Complications, risk factors, and patients-reported outcomes after skin-sparing mastectomy followed by breast reconstruction in women with BRCA mutations

Impact of breast surgical procedure on survival in BRCA mutated patients with invasive breast cancer: Mastectomy versus conservative treatment

INTRODUCTION

Patients with BRCA1/2 mutations have a higher risk of developing breast cancer compared to the wild-type population. For patients with a BRCA mutation, there are no specific recommendations for surgical management. The aim of this study was therefore to retrospectively investigate overall survival (OS) and recurrence-free survival (RFS) of BRCA mutated patients with localized invasive breast cancer, by comparing conservative surgery versus mastectomy.

METHODS

This study was based on data from the Côte d'Or breast and gynecological cancer registry. Data from patients with a constitutional BRCA1/2 mutation who presented with invasive breast cancer were collected retrospectively from 1998 to 2018. The Kaplan-Meier method was used to describe RFS and OS.

RESULTS

A total of 104 patients were included in the analysis, of whom 69 had conservative surgery and 35 underwent mastectomy. Regarding survival, there was no significant difference in OS (HR =1.49; 95 % confidence interval (CI) [0.76-2.93], p = 0.25). Similarly, there was no significant difference in RFS (HR =1.40; 95 % CI [0.81-2.40], p = 0.22), survival without homolateral recurrence (HR =0.88; 95 % CI [0.30-2.61], p = 0.89), without contralateral recurrence (HR =1.50; 95 % CI [0.55-4.09], p = 0.42), or without distant metastatic recurrence (HR =1.42, 95 % CI [0.69-2.90], p = 0.33).

CONCLUSION

In invasive breast cancer in a patient with a germline BRCA1/2 mutation, conservative surgery, when possible, appears to be a feasible option over total mastectomy, with no difference in overall survival. However, the patient should be informed of the aggressive nature of recurrence in this population requiring chemotherapy in most cases.

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.

Surgical Decision Making in Genetically High-Risk Women: Quantifying Postoperative Complications and Long-Term Risks of Supplemental Surgery After Risk-Reducing Mastectomy

BACKGROUND

Risk-reducing mastectomy (RRM) helps prevent breast cancer in high-risk women but also carries a risk of unanticipated supplemental surgeries. We sought to determine the likelihood of supplemental surgeries following RRM.

METHODS

We performed a retrospective cohort study of female patients with a confirmed germline pathogenic variant (GPV) in a breast cancer susceptibility gene (BRCA1/2, PALB2 and others) who underwent bilateral or contralateral RRM at our institution between 2006 and 2022. Supplemental surgeries were defined as any operation requiring general or local anesthesia performed outside of the initially planned procedure(s). The Kaplan-Meier method was used to estimate the 5-years cumulative incidence of supplemental surgery.

RESULTS

Of 560 GPV carriers, RRMs were performed in 258 (46.1%) women. The median age of the cohort was 44 years (interquartile range 37-52 years), with 33 (12.8%) patients undergoing RRM without reconstruction and 225 (87.2%) undergoing RRM with reconstruction. Following surgery, 34 patients (13.2%) developed early (< 30 days) postoperative complications, including infection, hematoma, seroma, loss of the nipple areola complex, flap necrosis, implant exposure and/or prosthesis removal. At a median follow-up of 3.8 years, 94 (36.4%) GPV carriers underwent at least one reoperation. Participants who experienced an early postoperative complication had the highest rate of reoperation (85.3% vs. 29.0%; p < 0.001) and a significantly higher likelihood of multiple additional surgical interventions (41.2% vs. 10.7%; p < 0.001). The 5-years rate of supplemental surgery was 39.2% [95% confidence interval (CI) 32.7-46.5] in the overall cohort and 31.5% (95% CI 24.9-39.3) in patients without an early postoperative complication.

