Long-term Patient-Reported Outcomes in Postmastectomy Breast Reconstruction

Sterile Draping of Operative Microscopes in Breast Free Flaps and Surgical Site Infections

BACKGROUND

Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections.

METHODS

We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact.

RESULTS

Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species. The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO2 and direct costs by $7.84 per item.

CONCLUSIONS

The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction.

Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes

BACKGROUND

A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care.

METHODS

A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed.

RESULTS

Overall, 137 subjects were identified and 64 met the inclusion criteria (n = 28 study, n = 36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p < 0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5 min, p < 0.01).

CONCLUSIONS

A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

INTRODUCTION

The transition away from routine clinical follow up after breast cancer towards imaging surveillance and patient-initiated contact limits opportunities for patients and doctors to communicate about the long-term effects of treatment. The ABS oncoplastic guidelines (2021) recommend that post-operative 2D images and patient-reported outcomes (PROMs) are routinely collected but give no guidance as to how best to implement this.

METHODS

From December 2019 until March 2024, women due for their year 3 or 5 surveillance mammogram at The Royal Marsden Sutton site were invited to complete a BREAST-Q questionnaire and attend medical photography. Panel assessment of photographs was undertaken. Results were presented to the oncoplastic MDT, including summary PROMs and illustrative case presentations. Free-text comments were shared with the relevant teams. Associations between demographic or clinic-pathological factors and uptake were investigated.

RESULTS

Of the 1211 women invited, 246 patients (20.3 %) completed BREAST-Q questionnaires, 182 (15.0 %) attended for medical photography and 114 (9.4 %) completed both. Uptake was not associated with age, ethnicity or surgical factors but patients with higher BMI were less likely to respond to the questionnaire. Patients who had undergone complex oncoplastic procedures were more likely to respond than those who had simple procedures. Patient-reported outcome results were in line with the published literature.

CONCLUSION

Reviewing images with their paired PROMs and discussing free-text feedback was instructive for the team. Work is needed to identify barriers to patient participation and improve uptake to be representative of the overall patient population. Quantifying appearance in photographs would help summarise aesthetic outcome data.

Predicting Postoperative Satisfaction with Breasts: How Important is the Preoperative BREAST-Q Score?

BACKGROUND

The role that preoperative Satisfaction with Breast plays in a patient's postoperative course after postmastectomy breast reconstruction (PMBR) is not understood. The aim of this study is to understand the impact of the preoperative score on postoperative outcome as an independent variable.

METHODS

We examined patients who underwent PMBR between 2017 and 2021 and who completed the BREAST-Q Satisfaction with Breasts at 1 year postoperatively. Two multiple linear regression models (Model 1 with the preoperative Satisfaction with Breasts score and Model 2 without the preoperative score), likelihood ratio tests, simple t-statistics, and sample patient dataset to predict the 1 year score were performed. Multiple imputation was used to account for missing preoperative scores.

RESULTS

Overall, 2324 patients were included. Model 1 showed that the preoperative score is significantly associated with the postoperative score (β = 0.09, 95% confidence interval 0.04-0.14; p < 0.001). Comparing Model 1 and Model 2 demonstrated that including preoperative Satisfaction with Breasts in a regression significantly improves model fit (test statistic = 10.04; p = 0.0021). Using the absolute value of the t-statistics as a measure of variable importance in linear regression, the importance of the preoperative score was quantified as 3.39-more important than neoadjuvant radiation, mastectomy weight, body mass index, bilateral prophylactic mastectomy, and race, but less than adjuvant radiation, reconstruction type, and psychiatric diagnoses.

CONCLUSION

Preoperative Satisfaction with Breasts scores are an important independent predictor of postoperative satisfaction after PMBR. Just as vital sign and work-up are carefully documented before surgery, preoperative scores should be collected to pre-emptively gauge patients' satisfaction and optimize postoperative outcomes.

Existing Psychiatric Diagnoses Among Breast Cancer Patients Interact with Outcomes After Autologous and Implant-Based Bilateral Breast Reconstruction: A Propensity Score Matched Analysis

BACKGROUND

Breast reconstruction is an integral postoncologic procedure that has been associated with improved mental health and psychological outcomes. The possible interaction between existing psychiatric diagnoses hospital courses and postoperative complications warrants further exploration.

METHODS

Bilateral breast reconstruction patients were identified from the 2016 to 2018 Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP - NIS). Number and type of psychiatric diagnoses within the cohort were then evaluated using a host of ICD-10 codes. A propensity score analysis was applied to control for confounding variables such as demographics, existing comorbidities, and hospital characteristics. A binary logistic regression model was then used to identify the prediction value of psychiatric diagnosis and its interaction with modality of reconstruction for objective outcomes like length of hospital stay, treatment charge, and postoperative complications.

RESULTS

A total of 10,114 patients were identified as the final cohort of breast reconstruction patients. 2621 (25.9%) patients possessed an average of 1.4 ± 0.6 existing psychiatric diagnoses. Presence of at least 1 psychiatric diagnosis was a strong predictor alone for extended length of stay (OR: 1.34, 95% CI: 1.28-1.41, P < .001) and occurrence of postoperative complications (OR: 1.31, 95% CI: 1.21-1.41, P < .001). Psychiatric diagnosis displayed a significant interaction with modality of breast reconstruction and conferred a lower increase in risk of extended length of stay in autologous reconstruction when compared to implant-based reconstruction (OR: 0.80, 95% CI: 0.72-0.89, P < .001).

CONCLUSION

Existing psychiatric diagnoses were shown to strongly predict and modulate risk of adverse postoperative outcomes depending on modality of reconstruction.

Navigating the Pandemic: Shifts in Breast Reconstruction Trends and Surgical Decision-Making in the United States

Background: This study aimed to investigate the impact of the COVID-19 pandemic on breast reconstruction trends in the United States, focusing on implant-based and autologous techniques, as well as the timing of reconstruction (immediate vs. delayed). Methods: A retrospective analysis of data from 2015 to 2022 from the American Society of Plastic Surgeons' National Plastic Surgery Statistics was conducted. Annual trends in breast reconstruction procedures were analyzed, comparing the pre-pandemic (2015-2019) and pandemic (2020-2022) periods. A sensitivity analysis was performed to assess the impact of missing data from 2019 and 2021. Results: The total number of breast reconstructions increased from 106,338 in 2015 to 151,641 in 2022. The proportion of implant-based reconstructions decreased from 81.41% pre-pandemic to 76.51% during the pandemic (p < 0.001), with a notable rise in direct-to-implant procedures from 10.37% to 19.12% (p < 0.001). Autologous reconstructions increased from 18.59% to 23.49% (p < 0.001). Among autologous techniques, DIEP flaps remained the most popular. Immediate reconstruction rates increased from 72.61% pre-pandemic to 75.57% during the pandemic, while delayed reconstruction rates decreased from 27.39% to 24.43% (p < 0.001). The sensitivity analysis confirmed the robustness of these trends. Conclusions: During the COVID-19 pandemic, there was a significant shift towards autologous breast reconstruction techniques, particularly DIEP flaps, and an increase in immediate reconstructions in the United States. Within implant-based reconstructions, the proportion of DTI procedures increased while the proportion of tissue expander procedures decreased. These changes likely reflect adaptations in surgical practice and decision-making processes in response to the unique challenges posed by the pandemic, rather than alterations in surgical techniques themselves. The insights gained from this study can help guide plastic surgeons and healthcare providers in preparing for future pandemics or similar disruptions.

Breast reconstruction through exclusive lipomodeling or in addition to a flap: Current status in Franche-Comté

INTRODUCTION

Breast reconstruction after cancer surgery through lipomodeling can be performed alone or in combination with a flap. Our objective is to describe the proportion of techniques used on patients who underwent autologous reconstructive surgery after tumorectomy or mastectomy in Franche-Comté.

