominal flaps, and latissimus dorsi (LD) muscle flaps. Differences in the cumulative incidence of lymphedema by the reconstruction method were analyzed, as well as their independent influence on the outcome. Further analyses were conducted with propensity-score matching for baseline characteristics.

RESULTS

In total, 664 cases were analyzed with a median follow-up of 83 months (402 prostheses, 180 abdominal flaps, and 82 LD flaps). The rate of axillary lymph node dissection was significantly higher in the LD flap group than in the other two groups. The 5-year cumulative incidences of lymphedema in the LD flap, abdominal flap, and prosthesis groups were 3.7%, 10.6%, and 10.9%, respectively. In multivariable analyses, compared to the use of the LD flap, that of tissue expander/implant and that of abdominal flaps were associated with increased risks of lymphedema. A similar association was observed in the propensity-score matching analysis. The use of abdominal flaps or prostheses was not associated with the outcomes.

CONCLUSIONS

Our results suggest that the method of immediate breast reconstruction might be associated with the development of postmastectomy lymphedema.

Outcomes of breast reconstruction in patients with stage IV breast cancer

BACKGROUND

Patients with Stage IV breast cancer are living longer but breast reconstruction in this setting remains controversial. There is limited research evaluating the benefits of breast reconstruction in this patient cohort.

STUDY DESIGN

Drawing from the Mastectomy Reconstruction Outcomes Consortium (MROC) dataset, a prospective cohort study that involved 11 leading medical centers in the US and Canada, we compared patient-reported outcomes (PROs) assessed utilizing the BREAST-Q, a condition-specific, validated patient-reported outcome measure (PROM) for mastectomy reconstruction, as well as complications between a cohort of patients with Stage IV disease undergoing reconstruction and a control group of women with Stage I-III disease also receiving reconstruction.

RESULTS

Among the MROC population, 26 patients with Stage IV and 2613 women with Stage I-III breast cancer underwent breast reconstruction. Preoperatively, the Stage IV cohort reported significantly lower baseline scores for satisfaction with breast (p = 0.004), psychosocial well-being (p = 0.043) and sexual well-being (p = 0.001), compared with Stage I-III women. Following breast reconstruction, Stage IV patients' mean PRO scores improved over baseline and were not significantly different from those of Stage I-III reconstruction patients. There were also no significant differences in overall/any (p = 0.782), major (p = 0.751) or minor complication (p = 0.787) rates between the two groups at two years following reconstruction.

CONCLUSIONS

The findings in this study suggest that breast reconstruction offers significant quality-of-life benefits for women with advanced breast cancer with no increase in postoperative complications and thus may be a reasonable option in this clinical setting.

Post-Mastectomy Tissue Expander Placement Followed by Radiation Therapy: A Cost-Effectiveness Analysis of Staged Autologous Versus Implant-Based Unilateral Reconstruction

BACKGROUND

There is no preferred approach to breast reconstruction for patients with locally advanced breast cancer (LABC) who require post-mastectomy radiation therapy (PMRT). Staged implant and autologous reconstruction both have unique risks and benefits. No previous study has compared their cost-effectiveness with utility scores.

METHODS

A literature review determined the probabilities and outcomes for mastectomy and staged implant or autologous reconstruction. Utility scores were used to calculate the quality-adjusted life years (QALYs) associated with successful surgery and postoperative complications. Medicare billing codes were used to assess costs. A decision analysis tree was constructed with rollback and incremental cost-effectiveness ratio (ICER) analyses. Sensitivity analyses were performed to validate results and account for uncertainty.

RESULTS

Mastectomy with staged deep inferior epigastric perforator (DIEP) flap reconstruction is costlier ($14,104.80 vs $3216.93), but more effective (QALYs, 29.96 vs 24.87). This resulted in an ICER of 2141.00, favoring autologous reconstruction. One-way sensitivity analysis showed that autologous reconstruction was more cost-effective if less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective.