CONCLUSIONS

Unanticipated supplemental surgeries occur in 40% of GPV carriers following RRM and in nearly one-third of patients without early postoperative complications.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

Patient-reported outcomes following bilateral prophylactic mastectomy and immediate breast reconstruction: comparing implant-based with autologous breast reconstruction

Background

Since the number of breast cancer genetic gene testing is increasing, more women opt for bilateral prophylactic mastectomy (BPM) followed by breast reconstruction. However, little is known about the differences in Quality of Life (QoL) after various reconstructive surgeries in this population. In this study, the long-term breast-related, body-related, and health-related QoL between immediate implant-based breast reconstruction (IBBR) and autologous breast reconstruction (ABR) were compared, in women who underwent BPM.

Methods

In this cross-sectional study, women who underwent postmastectomy breast reconstruction between January 2015 and December 2018 were invited for an online questionnaire, in which the BREAST-Q, the BODY-Q and the SF-36 were included. Women who underwent BPM and immediate breast reconstruction were included for analysis. Multivariable linear regression analysis was performed to adjust mean differences in patient-reported outcomes between IBBR and ABR for potential confounders.

Results

Of the included women (n = 47), 33 underwent ABR and 14 women underwent IBBR following BPM. BREAST-Q scores were in favor of the ABR group before and after adjustment, with statistically significance on Satisfaction with breasts (mean difference 15.8, p = 0.019) and Physical well-being (mean difference 13.5, p = 0.033). None of the mean differences in BODY-Q and SF-36 scores between groups, before and after adjustment, were statistically significant.

Conclusion

This study suggests that there is a higher satisfaction with breasts and better physical well-being in women who underwent immediate ABR compared to those who underwent immediate IBBR after BPM. However, these data should be interpreted carefully as a result of selection bias and a small sample size.

Level of Evidence: Level III, risk study.

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

Introduction

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

Materials and Methods

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

Results

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

Conclusion

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

Level of Evidence IV

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

Priority recommendations for the implementation of patient-reported outcomes in clinical cancer care: a Delphi study

Purpose

The aim of this study was to develop priority recommendations for the service level implementation of patient-reported outcomes (PROs) into clinical cancer care.

Methods

Development of draft guidance statements was informed by a literature review, the Knowledge to Action (KTA) implementation framework, and discussion with PRO experts and cancer survivors. A two-round modified Delphi survey with key stakeholders including cancer survivors, clinical and research experts, and Information Technology specialists was undertaken. Round 1 rated the importance of the statements and round 2 ranked statements in order of priority.

Results

Round 1 was completed by 70 participants with round 2 completed by 45 participants. Forty-seven statements were rated in round 2. In round 1, the highest agreement items (>90% agreement) included those that focused on the formation of strong stakeholder partnerships, ensuring ongoing communication within these partnerships, and the use of PROs for improvement and guidance in clinical care. Items ranked as the highest priorities in round 2 included assessment of current staff capabilities and service requirements, mapping of workflows and processes to enable collection, and using collected PROs to guide improved health outcomes.

Conclusions

This stakeholder consultation process has identified key priorities in PRO implementation into clinical cancer care that include clinical relevance, stakeholder engagement, communication, and integration within the existing processes and capabilities.

Implication for Cancer Survivors

Routine adoption of PRO collection by clinical cancer services requires multiple implementation steps; of highest priority is strong engagement and communication with key stakeholders including cancer survivors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01135-2.

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed.

METHODS

The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed.

RESULTS

A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen.