MATERIALS AND METHODS

A bicentric retrospective observational study was conducted between October 2017 and December 2021 (NCT06101732), including three groups: those who underwent exclusive lipomodeling reconstruction after mastectomy (1) or in addition to a flap (2), and those who underwent exclusive lipomodeling reconstruction after tumorectomy (3). Socio-demographic, medical, and surgical data were collected and recorded in a specially designed software.

RESULTS

Two hundred and fifty-one lipomodeling procedures were performed on 91 patients. In group 1, the average transferred volume was 1191mL with an average number of sessions of 4.4 spreads over 19.4months. In group 2, the average transferred volume was 676mL with an average operative time of 2.5 spread over 16.1months. In group 3, the average transferred volume was 223mL with an average number of sessions of 1.5 spreads over 6.2months. Regarding postoperative complications, 11% had cysts of fat necrosis, 4.4% had infections, and 2.2% had hematomas.

CONCLUSION

Lipomodeling is a technique that has clearly established itself in the field of breast reconstructive surgery. It results in a few complications and improves the final aesthetic outcome whether used exclusively or in addition to a flap.

The usefulness of artificial intelligence in breast reconstruction: a systematic review

BACKGROUND

Artificial Intelligence (AI) offers an approach to predictive modeling. The model learns to determine specific patterns of undesirable outcomes in a dataset. Therefore, a decision-making algorithm can be built based on these patterns to prevent negative results. This systematic review aimed to evaluate the usefulness of AI in breast reconstruction.

METHODS

A systematic review was conducted in August 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, EMBASE, SCOPUS, and Google Scholar online databases were queried to capture all publications studying the use of artificial intelligence in breast reconstruction.

RESULTS

A total of 23 studies were full text-screened after removing duplicates, and twelve articles fulfilled our inclusion criteria. The Machine Learning algorithms applied for neuropathic pain, lymphedema diagnosis, microvascular abdominal flap failure, donor site complications associated to muscle sparing Transverse Rectus Abdominis flap, surgical complications, financial toxicity, and patient-reported outcomes after breast surgery demonstrated that AI is a helpful tool to accurately predict patient results. In addition, one study used Computer Vision technology to assist in Deep Inferior Epigastric Perforator Artery detection for flap design, considerably reducing the preoperative time compared to manual identification.

CONCLUSIONS

In breast reconstruction, AI can help the surgeon by optimizing the perioperative patients' counseling to predict negative outcomes, allowing execution of timely interventions and reducing the postoperative burden, which leads to obtaining the most successful results and improving patient satisfaction.

BREAST-Q REACT: Qualitative Assessment of the Design, Functionality, and Clinical Utility of a New Score Interpretation Tool

BACKGROUND

The BREAST-Q real-time engagement and communication tool (REACT) was developed to aid with BREAST-Q score interpretation and guide patient-centered care.

OBJECTIVE

The purpose of this qualitative study was to examine the perspectives of patients and providers on the design, functionality, and clinical utility of REACT and refine the REACT based on their recommendations.

METHODS

We conducted three patient focus groups with women who were at least 6 postoperative months from their postmastectomy breast reconstruction, and two provider focus groups with plastic surgeons, breast surgeons, and advanced practice providers. Focus groups were audio-taped, transcribed verbatim, and analyzed thematically.

RESULTS

A total of 18 breast reconstruction patients and 14 providers participated in the focus groups. Themes identified by thematic analysis were organized into two categories: (1) design and functionality, and (2) clinical utility. On the design and functionality of REACT, four major themes were identified: visual appeal and usefulness; contextualizing results; ability to normalize patients' experiences, noting participants' concerns; and suggested modifications. On the clinical utility of REACT, three major themes were identified: potential to empower patients to communicate with their providers; increase patient and provider motivation to engage with the BREAST-Q; and effective integration into clinical workflow.

CONCLUSION

Patients and providers in this qualitative study indicated that with some modifications, REACT has a great potential to elevate the clinical utility of the BREAST-Q by enhancing patient-provider communication that can lead to patient-centered, clinically relevant action recommendations based on longitudinal BREAST-Q scores.

Surgical Management of Textured Breast Implants: Assessing Risk and Analyzing Patient-Reported Outcomes

BACKGROUND

Textured implants have been linked to breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). Patients who undergo explantation have options for reconstruction, but data on safety and patient-reported outcomes (PROs) are limited. The purpose of this study was to classify complications and PROs in patients opting for surgical management of textured implants.

METHODS

Complication rates and BREAST-Q scores were compared between (1) asymptomatic patients who underwent conversion from textured to smooth implants ( n = 224), (2) symptomatic patients who underwent conversion from textured to smooth implants ( n = 83), (3) patients who underwent explantation without replacement ( n = 44), and (4) patients who underwent replacement with autologous reconstruction ( n = 33). Linear regression examined PROs controlling for clinical and surgical variables.

RESULTS

Overall complication rates in 384 patients (637 implants) differed across groups ( P = 0.034), with the highest rate (25%) in patients who underwent explantation without replacement. These patients were specifically more impacted by minor complications, notably seroma. Capsulectomy extent did not significantly impact complications. Asymptomatic and symptomatic smooth implant patients had improvements in Satisfaction with Breasts ( P < 0.05). Autologous reconstruction patients had significant improvements in Satisfaction with Breasts sustained after 3 months postoperatively ( P < 0.01) and Sexual Well-being sustained after 6-months postoperatively ( P < 0.05). Patients who underwent removal without replacement had lower Physical Well-being of the Chest scores at 1 year or more than the other groups.

CONCLUSIONS

Replacement of textured implants with smooth implants or flaps is safe and is associated with improved satisfaction with breasts and quality of life. The degree of capsulectomy does not appear to impact the incidence of perioperative complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Long-term Evaluation of Acellular Dermal Matrix for Immediate Implant-based Breast Reconstruction following Risk-reducing Mastectomy

Background

Acellular dermal matrices (ADMs) are sometimes used in implant-based breast reconstructions (IBR), but long-term ADM-related evaluations are scarce. In this study, we evaluated early and late complications and patient-related outcomes (PROs) over an 8-year postoperative period in women who had undergone immediate IBR following risk-reducing mastectomy with bovine ADM (SurgiMend).

Methods

This prospective observational single-center analysis involved 34 women at high risk for breast carcinoma. Complications were prospectively recorded during the first year, followed by 4 years of postoperative retrospective chart reviews. Long-term evaluations were done using a questionnaire. Preoperative, 1 year, and 5- to 8-year postoperative PRO assessments were obtained based on results from the BREAST-Q questionnaire.

Results

In 56 breasts, complications after a mean of 12.4 months follow-up included implant loss (7.1%), implant change (1.8%), hematoma (7.1%), breast redness (41.1%), and seroma (8.9%). Most breasts (80.3%) were graded Baker I/II, which indicated a low capsular contracture incidence. After a mean of 6.9 years, the total implant explantation rate was 33.9%, and the revision surgery rate was 21.4%. Two cases of breast cancer were reported during the long-term evaluation. BREAST-Q results indicated significantly decreased satisfaction with outcome (P = 0.024). A positive trend regarding psychosocial well-being and declining trend regarding satisfaction with both breast physical- and sexual well-being parameters were reported.

Conclusions

The observed complication rates agree with previous findings concerning ADM-assisted IBR. A high demand for revision surgery exists, and PROs remain relatively stable over time.