CONCLUSIONS

For patients with LABC who require PMRT, staged autologous reconstruction is significantly more cost-effective than reconstruction with implants. Despite the decreased morbidity, staged implant reconstruction has greater rates of complication.

[Breast Reconstruction: Impact of the Procedure on Quality of Life]

English Breast cancer and the surgical procedures associated with it have a major impact on the quality of life of affected patients. Research shows that the loss of the breast and the associated change in body image have a major impact on the female self-image for many women. This has a strong negative impact on the quality of life of those affected. With modern clinical outcome research including treatment results from the patient's perspective in the form of patient-reported outcome measures (PROMs), the satisfaction and quality of life of those affected can be measured, analysed and compared. This review examines the extent to which breast reconstruction improves the quality of life for many women and how the different reconstruction methods vary in their impact on quality of life and satisfaction. In addition, the review discusses the importance of standardised recording and analysis of PROMs in combination with objective clinical data and their integration into the treatment process, and it demonstrates implementation options. Such systematic recording of PROMs enables the creation of databases and registers, the evaluation of which provides information that can be used for scientific and clinical purposes. Based on these research results, prognostic models can be created and treatment results can be examined in comparative studies facilitating clinical decision-making and quality controls.

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

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

Methods

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

Results

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

Conclusions

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

Impact on Patient's Appearance Perception of Autologous and Implant Based Breast Reconstruction Following Mastectomy Using BREAST-Q

Introduction

The purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis.

Materials and Methods

All patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher’s exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors.

Results

Of the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors.

Conclusion

This is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores.

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.

Understanding Preoperative Breast Satisfaction among Patients Undergoing Mastectomy and Immediate Reconstruction: BREAST-Q Insights

BACKGROUND

This study aims to present normative values for satisfaction with breasts among preoperative breast reconstruction patients as assessed using the BREAST-Q instrument and to delineate factors associated with preoperative breast satisfaction.

METHODS

A retrospective analysis of prospectively collected data was performed examining women undergoing postmastectomy breast reconstruction at a tertiary care center who preoperatively completed the BREAST-Q from 2010 to 2017. Because breast satisfaction scores were nonnormally distributed, scores were categorized into quartiles for analysis. Patient- and treatment-level variables were tested in a multivariable ordinal logistic regression model as predictors of breast satisfaction. Preoperative satisfaction was also tested for association with choice of reconstructive modality.

RESULTS

Among 1306 postmastectomy reconstruction patients included in the study, mean preoperative Satisfaction with Breasts score was 61.8 ± 21.5 and the median score was 58.0 (interquartile range, 48 to 70). Factors associated with significantly lower preoperative satisfaction included history of psychiatric diagnosis, preoperative radiotherapy, marital status (married), and higher body mass index. Factors associated with significantly higher scores were malignancy (localized tumor), medium bra size (B to C cup), and self-identification as black. Preoperative breast satisfaction was lower among patients who elected autologous reconstruction than among those with implant reconstruction (p < 0.001).

CONCLUSIONS

Preoperative breast satisfaction is influenced by multiple factors. Understanding these factors may improve preoperative counseling and expectation management for patients who undergo postmastectomy breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Impact of mastectomy for breast cancer on spinal curvature: Considerations when treating patients with scoliosis

OBJECTIVE

Mastectomy has been shown to influence body posture in women; however, there are limited data outlining changes in spine curvature after mastectomy in patients with scoliosis. We sought to quantify changes in spine curvature after mastectomy for breast cancer.

METHODS

We conducted a retrospective review of 62 patients with scoliosis who underwent mastectomy for breast cancer at a single institution between 1995 and 2018. Preoperative and postoperative radiographs were used to measure Cobb angles to assess lateral spinal curvature. Changes in Cobb angle were compared using paired two-tailed t-tests. The relationship between mass of breast removed and changes in Cobb angle was modeled using a linear regression.