CONCLUSION

The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Fat Grafting before Delayed Prophylactic Mastectomy and Immediate Implant Reconstruction for Patients at High Risk of Complications

SUMMARY

The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Factors Associated With Increased Complications in Patients With BRCA Gene Mutations Undergoing Reconstructive Breast Surgery

Reconstructive breast surgery after bilateral prophylactic mastectomy in patients who carry a mutation of the breast cancer (BRCA) gene has been increasing. Undergoing risk-reducing breast surgery can be of great benefit to young patients who have a high risk of developing breast cancer. There is little available evidence about the rate of complications in these patients and which factors are related to increased complications. The objective of this study was to identify predictors of complications in BRCA gene mutation carriers who underwent reconstructive breast surgery. A single-center, retrospective cohort study was conducted that included all patients with a mutation of the BRCA gene who underwent a breast reconstructive procedure, either immediate or delayed, between January 2013 and March 2019 and received a minimum of 6 months' follow-up. The results of our study showed that smoking is the most important modifiable risk factor associated with an increased complication rate for reconstructive breast surgery in patients with BRCA gene mutation. Smoking cessation will reduce the patient's risk for postoperative complications by 50%; therefore, it should be encouraged in all surgical patients and enforced in patients undergoing prophylactic procedures.

Management of patients with BRCA mutation from the point of view of a breast surgeon

Germ-line mutation in BRCA (BReast CAncer gene) 1 or BRCA2 are found in 3–4% of all women with breast cancer. These patients have a significant increased risk of breast and ovarian cancer. They are often younger when diagnosed with the mutation, and the possible breast cancer they get is often aggressive with inferior outcome. There are risk reducing strategies, and the most powerful strategy is risk reducing surgery, both risk reducing bilateral mastectomy (RRM) and risk reducing bilateral salpino-oophorectomy (PBSO). This review is meant to address breast surgery in patients with germline BRCA mutation. The guidelines and techniques applied is under continuous change and it is important for the clinicians to be well informed to provide the patient with the information needed for them to make an informed decision on what risk strategy to choose.

•

Patients with germ-line mutation in BRCA1 or BRCA2 have a significant increased risk of breast and ovarian cancer.

•

There are different risk reducing strategies and the most powerful strategy is risk-reducing surgery, both risk reducing bilateral mastectomy and risk reducing bilateral salpingo-oophorectomy.

•

Guidelines and techniques for the risk reducing surgery of the breast are under continuous change and improvement.

•

Breast conserving therapy is not associated with worse survival and is a good option for a BRCA mutation carrier diagnosed with breast cancer. Risk-reducing mastectomy can be performed in a later setting.

•

The management of BRCA mutation carriers, both affected and unaffected, should be performed in a multidisciplinary team. Physicians need to be systematically educated and updated on the most recent literature.

Analysis of Secondary Surgeries after Immediate Breast Reconstruction for Cancer Compared with Risk Reduction

Background:

This study sets out to compare reconstructive practice between patients undergoing immediate breast reconstruction (IBR) for cancer and those who opted for risk reduction (RR), with an emphasis on examining patterns of secondary surgery.

Methods:

Data collection was performed for patients undergoing mastectomy and IBR at a teaching hospital breast unit (2013–2016).

Results:

In total, 299 patients underwent IBR (76% cancer versus 24% RR). Implant-based IBR rate was similar in both groups (58% cancer versus 63% RR). Reconstruction loss (5.3% cancer versus 4.2% RR) and complication (16% cancer versus 12.9% RR) rates were similar. Cancer patients were more likely to undergo secondary surgery (68.4% versus 56.3%; P = 0.025), including contralateral symmetrization (22.8% versus 0%) and conversion to autologous reconstruction (5.7% versus 1.4%). Secondary surgeries were mostly planned for cancer patients (72% planned versus 28% unplanned), with rates unaffected by adjuvant therapies. This distribution was different in RR patients (51.3% planned versus 48.7% unplanned). The commonest secondary procedure was lipomodeling (19.7% cancer versus 23.9% RR). For cancer patients, complications resulted in a significantly higher unplanned secondary surgery rate (82.5% versus 38.8%; P = 0.001) than patients without complications. This was not evident in the RR patients, where complications did not lead to a significantly higher unplanned surgery rate (58.9% versus 35.2%; P = 0.086).

Conclusions:

Most of the secondary surgeries were planned for cancer patients. However, complications led to a significantly higher rate of unplanned secondary surgery. Approximately 1 in 4 RR patients received unplanned secondary surgery, which may be driven by the desire to achieve an optimal aesthetic outcome.