Patient-reported outcomes and quality of life after breast-conserving surgery, mastectomy, and breast reconstruction assessed using the BREAST-Q questionnaire

PURPOSE

Breast-conserving surgery is the preferred treatment for breast cancer; however, its associated risk of local recurrence is higher than that of mastectomy. We performed a comparative analysis of four patient-reported outcomes, psychosocial well-being, sexual well-being, breast satisfaction, and physical well-being of the chest, and quality of life after three surgical approaches, breast-conserving therapy (BCT), mastectomy alone, and mastectomy with breast reconstruction, for breast cancer treatment.

METHODS

A cross-sectional survey using the BREAST-Q questionnaire and including patients who had undergone breast surgery at least 1 year prior to survey completion was performed. The analysis included 1035 patients (mean age, 55.0 ± 9.1 years) who underwent breast reconstruction, 116 patients (mean age, 63.6 ± 12.2 years) who underwent mastectomy, and 64 patients (mean age, 60.8 ± 12.2 years) who underwent BCT.

RESULTS

Patients who underwent reconstruction had significantly higher psychosocial well-being scores (62.8 ± 18.4) than those who underwent BCT (57.0 ± 23.6) and mastectomy (50.8 ± 16.8) (p < 0.01). However, significant differences in self-acceptance scores among all patients were not observed. Regarding sexual well-being and breast satisfaction, patients who underwent mastectomy had significantly lower scores (29.9 ± 18.7 and 41.8 ± 17.7, respectively) than those who underwent BCT (45.8 ± 26.6 and 58.3 ± 17.5, respectively) and reconstruction (46.4 ± 20.3 and 58.8 ± 15.4, respectively) (p < 0.01). Physical well-being of the chest scores were not significantly different among all patients (p = 0.14). Symptoms after mastectomy included chest muscle pain and arm movement impairment. Breast pain was a notable symptom after BCT.

CONCLUSION

The study findings provide valuable insights regarding patient-reported outcomes, highlight the potential benefits of breast reconstruction, and emphasize the importance of patients' preferences.

Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases

BACKGROUND

 Autologous breast reconstruction (ABR) after mastectomy is increasing due to benefits over implant-based reconstruction. However, free flap reconstruction is not universally offered to patients of advanced age due to perceived increased perioperative risk.

METHODS

 Patients undergoing free flap breast reconstruction at our institution from 2005 to 2018 were included. Risk-adjusted logistic regression models were fit while controlling for demographic and comorbid characteristics to determine the association of age with the probability of venous thromboembolism (VTE), delayed healing, skin necrosis, surgical site infection (SSI), seroma, hematoma, hernia, and flap loss. Linear predictions from risk-adjusted logistic regression models were used to create spline curves and determine the risk of outcomes associated with age.

RESULTS

 A cohort of 2,598 patients underwent free flap breast reconstruction in the period examined. The median age was 51 with approximately 9% of patients being 65 or older. Increased age was associated with a greater risk of delayed healing, skin necrosis, and hematoma after surgery. There was no increased risk of medical complications such as VTE or complications such as flap loss, seroma, or SSI.

CONCLUSION

 A set age cutoff for patients undergoing free flap breast reconstruction does not appear warranted. There is no difference in major surgical complications such as flap loss with increasing age. However, older age does predispose patients to specific wound complications such as hematoma, skin necrosis, and delayed wound healing, which should guide preoperative counseling. Further, medical complications do not increase with advanced age. Overall, however, the safety of ABR in older patients appears uncompromised.

Nonresponse data in sexual well-being among breast reconstruction patients-who are we overlooking?

BACKGROUND

Missing data can affect the representativeness and accuracy of survey results, and sexual health-related surveys are especially at a higher risk of nonresponse due to their sensitive nature and stigma. The purpose of this study was to evaluate the proportion of patients who do not complete the BREAST-Q Sexual Well-being relative to other BREAST-Q modules and compare responders versus nonresponders of Sexual Well-being. We secondarily examined variables associated with Sexual Well-being at 1-year.

METHODS

A retrospective analysis of patients who underwent breast reconstruction from January 2018 to December 2021 and completed any of the BREAST-Q modules postoperatively at 1-year was performed.

RESULTS

The 2941 patients were included. Of the four BREAST-Q domains, Sexual Well-being had the highest rate of nonresponse (47%). Patients who were separated (vs. married, OR = 0.69), whose primary language was not English (vs. English, OR = 0.60), and had Medicaid insurance (vs. commercial, OR = 0.67) were significantly less likely to complete the Sexual Well-being. Postmenopausal patients were significantly more likely to complete the survey than premenopausal patients. Lastly, autologous reconstruction patients were 2.93 times more likely to respond than implant-based reconstruction patients (p < 0.001) while delayed (vs. immediate, OR = 0.70, p = 0.022) and unilateral (vs. bilateral, OR = 0.80, p = 0.008) reconstruction patients were less likely to respond. History of psychiatric diagnosis, aromatase inhibitors, and immediate breast reconstruction were significantly associated with lower Sexual Well-being at 1-year.

CONCLUSION

Sexual Well-being is the least frequently completed BREAST-Q domain, and there are demographic and clinical differences between responders and nonresponders. We encourage providers to recognize patterns in nonresponse data for Sexual-Well-being to ensure that certain patient population's sexual health concerns are not overlooked.

Preoperative Expectations of Women Undergoing Breast Reconstruction Surgery

Background

The study investigated the expectations of patients undergoing immediate breast reconstruction after mastectomy, considering factors such as the cause for mastectomy (cancer versus prophylactic due BRCA1 or BRCA2 gene mutations), age, marital status, and education.

Methods

The study had a cross-sectional design. Eligible patients at Oslo University Hospital received a link to the BREAST-Q Expectations questionnaire, which they filled out before surgery from 2019 to 2022.

Results

One hundred forty-six patients completed the questionnaire (79.8% response rate). The mean age was 46.6 years, and the majority (95.1%) were undergoing reconstruction with implants. Most patients (86.9%) wanted to be involved in the decision-making. The highest expectation was for breast appearance and the lowest for sensation after surgery. Patients not diagnosed with cancer (n = 27) before surgery expected significantly more pain after surgery compared with patients diagnosed with cancer (P = 0.016). Patients 40 years or younger had higher expectation of pain after surgery than patients 41 years or older, 73.2 versus 54.2, P < 0.001, respectively. After 10 years, 26.7% of the patients expected that further reconstruction procedures might be necessary.

Conclusions

Our study's results regarding patient's expectations with breast reconstruction, as assessed using the BREAST-Q Expectations module, align with previous research in terms of overall trends. However, our study provides a more nuanced understanding by exploring variations within different patient subgroups. These differences emphasize the need for personalized preoperative counseling and support to align patient's expectations with realistic outcomes.

No Skin Paddle, No Problem: Burying Deep Inferior Epigastric Artery Flaps in the Immediate Setting is Safe in Select Patient Populations

BACKGROUND

 In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery.

METHODS

 A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery.

RESULTS

 The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed-immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients.

CONCLUSION

 Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps.

Assessing the Content and Effect of Web-Based Decision Aids for Postmastectomy Breast Reconstruction: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Web-based decision aids have been shown to have a positive effect when used to improve the quality of decision-making for women facing postmastectomy breast reconstruction (PMBR). However, the existing findings regarding these interventions are still incongruent, and the overall effect is unclear.

OBJECTIVE

We aimed to assess the content of web-based decision aids and its impact on decision-related outcomes (ie, decision conflict, decision regret, informed choice, and knowledge), psychological-related outcomes (ie, satisfaction and anxiety), and surgical decision-making in women facing PMBR.