RESULTS

The median follow-up after mastectomy was 7.9 years (range 0.9-21.5). Median age was 62 years (range 30-85). Of 62 patients, 10 (16%) expressed that their back pain became worse after mastectomy. Nineteen patients had evaluable radiographs before and after mastectomy. In these patients, the average change in Cobb angle was 4.7° (range -0.2-12.2). Cobb angle significantly increased after mastectomy (P < .0001). Although not statistically significant, average Cobb angle was greater for patients who underwent unilateral compared to bilateral mastectomy (P = .09). Mass of breast removed significantly correlated with the difference in Cobb angle for patients who underwent unilateral mastectomy (P = .0006), but not for bilateral mastectomy (P = .55).

CONCLUSIONS

In this understudied patient population, mastectomy significantly increased the change in spine curvature. Further care should be taken to assess patient-reported pain and quality of life in patients with spine morbidity who undergo mastectomy for breast cancer.

Stability of Long-Term Outcomes in Implant-Based Breast Reconstruction: An Evaluation of 12-Year Surgeon- and Patient-Reported Outcomes in 3489 Nonirradiated and Irradiated Implants

BACKGROUND

Outcomes following prosthetic breast reconstruction have been well studied. However, the majority of studies are limited by short-term follow-up and a lack of aesthetic and patient-reported outcomes. This study objectively examines long-term surgeon- and patient-reported outcomes following two-stage prosthetic breast reconstruction.

METHODS

Consecutive patients undergoing two-stage prosthetic breast reconstruction from 1994 to 2016 performed by the senior author (P.G.C.), with at least 1-year follow-up after implant exchange, were reviewed retrospectively. Long-term surgeon-reported outcomes, including aesthetic and capsular contracture scores, and patient-reported outcomes using the BREAST-Q, were recorded at each outpatient visit and analyzed over the 12-year follow-up period.

RESULTS

Retrospective review revealed 2284 patients, or 3489 breasts, that fit the inclusion criteria. Aesthetic scores and capsular contracture rates remained stable over the entire follow-up period. Subset analysis demonstrated that bilateral and nonirradiated reconstructions consistently had the highest aesthetic scores, whereas unilateral irradiated breasts had the lowest. Irradiated breasts consistently had high rates of capsular contracture, although the extent of contracture improved over time in all patients. Patient-reported BREAST-Q scores showed either stability or improvement over time in all patients. Irradiated and nonirradiated patients demonstrated comparable long-term satisfaction with outcomes despite significant differences in satisfaction with their breasts.

CONCLUSIONS

The authors' study, the largest of its kind, demonstrates that prosthetic breast reconstruction outcomes do not deteriorate over time. This stability is apparent in both long-term surgeon- and patient-reported outcomes data measured in the same patients. These results contradict the surgical dogma surrounding prosthetic breast reconstruction and therefore should be given significant consideration when counseling patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Autologous versus implant-based breast reconstruction: A systematic review and meta-analysis of Breast-Q patient-reported outcomes

OBJECTIVE

Breast reconstruction following mastectomy can increase the quality of life of patients. Reconstruction methods can broadly be divided into implant-based and autologous tissue reconstruction. Patient-reported outcomes following breast reconstruction are one of the most important success parameters. In this systematic review and meta-analysis, we aimed to compare the two methods using the recognized Breast-Q questionnaire.

METHODS

We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on the five most commonly reported Breast-Q modules. RevMan 5.3 was used for statistical analysis. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies.

RESULTS

The search strategy resulted in 219 studies of which nine studies were included in the analysis, yielding 2129 implant-based and 825 autologous breast reconstructions. Overall satisfaction with outcome as well as breast was significantly higher among patients with autologous breast reconstructions (mean Breast-Q difference between the two groups was 9.82 [3.09, 16.54], p = 0.004, and 10.33 [95% CI 5.93, 14.74], p<0.00001, respectively). Sexual and psychosocial well-being was higher among autologous breast reconstructions. There was no difference in the physical well-being.