Factors associated with completion of patient surveys 1 year after bariatric surgery

BACKGROUND

Patient-reported outcomes (PRO) obtained from follow-up survey data are essential to understanding the longitudinal effects of bariatric surgery. However, capturing data among patients who are well beyond the recovery period of surgery remains a challenge, and little is known about what factors may influence follow-up rates for PRO.

OBJECTIVES

To assess the effect of hospital practices and surgical outcomes on patient survey completion rates at 1 year after bariatric surgery.

SETTING

Prospective, statewide, bariatric-specific clinical registry.

METHODS

Patients at hospitals participating in the Michigan Bariatric Surgery Collaborative are surveyed annually to obtain information on weight loss, medication use, satisfaction, body image, and quality of life following bariatric surgery. Hospital program coordinators were surveyed in June 2017 about their practices for ensuring survey completion among their patients. Hospitals were ranked based on 1-year patient survey completion rates between 2011 and 2015. Multivariable regression analyses were used to identify associations between hospital practices, as well as 30-day outcomes, on hospital survey completion rankings.

RESULTS

Overall, patient survey completion rates at 1 year improved from 2011 (33.9% ± 14.5%) to 2015 (51.0% ± 13.0%), although there was wide variability between hospitals (21.1% versus 77.3% in 2015). Hospitals in the bottom quartile for survey completion rates had higher adjusted rates of 30-day severe complications (2.6% versus 1.7%, respectively; P = .0481), readmissions (5.0% versus 3.9%, respectively; P = .0157), and reoperations (1.5% versus .7%, respectively; P = .0216) than those in the top quartile. While most hospital practices did not significantly impact survey completion at 1 year, physically handing out surveys during clinic visits was independently associated with higher completion rates (odds ratio, 13.60; 95% confidence interval, 1.99-93.03; P =.0078).

CONCLUSIONS

Hospitals vary considerably in completion rates of patient surveys at 1 year after bariatric surgery, and lower rates were associated with hospitals that had higher complication rates. Hospitals with the highest completion rates were more likely to physically hand surveys to patients during clinic visits. Given the value of PRO on longitudinal outcomes of bariatric surgery, improving data collection across multiple hospital systems is imperative.

Management of early breast cancer during the COVID-19 pandemic in Brazil

PURPOSE

The COVID-19 pandemic has impacted early breast cancer (EBC) treatment worldwide. This study analyzed how Brazilian breast specialists are managing EBC.

METHODS

An electronic survey was conducted with members of the Brazilian Society of Breast Cancer Specialists (SBM) between April 30 and May 11, 2020. Bivariate analysis was used to describe changes in how specialists managed EBC at the beginning and during the pandemic, according to breast cancer subtype and oncoplastic surgery.

RESULTS

The response rate was 34.4% (503/1462 specialists). Most of the respondents (324; 64.4%) lived in a state capital city, were board-certified as breast specialists (395; 78.5%) and either worked in an academic institute or one associated with breast cancer treatment (390; 77.5%). The best response rate was from the southeast of the country (240; 47.7%) followed by the northeast (128; 25.4%). At the beginning of the pandemic, 43% changed their management approach. As the outbreak progressed, this proportion increased to 69.8% (p < 0.001). The southeast of the country (p = 0.005) and the state capital cities (p < 0.001) were associated with changes at the beginning of the pandemic, while being female (p = 0.001) was associated with changes during the pandemic. For hormone receptor-positive tumors with the best prognosis (Ki-67 < 20%), 47.9% and 17.7% of specialists would recommend neoadjuvant endocrine therapy for postmenopausal and premenopausal women, respectively. For tumors with poorer prognosis (Ki-67 > 30%), 34% and 10.9% would recommend it for postmenopausal and premenopausal women, respectively. Menopausal status significantly affected whether the specialists changed their approach (p < 0.00001). For tumors ≥ 1.0 cm, 42.9% of respondents would recommend neoadjuvant systemic therapy for triple-negative tumors and 39.6% for HER2 + tumors. Overall, 63.4% would recommend immediate total breast reconstruction, while only 3.4% would recommend autologous reconstruction. In breast-conserving surgery, 75% would recommend partial breast reconstruction; however, 54.1% would contraindicate mammoplasty. Furthermore, 84.9% of respondents would not recommend prophylactic mastectomy in cases of BRCA mutation.