METHODS

This systematic review and meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 6 databases, PubMed, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science Core Collection, were searched starting at the time of establishment of the databases to May 2023, and an updated search was conducted on April 1, 2024. MeSH (Medical Subject Headings) terms and text words were used. The Cochrane Risk of Bias Tool for randomized controlled trials was used to assess the risk of bias. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

In total, 7 studies included 579 women and were published between 2008 and 2023, and the sample size in each study ranged from 26 to 222. The results showed that web-based decision aids used audio and video to present the pros and cons of PMBR versus no PMBR, implants versus flaps, and immediate versus delayed PMBR and the appearance and feel of the PMBR results and the expected recovery time with photographs of actual patients. Web-based decision aids help improve PMBR knowledge, decisional conflict (mean difference [MD]=-5.43, 95% CI -8.87 to -1.99; P=.002), and satisfaction (standardized MD=0.48, 95% CI 0.00 to 0.95; P=.05) but have no effect on informed choice (MD=-2.80, 95% CI -8.54 to 2.94; P=.34), decision regret (MD=-1.55, 95% CI -6.00 to 2.90 P=.49), or anxiety (standardized MD=0.04, 95% CI -0.50 to 0.58; P=.88). The overall Grading of Recommendations, Assessment, Development, and Evaluation quality of the evidence was low.

CONCLUSIONS

The findings suggest that the web-based decision aids provide a modern, low-cost, and high dissemination rate effective method to promote the improved quality of decision-making in women undergoing PMBR.

TRIAL REGISTRATION

PROSPERO CRD42023450496; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=450496.

Is There a Difference in Abdominal Wall Muscle Strength, Endurance, and Motor Control Following Bilateral DIEP and TRAM Flaps for Breast Reconstruction?

Background

Abdominal donor site complications in bilateral pedicled transverse rectus abdominis muscle (TRAM) have been a concern when compared with bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study aimed to assess the strength, endurance, and motor control in patients undergoing DIEP and TRAM flaps.

Methods

A prospective, cohort study was performed at a single institution including patients who underwent pedicled TRAM and DIEP flap reconstruction after mastectomy from August 2017 to August 2018. Patients underwent pre- and postoperative testing involving rectus abdominis, prone plank, side bridge, and trunk flexor tests. Descriptive analyses and multivariate linear regressions were performed.

Results

The final analysis included a total of 9 patients, 4 of whom underwent TRAM flap reconstruction while 5 underwent DIEP flap reconstruction. The tests were not statistically significant between the TRAM versus DIEP groups, including rectus abdominis mean time decrease (0.25 vs 0.60 sec, P = .51), prone plank time increase (1.38 vs 1.38 sec, P = .51), right side bridge time increase (7.54 sec vs 32.15 sec, P = 1.00), left side bridge time increase (2.14 vs 44.5 sec, P = .37), and trunk flexor time decrease (4.68 vs 1.68 sec, P = .44). Overall complications were similar between the 2 groups.

Conclusions

No significant difference in abdominal donor site morbidity was found when comparing the 2 groups. This article provides a point of conversation with patients when discussing available reconstruction options.

An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery

INTRODUCTION

Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions.

METHODS

All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared.

RESULTS

Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01).

CONCLUSIONS

This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction

INTRODUCTION

Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction.

METHODS

A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests.

RESULTS

34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035).

CONCLUSION

In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.

PlasmaBlade versus Electrocautery for Deep Inferior Epigastric Perforator Flap Harvesting in Autologous Breast Reconstruction: A Comparative Clinical Outcome Study

(1) Background: DIEP-based breast reconstruction necessitates wide undermining at the abdominal donor site, creating large wound areas. Flap harvesting is usually conducted using electrosurgical dissection devices. This study sought to compare the clinical outcomes in patients after using the PEAK PlasmaBlade (PPB) versus monopolar electrocautery (MPE). (2) Methods: This retrospective cohort study included 128 patients with DIEP-based breast reconstruction. Patient characteristics and information on the postoperative course were collected and a comparative evaluation was conducted. (3) Results: The MPE group exhibited significantly (p* = 0.0324) higher abdominal drainage volume (351.11 ± 185.96 mL) compared to the PPB group (279.38 ± 183.38 mL). A subgroup analysis demonstrated that PPB significantly reduced postoperative wound fluid in patients with BMI > 30 kg/m2 (p* = 0.0284), without prior neoadjuvant chemotherapy (p** = 0.0041), and among non-smokers (p = 0.0046). Furthermore, postoperative pain was significantly (p**** < 0.0001) lower in the PPB cohort. (4) Conclusions: This study confirms the non-inferiority of the PEAK PlasmaBlade to conventional electrocautery for abdominal flap harvesting. The PPB demonstrated advantages, notably reduced drainage volume and lower postoperative pain levels. Recognizing patient subsets that benefit more from the PPB highlights the importance of personalized device selection based on patient characteristics.

Serial Comparison of Patient-Reported Outcomes of Immediate Breast Reconstruction: Direct-to-Implant Versus Deep Inferior Epigastric Perforator Flap

BACKGROUND

Direct-to-implant (DTI) and deep inferior epigastric artery perforator (DIEP) flaps are the two most common methods of immediate breast reconstruction. This study aimed to compare patient-reported outcomes between the two methods and to evaluate whether outcomes change over time.

METHODS

The data of patients who underwent immediate breast reconstruction using DTI or DIEP flaps between July 2017 and October 2021 were retrospectively reviewed. Patients who completed the BREAST-Q Reconstruction Module at 6 months and > 12 months after reconstruction were analyzed. Mann-Whitney and Wilcoxon signed-rank test were used to compare outcome between DTI and DIEP groups, and serial comparisons were performed.

RESULTS

Of 375 patients included in the analysis, 146 patients completed questionnaires > 1 year of follow-up (20.79 ± 8.55 months). The DTI and DIEP groups had 102 (69.9%) and 44 (30.1%) patients, respectively. There were no intergroup differences in the mean scores representing any of the domains at 6 postoperative months. After > 1 year of follow-up, patients who underwent DIEP-flap reconstruction had greater satisfaction with their breast reconstructions (p < 0.001) and greater satisfaction with their overall outcomes (p < 0.001). In the DTI group, satisfaction scores did not change over time in any of the domains. In the DIEP group, however, the mean scores reflecting satisfaction with the breast (p = 0.001), overall outcome (p = 0.045), psychosocial well-being (p = 0.015), and sexual well-being (p = 0.042) significantly increased over long-term follow-up relative to the scores at 6 postoperative months.

CONCLUSIONS

Patient-reported outcomes improved over time in association with DIEP reconstructions, reflecting higher satisfaction levels than those associated with DTI 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 .

Patients' Satisfaction After Breast Reconstruction Surgery Using Autologous versus Implants: A Meta-Analysis

INTRODUCTION

Breast cancer is a common disease that affects women globally and causes physical and emotional challenges. Breast reconstructive surgery aims to restore the shape of the breast after a mastectomy. Two common approaches used today are tissue-based or autologous and implant-based reconstruction. Autologous breast reconstruction has the advantage of being more affordable, but the resulting shape is less attractive. At the same time, the implant technique produces a more pleasing shape at a more expensive cost.

OBJECTIVE

To compare the level of patients' satisfaction after breast reconstruction using the implant technique with the autologous technique using the Breast-Q questionnaire.

METHODS

This research was a meta-analytic study to compare patients' satisfaction levels with breast reconstruction using the autologous technique compared with the implant technique. We searched several research articles from PubMed, EMBASE, and the Cochrane Library from 2014 to 2023. Then, we conducted an analysis using Revman 5.4. The results of the study were presented in a forest plot diagram.