CONCLUSION

This is the first systematic review and meta-analysis to compare patient-reported outcomes of implant-based and autologous breast reconstruction. We found that autologous reconstruction yields a higher satisfaction with overall outcome and breast. These findings can aid clinicians when discussing breast reconstruction options with patients.

The use of Patient Reported Outcome Measures in assessing patient outcomes when comparing autologous to alloplastic breast reconstruction: a systematic review

Breast reconstruction surgery after mastectomy has demonstrated positive psychological benefits, and is reflected in the number of patients undergoing the procedure, rising from 26.94% of patients after mastectomy in 2005, to 43.30% in 2014. Most of this is attributable to implant and expander-based reconstruction, with the rate of free flaps only increasing from 1.25% to 3.96% in this time period. Increasingly, breast cancer patients have higher survival rates. There is now an emphasis on Value Based Health Care (VBHC), which focusses on outcomes, and that can be measured by Patient Reported Outcome Measures (PROMs). To date, there has been no systematic review to analyse PROMs between those undergoing autologous or alloplastic reconstruction, using validated measurement tools, to determine if there is a preferred technique from the patient's perspective. We performed a systematic search on EMBASE, and together with bibliographic linkage, identified 146 articles. After screening and assessment of articles through abstract, and full article appraisal, 13 were identified suitable for inclusion in this systematic review. Using BREAST-Q, satisfaction of breast and psychosocial well-being were rated highly by the autologous group when compared to implant-based reconstruction. Physical well-being was less significant, with the least significant difference noted for sexual well-being. EORTC-QLQ-BR23/C30 PROMs noted similar trends. SF-36 however, noted virtually no difference between the two methods of reconstruction regarding similar PROM quality of life (QoL) domains. From the patient perspective, autologous reconstruction is either equal to or superior to implant-based reconstruction, and should be offered to all patients.

Patient reported outcome measures (PROMs) following mastectomy with breast reconstruction or without reconstruction: a systematic review

The cornerstone of reconstructive surgery following mastectomy is to restore cosmesis and improve physical and psychological health. Consequently, it has become essential for instruments that measure surgical outcomes to include the direct perspective of patients. Many reviews have failed to show significant improvements in quality of life domains following breast reconstruction compared to mastectomy alone. However, with advances in surgical techniques and patient reported outcome measure (PROM) assessment tools designed precisely for breast reconstruction patients, a modern systematic review is warranted. An electronic literature review was performed using CINAHL, Cochrane Library and Medline (using PubMed) comparing patient reported outcome measures of patients undergoing mastectomy alone versus patients undergoing mastectomy with breast reconstruction. Studies in the English and Portuguese languages since the year 2000 were included. The review was undertaken adhering to PRISMA guidelines with last entry on the 31/5/2018. Full text review yield 42 articles of relevance to the inclusion criteria. The most widely used PROM instruments such as Breast-Q, EORTC-Q30/Q23, Short Form 36, FACT-B and others are explored. The specific difficulties conducting such studies and biases identified are investigated further. Studies comparing mastectomy alone against mastectomy with reconstruction show difficulties forming groups with similar clinical and epidemiological characteristics. There are inherent limitations to performing a randomised controlled trial on this topic, including matching patient groups in terms of age, socioeconomical background and cancer staging, and this affects the results of the PROM instruments. Within these limitations, the literature suggests that PROM support the use of breast reconstruction following mastectomy but care must be made selecting patients. The finding is supported by the National Institute for Health and Clinical Excellence (NICE) guidelines which state that breast reconstruction should be offered to all women undergoing breast cancer surgery.