CONCLUSIONS

Important changes occurred in EBC treatment, particularly for hormone receptor-positive tumors, as the outbreak progressed in each region. Systematic monitoring could assure appropriate breast cancer treatment, mitigating the impact of the pandemic.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical Outcomes of Implant-based Breast Reconstruction Using TiLoop Bra Mesh Combined With Pectoralis Major Disconnection

OBJECTIVE

This study aimed to compare breast symmetry and patient satisfaction with breast appearance between implant-based breast reconstruction using TiLoop Bra mesh combined with pectoralis major disconnection (IMR) and conventional implant reconstruction (IR), and to analyze differences in complications.

METHODS

This retrospective study included 59 patients administered IMR or IR in 2016 to 2018. Three-dimensional scanning was performed to objectively evaluate breast symmetry. The BREAST-Q scale was used to survey satisfaction with breast appearance, social psychosocial health, physical health, and sexual well-being.

RESULTS

There were no significant differences in age, TNM stage, and chemotherapy between the 2 groups (all P > 0.05). In 3-dimensional scanning data, patients who underwent IMR had better bilateral breast symmetry compared with those administered IR (all P < 0.001). Based on the BREAST-Q survey, the satisfaction rate was significantly higher for IMR compared with IR (P = 0.0368), whereas psychosocial health, physical health, and sexual well-being showed no significant differences between the 2 groups (all P > 0.05). The IMR model showed no obvious advantages in common complications, including hematoma, incision site infection, skin flap necrosis, and prosthesis exposure and rupture compared with IR; loss of skin and nipple sensations was evident in both groups. The IMR model was associated with reduced incidence of fibrous capsule contracture compared with IR (0% vs 18.75%, P = 0.0267). The incidence rates of pectoralis major disconnection syndrome after IMR and IR were 18.50% and 0%, respectively (P = 0.0161).

CONCLUSIONS

Patients administered IMR have better breast symmetry and greater satisfaction with breast appearance compared with those treated by IR; however, IMR has unique complications, including pectoralis major disconnection syndrome.

Patient-Reported Satisfaction after Prophylactic Operations of the Breast

Background

Prophylactic mastectomies in carriers of mutations in BRCA1 or BRCA2 are becoming increasingly more accepted. We investigated the outcome after prophylactic mastectomy, especially regarding satisfaction with the procedure, in a monocenter study.

Methods

BRCA1/2 mutation carriers and non-carriers with elevated pedigree-based cancer risk were followed prospectively in a structured surveillance program between 2000 and 2017. A retrospective telephone survey was conducted among all patients with documented prophylactic mastectomy. Complications and satisfaction with the decision for prophylactic mastectomy were recorded.

Results

39 patients who opted for a prophylactic mastectomy (38 BRCA1/2 mutation carriers and 1 non-carrier) were interviewed. Mostly nipple-sparing mastectomy with reconstruction was performed (87%). Half of the patients (22/39; 56.4%) had a history of unilateral breast cancer. The median time since prophylactic mastectomy was 5.6 years. While 61.5% did not report any complications, flap loss was seen in 15% (3/20) and moderate limitations in everyday life were present in 20% (7/35). An improvement in quality of life was noticed by 82% after prophylactic mastectomy and no patient expressed regret with regard to the decision.

Conclusions

Prophylactic mastectomy is a procedure with risk for long-term complications in some cases. Our results confirm high satisfaction with the decision and improved quality of life.