RESULTS

From the search results, there were 3980 studies. Then, exclusion and inclusion were carried out, and the results obtained were 16 research articles. Of the 16 studies, analysis was then carried out, and the results obtained were satisfaction in breast patients with a sample size of 7284. The standard result of the mean difference was 0.55 (95% CI 0.41-0.68) p < 0.00001. Satisfaction with the reconstruction results with a sample size of 2935. The standard result of the mean difference was 0.48 (95% CI 0.28-0.69) p < 0.00001. Patients' sexual satisfaction with a sample size of 7149. The standard result of the mean difference was 0.27 (95% CI 0.17-0.37) p < 0.00001. Patients' satisfaction with nipple shapes with a sample of 426. The standard result of the mean difference was 0.22 (95% CI -0.00-0.44) p = 0.06. Patients' satisfaction with plastic surgeons with a sample size of 272. The standard result of the mean difference was 0.52 (95% CI 0.25-0.80) p= 0.0002.

CONCLUSION

The autologous breast reconstruction technique is better than the implant-based reconstruction technique in terms of patient satisfaction with the breast, reconstruction outcome, sexual satisfaction, nipple shapes, and plastic surgeons based on the Breast-Q questionnaire. The findings of this comprehensive study indicate that breast cancer survivors who choose autologous reconstruction have higher levels of satisfaction across multiple domains than those who decide implant-based reconstruction.

[RECOMA study: Evaluation of quality of life and satisfaction after immediate or delayed breast reconstruction]

OBJECTIVE

Breast reconstruction after mastectomy, whether immediate or delayed, is an integral part of the overall management of breast cancer. However, up to 40 % of reconstructed patients are not satisfied with the aesthetic result. The primary objective of the study was to evaluate satisfaction and quality of life according to the reconstruction techniques used in our center. The secondary objectives were to identify the parameters that could influence satisfaction and quality of life after surgery, to list the main complications, and the number of operations required to consider the reconstruction process as completed.

METHOD

A retrospective monocentric study, RECOMA, was carried out at the CHRU Minjoz in Besançon. All patients who underwent immediate or delayed breast reconstruction between 2010 and 2021 were contacted by post or e-mail and asked to complete the standardized BREAST-Q postoperative module.

RESULTS

Of 508 patients contacted, 149 were included. Reconstructed patients reported satisfaction, but also "average" quality of physical and psychological sexual life. Only the surgeon's assessment was rated as "good". There was no significant difference in satisfaction and quality of life depending on the reconstruction method chosen. On the other hand, patients who underwent nipple areolar complex (NAC) reconstruction had a significantly higher psychic quality of life score (P=0.02). In addition, a significant decrease in physical satisfaction was observed over time(P=0.049). An average of 2.4 operations was required to consider breast reconstruction complete.

CONCLUSION

In our opinion, breast reconstruction is an essential procedure to be considered as soon as the indication for mastectomy is given, but it is a process that requires the patient to be prepared for a result that may be weaker than expected, may require several operations, and may be complicated.

Breast reconstruction after mastectomy

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

Upper Extremity Functional Outcomes After Breast Cancer Treatment: An Analysis of DASH Score in Breast Reconstruction Patients

BACKGROUND

Patients undergoing postoncologic breast reconstruction can experience upper extremity (UE) functional deficits.

OBJECTIVES

In this study, we utilized the disabilities of the arm, shoulder, and hand (DASH) questionnaire to identify patient factors that impacted UE functional recovery.

METHODS

Patients who underwent oncologic followed by reconstructive surgery by a single surgeon from 2014 to 2019 and completed the DASH survey were included. A DASH score was calculated for each patient, with values ranging from 0 (no impairment) to 100 (severe impairment). Regression analysis was conducted to identify significant predictors for DASH score with a significance level for entry and stay set at P = .15.

RESULTS

Among 289 patients who underwent breast reconstruction, 157 completed the questionnaire. The average patient age was 52.6yrs ± 8.6 at the time of reconstruction. A total of 111 had implant-based reconstruction, 15 had autologous reconstruction, and 24 had a combination of both. Average DASH score was 7.7 (range 0.0-52.5), with 74.1% of patients having a score greater than 0. Regression analysis showed 5 variables associated with significantly higher DASH scores: age between 50 and 60 years (P = .13), history of radiation (P = .01), placement of a subpectoral implant (P = .06), postoperative complications (P = .10), and lymphedema (P < .01). Autologous breast reconstruction (P = .04) was associated with a significantly lower DASH score.

CONCLUSIONS

Implant-based reconstruction, radiation history, postoperative complications, and age at reconstruction were associated with increased UE functional impairment in patients who underwent breast reconstructive surgery. Identification of these factors can inform areas for potential practice changes and improve patient counseling regarding postoperative expectations.

LEVEL OF EVIDENCE: 3

Long-Term Patient-Reported Arm Symptoms in Breast Cancer Survivors

BACKGROUND

Understanding long-term arm symptoms in breast cancer survivors is critical given excellent survival in the modern era.

METHODS

This cross-sectional study included patients treated for stage 0-III breast cancer at our institution from 2002 to 2012. Patient-reported arm symptoms were collected from the EORTC QLQ-BR23 questionnaire. We used linear regression to evaluate adjusted associations between locoregional treatments and the continuous Arm Symptom (AS) score (0-100; higher score reflects more symptoms).

RESULTS

A total of 1126 patients expressed interest in participating and 882 (78.3%) completed the questionnaire. Mean time since surgery was 10.5 years. There was a broad distribution of locoregional treatments, including axillary lymph node dissection (ALND) in 37.1% of patients, mastectomy with reconstruction in 36.5% of patients, and post-mastectomy radiation in 38.2% of patients. Overall, 64.3% (95% confidence interval [CI] 61.1-67.4%) of patients reported no arm symptoms, 17.0% (95% CI 14.7-19.6%) had one mild symptom, 9.4% (95% CI 7.7-11.5%) had two or more mild symptoms, and 9.3% (95% CI 7.6-11.4%) reported one or more severe symptoms. Adjusted AS scores were significantly higher with ALND versus sentinel node biopsy (β 3.5, p = 0.01), and with autologous reconstruction versus all other breast/reconstructive surgery types (β 4.5-5.5, all p < 0.05). There was a significant interaction between axillary and breast/reconstructive surgery, with the greatest effect of ALND in those with mastectomy with implant (β 9.7) or autologous (β 5.7) reconstruction.

CONCLUSIONS

One in three patients reported arm symptoms at a mean of 10 years from treatment for breast cancer, although rates of severe symptoms were low (<10%). Attention is warranted to the arm morbidity related to both axillary and breast surgery during treatment counseling and survivorship.

Flap neurotisation improves sensation outcomes in abdominally based autologous breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Flap neurotisation is a promising solution to restore the diminished or complete loss of sensation following mastectomy. This systematic review compared sensory outcomes in neurotised versus non-neurotised abdominal-based autologous breast reconstructions to establish its benefit in routine clinical practice.

METHODS

A literature search was performed according to the PRISMA guidelines. Medline, PubMed, EMBASE, and Cochrane databases were queried for relevant studies. Pressure sensitivity, measured using Semmes-Weinstein monofilaments (SWM) or the pressure-specified sensory device (PSSD), was the primary outcome measure.

RESULTS

A total of 12 studies comprising 367 neurotised and 295 non-neurotised flap reconstructions were included, with 8 studies included in the meta-analysis. Neurotised flaps demonstrated superior sensory outcomes over non-neurotised flaps, with significant differences in SWM scores (mean difference [MD], -1.552 95% CI, -2.351 to -0.7535; p = 0.0001) and PSSD (MD -13.36; 95% CI, -26.41 to -0.3117; p = 0.0448) at follow-up (range 8 to 77 months). The differences in total skin sensation (native and flap skin combined) were statistically significant in the SWM group (p = 0.0010) but not in the PSSD group (p = 0.0649). Investigation on the factors impacting sensation recovery in neurotised flaps yielded inconclusive outcomes.