The Functional Impact of Breast Reconstruction: An Overview and Update

As rates of bilateral mastectomy and immediate reconstruction rise, the aesthetic and psychosocial benefits of breast reconstruction are increasingly well understood. However, an understanding of functional outcome and its optimization is still lacking. This endpoint is critical to maximizing postoperative quality of life. All reconstructive modalities have possible functional consequences. Studies demonstrate that implant-based reconstruction impacts subjective movement, but patients’ day-to-day function may not be objectively hindered despite self-reported disability. For latissimus dorsi flap reconstruction, patients also report some dysfunction at the donor site, but this does not seem to result in significant, long-lasting limitation of daily activity. Athletic and other vigorous activities are most affected. For abdominal free flaps, patient perception of postoperative disability is generally not significant, despite the varying degrees of objective disadvantage that have been identified depending on the extent of rectus muscle sacrifice. With these functional repercussions in mind, a broader perspective on the attempt to ensure minimal functional decline after breast surgery should focus not only on surgical technique but also on postoperative rehabilitation. Early directed physical therapy may be an instrumental element in facilitating return to baseline function. With the patient’s optimal quality of life as an overarching objective, a multifaceted approach to functional preservation may be the answer to this continued challenge. This review will examine these issues in depth in an effort to better understand postoperative functional outcomes with a focus on the younger, active breast reconstruction patient.

Patient-Centered Breast Reconstruction Based on Health-Related Quality-of-Life Evidence

The article summarizes the available evidence regarding clinical decision making in breast reconstruction from the patient perspective of satisfaction and health-related quality of life. A review of generic and specific patient reported outcome measures is provided. Important components of breast reconstruction care are compared, such as timing of reconstruction, autologous and implant-based reconstruction, and the use of nipple-sparing and skin-sparing mastectomy. This evidence-based summary will be useful to guide clinicians when discussing breast reconstruction with their patients.

Breast Cancer and Reconstruction: Normative Data for Interpreting the BREAST-Q

BACKGROUND

The BREAST-Q is a patient-reported outcome instrument used to evaluate outcomes in patients undergoing breast cancer surgery and reconstruction. Normative values for the BREAST-Q breast cancer modules have not been established, limiting data interpretation.

METHODS

Participants were recruited by means of the Army of Women, an online community of women (with and without breast cancer), to complete Mastectomy, Breast Conserving Therapy, and Reconstruction preoperative BREAST-Q scales. Inclusion criteria were women aged 18 years or older without a history of breast surgery or breast cancer. Analysis included descriptive statistics, a linear multivariate regression, and a comparison of the generated normative data to previously published BREAST-Q findings.

RESULTS

The BREAST-Q was completed by 1201 women. The mean patient age was 54 ± 13 years, mean body mass index 26 ± 6 kg/m, and 38 percent (n = 455) had a bra cup size of D or greater. Mean ± SD scores for BREAST-Q scales were as follows: Satisfaction with Breasts (58 ± 18), Psychosocial Well-being (71 ± 18), Sexual Well-being (56 ± 18), Physical Well-being-Chest (93 ± 11), and Physical Well-being Abdomen (78 ± 20). Women with a body mass index of 30 kg/m or greater, cup size of D or greater, age younger than 40 years, and annual income less than $40,000 reported lower scores. Comparing normative scores to published data in breast cancer patients, Satisfaction with Breasts scores were higher after autologous reconstruction and lower after mastectomy; Sexual Well-being scores were lower after mastectomy and breast conserving therapy; and Physical Well-being Chest scores were lower after mastectomy, breast conserving therapy, and reconstruction.

CONCLUSION

These are the first published normative scores for the BREAST-Q breast cancer modules and provide a clinical reference point for the interpretation of data.

Breast Reconstruction Following Cancer Treatment

BACKGROUND

About 8000 breast reconstructions after mastectomy are per - formed in Germany each year. It has become more difficult to advise patients because of the wide variety of heterologous and autologous techniques that are now available and because of changes in the recommendations about radiotherapy.

METHODS

This article is based on a review of pertinent articles (2005-2014) that were retrieved by a selective search employing the search terms "mastectomy" and "breast reconstruction."