CONCLUSIONS

Neurotised flaps consistently demonstrated superior sensation outcomes compared with non-neurotised flaps, irrespective of flap type or neurotisation technique. However, further research is essential to elucidate the factors that impact sensory recovery and standardise neurotisation practices for more optimal post-mastectomy reconstruction outcomes.

Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis

BACKGROUND

 Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS).

METHODS

 A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes.

RESULTS

 Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different.

CONCLUSION

 CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Challenges in Autologous Breast Reconstruction: A Review of Recommendations

Breast reconstruction is an integral part of breast cancer treatment and offers significant psychosocial benefits for patients undergoing mastectomy as a part of their treatment plan. Autologous breast reconstruction (ABR) utilizes a patient's own tissue to reconstruct the mastectomy defect, obviating the need for the implantation of a foreign object. As the field of plastic surgery progresses, ABR has become an excellent option for the recreation of a native breast mount. With that said, there are patient populations who present unique challenges when optimizing an aesthetic ABR result. We aim to discuss these challenging groups, including patients with both high and low body mass index (BMI), patients with a history of massive weight loss, patients who require post-mastectomy radiation therapy (PMRT), and patients electing for unilateral procedures where the surgeon attempts to match the reconstructed breast with the native breast. In our discussion, we review the literature recommendations for management as well as our experiences with our own patient cases. Ultimately, we believe this procedure can be performed in a wide variety of patient types and can be offered to those who may not be considered the "ideal" candidate.

Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges

INTRODUCTION

Efforts to improve global healthcare persist, yet LMICs face challenges accessing surgical care, especially breast reconstruction amidst rising breast cancer cases. This review evaluates the present state and challenges of autologous breast reconstruction in low- and middle-income countries (LMICs).

EVIDENCE ACQUISITION

Utilizing the PRISMA guidelines and the Cochrane Collaboration's standards, databases such as EMBASE, MEDLINE, Cochrane, PubMed, and Google Scholar were examined for studies on breast reconstruction in LMICs (based on the World Bank's 2022-2023 definitions) up to August 2022. Articles and case reports focusing on autologous reconstruction following breast cancer surgery in these regions were incorporated.

EVIDENCE SYNTHESIS

From an initial 288 articles, 19 met the criteria after thorough assessment. These articles documented 4899 patient cases from LMICs, with the breakdown being: 11 on LD flaps, nine on TRAM flaps, eight on DIEP flaps, two on TDAP flaps, and one on TMG flap. Flap necrosis emerged as the prevalent complication in four studies.

CONCLUSIONS

While autologous breast reconstruction presents superior aesthetic benefits without notable long-term economic setbacks, its adoption in LMICs is limited. This is partly due to the domination of implant-based methods among patients and surgeons, selected due to convenience. The scarcity of concrete evidence and standardized metrics in LMICs clouds the understanding of this procedure. Despite its advantages, awareness is low, necessitating more training and awareness campaigns. Uniform reporting, quality data, and financial analysis can provide a comprehensive LMIC understanding, aiding future research.

American Radium Society Appropriate Use Criteria Postmastectomy Radiation Therapy: Executive Summary of Clinical Topics

PURPOSE

To conduct an appropriate use criteria expert panel update on clinical topics relevant to current clinical practice regarding postmastectomy radiation therapy (PMRT).

METHODS AND MATERIALS

An analysis of the medical literature from peer-reviewed journals was conducted from May 4, 2010 to May 4, 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to search the PubMed database to retrieve a comprehensive set of relevant articles. A well-established methodology (modified Delphi) was used by the expert panel to rate the appropriate use of procedures.

RESULTS

Evidence for key questions in PMRT regarding benefit in special populations and technical considerations for delivery was examined and described. Risk factors for local-regional recurrence in patients with intermediate-risk disease that indicate benefit of PMRT include molecular subtype, age, clinical stage, and pathologic response to neoadjuvant chemotherapy. Use of hypofractionated radiation in PMRT has been examined in several recent randomized trials and is under investigation for patients with breast reconstruction. The use of bolus varies significantly by practice region and has limited evidence for routine use. Adverse effects occurred with both PMRT preimplant and postimplant exchange in 2-staged breast reconstruction.

CONCLUSIONS

Most patients with even limited nodal involvement will likely benefit from PMRT with significant reduction in local-regional recurrence and potential survival. Patients with initial clinical stage III disease and/or any residual disease after neoadjuvant chemotherapy should be strongly considered for PMRT. Growing evidence supports the use of hypofractionated radiation for PMRT with equivalent efficacy and decreased acute side effects, but additional evidence is needed for special populations. There is limited evidence to support routine use of bolus in all patients. Timing of PMRT regarding completion of 2-staged breast reconstruction requires a discussion of increased risks with radiation postimplant exchange compared with increased risk of failure of reconstruction or surgical complications with radiation preimplant exchange.

Outcomes after tissue expander exchange to implant in two-stage prepectoral breast reconstruction with and without acellular dermal matrix: A retrospective cohort study

As prepectoral implant placement becomes widely adopted, recent studies investigating the use of acellular dermal matrix (ADM) during tissue expander placement have demonstrated no major benefit with regard to postoperative outcomes. We sought to evaluate second-stage outcomes 1 year after tissue expander exchange to implant with and without ADM. Consecutive patients who underwent prepectoral tissue expander-based breast reconstruction with and without ADM were identified. Patients were followed up for 1 year after tissue expander exchange to implant. Second-stage outcomes of interest including implant rippling, capsular contracture, implant explantation, additional revision surgeries, and patient-reported outcomes were collected and compared. Sixty-eight breasts in the ADM cohort and sixty-one breasts in the no ADM cohort underwent tissue expander exchange to implant. Second-stage outcomes of interest were similar between the ADM and no ADM cohorts with no statistically significant differences identified regarding incidences of implant rippling (24.6% vs. 12.1%, p = 0.08), capsular contracture (4.5% vs. 3.3%, p = 1.00), and explantation (6.6% vs. 1.7%, p = 0.67) between the two cohorts. BREAST-Q scores were similar between the two cohorts with the exception of physical wellbeing and satisfaction in terms of implant rippling, as can be seen, which improved in the no ADM cohort (p = 0.04). Our study reports no major benefit for the inclusion of ADM with respect to implant rippling, capsular contracture, explantation, need for additional revision surgeries, and patient-reported satisfaction in prepectoral second-stage implant-based breast reconstruction.

Vanderbilt Mini-PROM-Breast for Breast Reconstruction: A Short-Form, Patient-Reported Outcomes Measure

BACKGROUND

Breast reconstruction procedures are among the most commonly performed plastic surgery operations. Although there are well-validated patient-reported outcomes measures (PROMs) for breast reconstruction, there are several patient-, provider-, and service-level barriers to their implementation in routine clinical settings. Therefore, we developed a short-form PROM to evaluate breast reconstruction outcomes.

METHODS

Using a mixed-methods approach, the Vanderbilt Mini-PROM-Breast (VMP-B) was constructed and validated to assess patient-reported outcomes from breast reconstruction. Classic test theory methods were used to evaluate acceptability, reliability, and validity. External validation was subsequently performed using the BREAST-Q as a reference standard.

RESULTS

The VMP-B is a 16-item instrument composed of three domains: quality of life, body image, and breast satisfaction. Psychometric properties including acceptability, reliability, and validity exceeded reference criteria. When tested with 104 patients, the authors found significant benefits of breast reconstruction on quality of life, body image, and breast satisfaction. These results were associated with sizeable effect sizes (g) (g = 0.421, g = 0.520, and g = 1.25) demonstrative of clinically meaningful results. When tested concurrently in 70 patients, the VMP-B and the BREAST-Q showed similar results, exhibiting excellent convergent validity.

CONCLUSIONS

The VMP-B is a validated short-form PROM that reliably assesses breast reconstruction outcomes. As a short form, the VMP-B decreases both patient and provider burden, which allows for routine, point-of-care collection of breast reconstruction outcomes.

Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale

BACKGROUND

The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited.

OBJECTIVES

The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap.

METHODS

All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature.

RESULTS

Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11).

CONCLUSIONS

Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

LEVEL OF EVIDENCE: 3

Impact of autologous breast reconstruction on bra fit

PURPOSE

To inform bra design by analyzing 3D surface images of breast cancer patients who underwent autologous breast reconstruction.

METHODS

We computed bra design measurements on 3D surface images of patients who underwent unilateral and bilateral autologous breast reconstruction. Breast measurements and right-left symmetry between preoperative baseline and postoperative time points were compared using either paired Student t-test or Wilcoxon signed-rank test, depending on the data's distribution. Regression analysis determined associations between measurements and patient characteristics such as age. Postoperative measurements and symmetry differences were also compared between autologous and implant-based breast reconstruction.

RESULTS

Among participants who underwent bilateral autologous breast reconstruction, the reconstructed breasts were smaller and positioned higher on the chest wall than their native breasts. For patients who underwent unilateral reconstruction, similar postoperative changes were observed in the contralateral breast due to symmetry procedures. Overall, for participants whose baseline breast measurements showed substantial asymmetry, unilateral reconstruction decreased right-left asymmetry whereas bilateral reconstruction amplified right-left asymmetry. Preoperative baseline breast measurements, age, and BMI were statistically significantly associated with most postoperative breast measurements for participants who underwent bilateral autologous reconstruction. Compared to implant-based reconstruction, autologous reconstruction resulted in fewer changes in breast shape and symmetry that are pertinent to bra fit.

CONCLUSION

Preoperative baseline breast measurements, age, and BMI can impact bra designs for breast cancer survivors who undergo autologous reconstruction due to size, shape, and symmetry changes. Bra needs of people who undergo autologous reconstruction differ from those who undergo implant-based reconstruction.

Counselling Framework for Germline BRCA1/2 and PALB2 Carriers Considering Risk-Reducing Mastectomy

Female BRCA1/2 and PALB2 germline pathogenic variant carriers have an increased lifetime risk of breast cancer and may wish to consider risk-reducing mastectomy (RRM) for surgical prevention. Quantifying the residual lifetime risk and absolute benefit from RRM requires careful consideration of a patient's age, pathogenic variant, and their personal history of breast or ovarian cancer. Historically, patients have been counselled that RRM does not necessarily prolong survival relative to high-risk surveillance, although recent studies suggest a possible survival benefit of RRM in BRCA1 carriers. The uptake of RRM has increased dramatically over the last several decades yet varies according to sociodemographic factors and geographic region. The increased adoption of nipple-sparing mastectomy techniques, ability to avoid axillary staging, and availability of reconstructive options for most germline pathogenic variant carriers has helped to minimize the morbidity of RRM. Preoperative discussions should include evidence regarding postmastectomy sensation, the potential for supplemental surgery, pregnancy-related chest wall changes, and the need for continued clinical surveillance. Approaches that include sensation preservation and robotic nipple-sparing mastectomy are an area of evolving research that may be more widely adopted in the future.

National long-term patient-reported outcomes following mastectomy with or without breast reconstruction: The Swedish Breast Reconstruction Outcome Study Part 2 (SweBRO 2)

BACKGROUND

The Swedish Breast Reconstruction Outcome Study (SweBRO) initiative is a nationwide study with the primary aim of assessing long-term outcomes after mastectomy with and without breast reconstruction (BR). The current part (SweBRO 2) is designed to evaluate health-related quality of life (HRQoL), with the hypothesis that BR has a positive impact on patient-reported HRQoL in the long-term.

METHODS

Women who underwent mastectomy in Sweden in 2000, 2005, or 2010 and were alive at the time of the survey were identified through the National Breast Cancer Registry. Eligible participants received formal invitation letters to take part in a survey evaluating their HRQoL at 5 , 10, or 15 years post-mastectomy. The EORTC QLQ-C30, EORTC QLQ-BR23, and EQ-5D-3L questionnaires were employed.

RESULTS

Of 2904 respondents (50% of 5853 invited), 895 (31%) had received BR. Among them, 516 (58%) were reconstructed with implants and 281 (31%) with autologous tissue. Women with BR scored significantly better in the EORCT QLQ-C30 physical functioning domain (mean 90 versus 81 points), fatigue (mean 21 versus 25), and dyspnoea (mean 16 versus 22) compared to non-reconstructed women. The EORTC QLQ-BR23 revealed that women with BR experienced favourable sexual functioning compared with non-reconstructed women (mean 26 versus 14). The EQ-5D-3L visual analogue scale score was similar between groups.

CONCLUSION

The current study underscores the benefits of BR for long-term well-being, for example, in terms of physical and sexual functioning. These underline the importance of informing women undergoing mastectomy about BR alternatives and its potential benefits in enhancing long-term well-being.

Microsurgical training curriculum in a gynecological breast cancer center: a benefit for patients and surgeons?

PURPOSE

Autologous breast reconstruction improves patient satisfaction and quality of life after mastectomy. In Germany, free flap surgery and implant-based reconstruction is usually separate between reconstructive surgery and gynecology. Cooperation between the specialist disciplines and implementation of microsurgery into breast surgeon training could enhance surgical treatment for breast cancer patients. This evaluation is intended to demonstrate the learning progress within a microsurgical training program and the complication rate in relation to microsurgical experience.

METHODS

At the breast cancer center at Klinikum rechts der Isar, TU Munich, a three-stage training program for autologous breast reconstruction and microsurgery for gynecological breast surgeons was developed. Between 2019 and 2022, 74 women received autologous free flap breast reconstruction by a consistent team consisting of a gynecological surgeon in training and an expert microsurgeon. Peri- and postoperative data were collected to analyze the feasibility and safety of a microsurgical training in gynecology.

RESULTS

Within the training, operative steps of free autologous breast reconstruction were increasingly taken over by the gynecological surgeon in training. The analysis showed a decrease in operating times with consistently low complication rates during the training.

CONCLUSION

This study demonstrated that a training in free autologous breast reconstruction for gynecological surgeons is safely feasible through close cooperation between gynecological and reconstructive surgery.

A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest

BACKGROUND

 The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients.

METHODS

 This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications.

RESULTS

 Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87.

CONCLUSION

 This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

Applying unsupervised machine learning approaches to characterize autologous breast reconstruction patient subgroups: an NSQIP analysis of 14,274 patients

BACKGROUND

Autologous breast reconstruction is composed of diverse techniques and results in a variety of outcome trajectories. We propose employing an unsupervised machine learning method to characterize such heterogeneous patterns in large-scale datasets.

METHODS

A retrospective cohort study of autologous breast reconstruction patients was conducted through the National Surgical Quality Improvement Program database. Patient characteristics, intraoperative variables, and occurrences of acute postoperative complications were collected. The cohort was classified into patient subgroups via the K-means clustering algorithm, a similarity-based unsupervised learning approach. The characteristics of each cluster were compared for differences from the complementary sample (p < 2 ×10-4) and validated with a test set.

RESULTS

A total of 14,274 female patients were included in the final study cohort. Clustering identified seven optimal subgroups, ordered by increasing rate of postoperative complication. Cluster 1 (2027 patients) featured breast reconstruction with free flaps (50%) and latissimus dorsi flaps (40%). In addition to its low rate of complications (14%, p < 2 ×10-4), its patient population was younger and with lower comorbidities when compared with the whole cohort. In the other extreme, cluster 7 (1112 patients) almost exclusively featured breast reconstruction with free flaps (94%) and possessed the highest rates of unplanned reoperations, readmissions, and dehiscence (p < 2 ×10-4). The reoperation profile of cluster 3 was also significantly different from the general cohort and featured lower proportions of vascular repair procedures (p < 8 ×10-4).