RESULTS

The goal of reconstruction is to achieve an oncologically safe and aestically satisfactory result for the patient over the long term. Heterologous, i.e., implant-based, breast reconstruction (IBR) and autologous breast reconstruction (ABR) are complementary techniques. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. If post-mastectomy radiotherapy (PMRT) is not indicated, implant-based reconstruction with or without a net/acellular dermal matrix (ADM) is a common option. Complications such as seroma formation, infection, and explantation are significantly more common when an ADM is used (15.3% vs. 5.4% ). If PMRT is performed, then the complication rate of implant-based breast reconstruction is 1 to 48% ; in particular, Baker grade III/IV capsular fibrosis occurs in 7 to 22% of patients, and the prosthesis must be explanted in 9 to 41% . Primary or, preferably, secondary autologous reconstruction is an alternative. The results of ABR are more stable over the long term, but the operation is markedly more complex. Autologous breast reconstruction after PMRT does not increase the risk of serious complications (20.5% vs. 17.9% without radiotherapy).

CONCLUSION

No randomized controlled trials have yet been conducted to compare the reconstructive techniques with each other. If radiotherapy will not be performed, immediate reconstruction with an implant is recommended. On the other hand, if post-mastectomy radiotherapy is indicated, then secondary autologous breast reconstruction is the procedure of choice. Future studies should address patients' quality of life and the long-term aesthetic results after breast reconstruction.

Cost-Effectiveness Analysis of Breast Reconstruction Options in the Setting of Postmastectomy Radiotherapy Using the BREAST-Q

BACKGROUND

A consensus is lacking on a uniform reconstructive algorithm for patients with locally advanced breast cancer who require postmastectomy radiotherapy. Both delayed autologous and immediate prosthetic techniques have inherent advantages and complications. The study hypothesis is that implants are more cost effective than autologous reconstruction in the setting of postmastectomy radiotherapy because of immediate restoration of the breast mound.

METHODS

A cost-effectiveness analysis model using the payer perspective was created comparing delayed autologous and immediate prosthetic techniques against the do-nothing option of mastectomy without reconstruction. Costs were obtained from the 2010 Nationwide Inpatient Sample database. Effectiveness was determined using the BREAST-Q patient-reported outcome measure. A breast quality-adjusted life-year value was considered 1 year of perfect breast health-related quality of life. The incremental cost-effectiveness ratio was calculated for both treatments compared with the do-nothing option.

RESULTS

BREAST-Q scores were obtained from patients who underwent immediate prosthetic reconstruction (n = 196), delayed autologous reconstruction (n = 76), and mastectomy alone (n = 71). The incremental cost-effectiveness ratios for immediate prosthetic and delayed autologous reconstruction compared with mastectomy alone were $57,906 and $102,509, respectively. Sensitivity analysis showed that the incremental cost-effectiveness ratio for both treatment options decreased with increasing life expectancy.

CONCLUSIONS

For patients with advanced breast cancer who require postmastectomy radiotherapy, immediate prosthetic-based breast reconstruction is a cost-effective approach. Despite high complication rates, implant use can be rationalized based on low cost and health-related quality-of-life benefit derived from early breast mound restoration. If greater life expectancy is anticipated, autologous transfer is cost effective as well and may be a superior option.

Immediate Implant Reconstruction Is Associated With a Reduced Risk of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study

OBJECTIVE

We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone.

BACKGROUND

Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema.

METHODS

A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months' median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors.

RESULTS

Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59-6.41%] implant, 9.89% (95% CI: 4.98-19.1%) autologous, and 26.7% (95% CI: 20.4-34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, P < 0.0001] but not autologous (HR: 0.706, P = 0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (P < 0.0001), higher body mass index (P < 0.0001), and greater number of nodes dissected (P = 0.0324) were associated with increased lymphedema risk.

CONCLUSIONS

This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.

The BREAST-Q in surgical research: A review of the literature 2009-2015

BACKGROUND

Health outcomes research has gained considerable traction over the past decade as the medical community attempts to move beyond traditional outcome measures such as morbidity and mortality. Since its inception in 2009, the BREAST-Q has provided meaningful and reliable information regarding health-related quality of life (HRQOL) and patient satisfaction for use in both clinical practice and research. In this study, we review how researchers have used the BREAST-Q and how it has enhanced our understanding and practice of plastic and reconstructive breast surgery.

METHODS

An electronic literature review was performed to identify publications that used the BREAST-Q to assess patient outcomes. Studies developing and/or validating the BREAST-Q or an alternate patient-reported outcome measure (PROM), review papers, conference abstracts, discussions, comments and/or responses to previously published papers, studies that modified a version of BREAST-Q, and studies not published in English were excluded.

RESULTS

Our literature review yielded 214 unique articles, 49 of which met our inclusion criteria. Important trends and highlights were further examined.

DISCUSSION

The BREAST-Q has provided important insights into breast surgery highlighted by literature concerning autologous reconstruction, implant type, fat grafting, and patient education. The BREAST-Q has increased the use of PROMs in breast surgery and provided numerous important insights in its brief existence. The increased interest in PROMs as well as the underutilized potential of the BREAST-Q should permit its continued use and ability to foster innovations and improve quality of care.

What Is the Optimum Timing of Postmastectomy Radiotherapy in Two-Stage Prosthetic Reconstruction: Radiation to the Tissue Expander or Permanent Implant?

BACKGROUND

Postmastectomy radiotherapy is increasingly common for patients with advanced breast cancer. The optimal timing and sequence of mastectomy, reconstruction, and radiotherapy remains unresolved for patients choosing immediate two-stage prosthetic reconstruction.

METHODS

Long-term outcomes were compared for all patients with prosthetic-based reconstruction without radiation, radiation to the tissue expander, or to the permanent implant from 2003 to 2012 performed by the senior author (P.G.C.). Surgeon-evaluated outcomes included reconstructive failure, aesthetic results, and capsular contracture. Odds of failure with radiotherapy at different times were evaluated with logistic regression and Kaplan-Meier analysis. Patient-reported outcomes were assessed using the BREAST-Q.

RESULTS

A total of 1486 reconstructions without radiation, 94 reconstructions with tissue expander radiation, and 210 reconstructions with permanent implant radiation were included. Six-year predicted failure rates were greater for patients with tissue expander radiation than for patients with permanent implant radiation (32 percent versus 16.4 percent; p < 0.01). Patients undergoing radiation to the tissue expander had a greater proportion of very good to excellent aesthetic results compared to patients with permanent implant radiation (75.0 percent versus 67.6 percent; p < 0.01) and lower rates of grade IV capsular contracture (p < 0.01). BREAST-Q scores were similar for patients with the different radiation timings.

CONCLUSIONS

Although the risk of reconstructive failure is significantly higher for patients with tissue expander radiation compared to patients with permanent implant radiation, the aesthetic results and capsular contracture rates are slightly better. Patient reported outcomes do not differ between patients with tissue expander or permanent implant radiation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Understanding the recovery phase of breast reconstructions: Patient-reported outcomes correlated to the type and timing of reconstruction

INTRODUCTION

During preoperative discussions with breast reconstruction patients, questions often arise about what to expect during the recovery period. However, there is a paucity of data elucidating post-breast reconstruction pain, fatigue, and physical morbidity. This information is important to patient and physician understanding of reconstructive choices and the postoperative recovery process. We sought to evaluate how recovery may vary for patients based on the timing and type of reconstruction.

MATERIALS AND METHODS

Patients were recruited as part of the Mastectomy Reconstruction Outcomes Consortium (MROC) study, which is a prospective, multicentered National Institute of Health (NIH)-funded study (1RO1CA152192). Here, patients completed the Numerical Pain Rating Scale (NPRS), McGill Pain Questionnaire, and Breast-Q preoperatively, at 1 week, and 3 months postoperatively. Pain, fatigue, and upper body morbidity were evaluated by the type and timing of reconstruction.