CONCLUSIONS

This study presents a novel, generalizable application of an unsupervised learning model to organize patient subgroups with associations between comorbidities, modality of breast reconstruction, and postoperative outcomes.

Immediate versus delayed breast reconstruction: Long-term follow-up on health-related quality of life and satisfaction with breasts

INTRODUCTION

Health-related quality of life (HRQL) can be improved by breast reconstruction following mastectomy. The optimal timing of the reconstruction remains unclear.

METHODS

A cross-sectional study on 338 women who had undergone immediate or delayed breast reconstruction between 08/2017 and 07/2019 was performed. The postoperative HRQL was assessed using the BREAST-Q Reconstruction Module and the 36-Item Short Form Survey (SF-36). Regression analysis was performed for group-wise comparison.

RESULTS

A total of 146 (43%) patients participated. Seventy-seven patients (53%) had undergone immediate, and 69 patients (47%) had delayed reconstruction. The median age was 55 years (interquartile ratio [IQR] 50-62) for the Immeda group te, and 60 years (IQR 54-65) for the delayed reconstruction group. The median follow-up time was 2.3 years (IQR 1.8-2.9). No difference between the groups was detected in satisfaction with breasts (median 61, IQR 53-71 vs. 62, IQR 46-71, p = 0.62), physical well-being of the chest (median 100, IQR 80-100 vs. 100, IQR 80-100, p = 0.95) or psychosocial well-being (median 69, IQR 54-83 vs. 62, IQR 54-74, p = 0.19). No difference was detected in the SF-36 domains either.

CONCLUSIONS

The timing of the breast reconstruction does not affect the postoperative HRQL. Patients with both immediate and delayed breast reconstruction reported high satisfaction with the breast and psychosocial well-being.

Impact of Adjuvant Radiotherapy on Free Flap Volume in Autologous Breast Reconstruction: A Scoping Review

In autologous breast reconstruction, a sufficient flap volume is fundamental to restore breast shape and ensure an aesthetic outcome. After mastectomy, postoperative irradiation is regularly indicated in the oncological treatment algorithm. When administering radiation therapy after autologous reconstruction, the tissue transferred is inherently irradiated. Although there is evidence that points to a reduction in flap volume after adjuvant radiotherapy, the data have been contradicting and inconclusive. To address this anecdotal evidence, we performed a scoping review of the current literature that addresses the effect of radiotherapy on breast flap volume. Six two-armed studies, comprising a total of 462 patients, reported on the effect of adjuvant radiotherapy on free flap volume changes. Of those, two studies found a significant negative impact of radiotherapy on free flap volume, while the other four studies did not. Reported flap volume changes ranged from no change to a reduction of 26.2%, measured up to two years postoperatively. The selected studies contain varying patient numbers, follow-up timepoints, types of flaps, and measuring methods, contributing to a relatively high heterogeneity. While we present some evidence suggesting a significant impact of adjuvant radiotherapy on breast flap volume, future studies are needed to further investigate this potential correlation.

The impact of chest contouring aesthetics outcomes: a pilot eye tracking study

Eye-tracking technology was used to assess aesthetic surgical outcomes in transgender and gender diverse patients who are assigned female at birth and who seek gender affirming chest surgery. Post-surgery, observers focused more on scars than on the nipple-areolar complex. Ratings for similarity to cis-male chests significantly increased. This series highlights the objective evaluation of visual perception and masculinity assessments using eye-tracking.

Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Background and Objective

After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway.

Methods

All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed.

Key Content and Findings

Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions.

Conclusions

Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

Narrative review of patient-reported outcomes of breast reconstruction

Background and Objective

The treatment of breast cancer encompasses both the elimination of malignancy as well as reconstruction after tumor extirpation. Although the patient may have had successful treatment of her breast cancer, the resulting disfigurement and deformity can have a substantial impact on her physical and mental well-being. Breast reconstruction affords these patients the opportunity to correct these deformities and potentially to improve their quality of life. The current literature review evaluates patient-reported outcomes for the various options of breast reconstruction that are most commonly performed.

Methods

A literature review on PubMed with the key words "patient-reported outcomes", "breast reconstruction", and "breast cancer" yielded 738 results, which were screened. Articles that specifically focused on patient-reported outcomes after various types of breast reconstruction were evaluated and included in this literature review.

Key Content and Findings

The main options of alloplastic reconstruction, autologous tissue reconstruction, and oncoplastic reconstruction were reviewed and found to demonstrate high levels of patient satisfaction. Although there is no clear superior option, patient-reported outcomes demonstrate improved well-being compared to no reconstruction.

Conclusions

Breast reconstruction provides the opportunity to correct the deformities after breast cancer treatment making it a crucial component of comprehensive cancer care. A variety of reconstructive options are available which can be tailored to each individual patient to achieve the optimal results for that particular patient. Therefore patient-reported outcomes are paramount to gauge the true success of not only breast cancer treatment but also reconstructive aspects after treatment.

Prolonged operative time is a risk factor for adverse postoperative outcomes in the unilateral deep inferior epigastric perforator (DIEP) flap surgery: A retrospective cohort study

BACKGROUND

Currently, one published study documented operative time (OT) as a predictor for postoperative outcomes in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstructions. No literature has investigated this in unilateral DIEP flaps. We aimed to determine the relationship between unilateral OT, postoperative complications, unplanned reoperations (UR), and extended length-of-stay (eLOS).

METHODS

Patients who underwent elective unilateral DIEP reconstruction from 2018 to 2023 at a tertiary centre in London, United Kingdom, were retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive covariates, including procedural complexity, was recorded and used in univariable and multivariable regression models.

RESULTS

The final cohort contained 173 patients. After risk-adjustment, ≥421-minute operations led to a significantly higher overall complication rate (HR: 2.14, 95% CI: 1.26, 3.64, p = 0.005) relative to <421 min. Significantly higher odds of eLOS were observed in the ≥460-minute group (OR: 2.07, 95% CI: 1.07, 3.99, p = 0.03) compared to <460 min. There was no significant effect on the rate of postoperative UR across any OT group.

CONCLUSIONS

We confirmed OT was an independent predictor for postoperative outcomes in the DIEP flap, and demonstrated this in unilateral reconstructions. A clinical maximum threshold of 7 h was derived based on this cohort to help guide future surgical practice. Efficiency can be achieved by meticulous preoperative planning and process standardisation, multiple senior surgeons working per flap, and smooth teamwork between specialities and intraoperative staff.

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.

Thoraco-dorsal artery perforator flap for totally autologous primary breast reconstruction. Assessment of feasibility with standard reporting scales

This study reports on feasibility and applicability of totally autologous primary breast reconstructions based on TDAP flaps using a standard set of internationally approved reporting scales. We reviewed 15 cases in patients with a good donor area in the back not suitable for implant or free flaps reconstructions. Complications according to Clavien Dindo were: 1 Grade 1 (seroma in the back). The ABS-BAPRAS quality assurance indicators 10, 11, and 12 were entirely fulfilled. No pedicled flap loss occurred; no unplanned return to theatre and no unplanned readmission within 3 months. Breast-related quality of life values are reported at 3 months and one year in four domains of the BREAST Q v. 2.0 (breast reconstruction post-op questionnaire). At 1 year the mean Q-score for satisfaction with breast was 70.5, for psychosocial well-being was 72.3; for sexual well-being was 58.8; for physical well-being (chest wall) was 70.60. The TDAP based totally autologous breast reconstruction reported to be a feasible and safe alternative to implant based or free flaps reconstructions according to consolidate international outcome reporting measures.