RESULTS

A total of 2013 MROC study participants had completed a 3-month follow-up, and therefore they were included for the analysis. A total of 1583 (78.6%) and 1517 patients (75.3%) completed surveys at 1 week and 3 months, respectively, post reconstruction. Across all procedure groups, fatigue and physical well-being scores did not return to preoperative levels by 3 months. At 3 months, pain measured by the NPRS differed across procedure types (P = 0.01), with tissue expander/implant (TE/I) having more pain than direct to implant (P < 0.01). Similarly, at 3 months, chest and upper body physical morbidity, as measured by BREAST-Q, differed by procedure types (P < 0.001), with generally less morbidity for autologous reconstruction as compared with TE/Is.

CONCLUSIONS

For all reconstructive procedure groups, patients did not fully recover at 3 months post surgery. In addition, postoperative pain and upper body physical morbidity vary significantly by reconstructive procedure with patients undergoing TE/I reporting the most distress.

Diminishing relative contraindications for immediate breast reconstruction

BACKGROUND

The rise in U.S. immediate breast reconstruction over the past decade may reflect greater patient awareness or expanding use in women not previously offered reconstruction. The purpose of the current study was to determine whether reconstruction in high-risk surgical and oncologic patients was a factor contributing to increased reconstruction rates, specifically using prosthetic techniques.

METHODS

Information from a cohort of mastectomy patients from 2001 to 2012 was extracted from an institutional database, including the presence of high-risk surgical or oncologic features (age over 60 years old, body mass index greater than 30, comorbidities, smoking, advanced disease, and prior or postmastectomy radiotherapy). Trends in reconstruction rates and method were analyzed with Poisson regression. Reconstructive success was defined as tissue expander exchange to a permanent implant or autologous techniques without vascular complications.

RESULTS

A total of 10,299 patients were included. Immediate reconstruction in high-risk patients increased from 45.0 to 70.7 of 100 mastectomies (p < 0.01). Although autologous use increased only for obese patients (p < 0.01), prosthetic techniques were greater for all high-risk features (p < 0.01). Reconstructive success was 88 percent in high-risk patients; however, the number of failures was greater, including tissue expander loss, implant explantation, and flap vascular complications.

CONCLUSIONS

The proportion of high-risk patients undergoing immediate breast reconstruction-specifically using prosthetic-based techniques-increased over the study period. Increased complications may be a tradeoff for the benefits of reconstruction. These findings support diminishing relative contraindications for immediate breast reconstruction at a tertiary cancer center.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Diminishing relative contraindications for immediate breast reconstruction: a multicenter study

BACKGROUND

During the past decade, there has been a rise in US breast reconstruction rates, with a greater expansion in prosthetic-based techniques relative to autologous transfer. Immediate reconstruction in high-risk oncologic and surgical patients might be a contributing factor to these trends.

STUDY DESIGN

The National Cancer Data Base from the American College of Surgeons and the American Cancer Society was used to identify a breast cancer cohort (1998 to 2011) treated with mastectomy. The patients were divided into high risk and low risk based on presence or absence of historic surgical or oncologic relative contraindications. Reconstructions were categorized as either autologous or implants. To understand trends for each high-risk characteristic, rates were adjusted by 1,000 total mastectomies performed for patients within each specific group and analyzed with Poisson regression.

RESULTS

Information from 1,040,088 patients with mastectomy was included. Rates of high-risk features did not change from 1998 to 2011. The increase in immediate reconstruction rates was greater for high-risk than low-risk patients (incidence rate ratio = 1.09 vs 1.06; p < 0.05 for both). There was a greater rate increase in implant than autologous reconstructions for both high-risk and low-risk groups. For high-risk patients, implant use increased for all features, but with the greatest change for elderly, comorbidities, and post-mastectomy radiotherapy (p < 0.01). For high-risk patients, autologous tissue use increased significantly for all features except pre-mastectomy radiotherapy.

CONCLUSIONS

Breast reconstruction increased in high-risk surgical and oncologic patients, suggestive of a diminishing set of relative contraindications. Increased implant use in high-risk patients might be a contributing factor toward the preferential national expansion of prosthetic techniques.