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Zong AM, Leibl KE, Weichman KE. Effects of Elective Revision after Breast Reconstruction on Patient-Reported Outcomes. J Reconstr Microsurg 2024. [PMID: 38782031 DOI: 10.1055/a-2332-0359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life. METHODS A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015 to 2021. Patients were included if they had completed BREAST-Q preoperatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed. RESULTS Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and body mass index (BMI) was 29.55 ± 5.63 kg/m2. Forty-eight patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or preoperative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared with after initial reconstruction alone (p = 0.04). Autologous reconstruction patients who had at least one revision had significantly higher satisfaction with outcome (p = 0.02) and satisfaction with surgeon (p = 0.05) in the 2-year follow-up period compared with patients who had no revisions. CONCLUSION Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.
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Affiliation(s)
- Amanda M Zong
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Kayla E Leibl
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Katie E Weichman
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, New York
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Honig SE, Habarth-Morales TE, Davis HD, Niu EF, Amro C, Broach RB, Serletti JM, Azoury SC. Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases. J Reconstr Microsurg 2024. [PMID: 38866038 DOI: 10.1055/s-0044-1787728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
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.
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Affiliation(s)
- Stephanie E Honig
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Theodore E Habarth-Morales
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Harrison D Davis
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Ellen F Niu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Chris Amro
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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3
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Francis SD, Kang AW, Maheta BJ, Sangalang BR, Salingaros S, Wu RT, Nazerali RS. National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches. J Plast Reconstr Aesthet Surg 2024; 95:127-133. [PMID: 38905789 DOI: 10.1016/j.bjps.2024.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/22/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates. METHOD Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p < 0.05. RESULTS Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p < 0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06 ± 0.32) and two-stage IBR (0.05 ± 0.32, p = 0.95). Immediate IBR demonstrated 12% (OR = 0.88, p = 0.0022) and 70% (OR = 0.30, p < 0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66 % lower odds of requiring only fat grafting than ABR (OR = 0.34, p < 0.001). CONCLUSION ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.
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Affiliation(s)
| | | | - Bhagvat J Maheta
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Brian R Sangalang
- University of California Riverside School of Medicine, Riverside, CA, USA
| | | | - Robin T Wu
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rahim S Nazerali
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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4
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Fijany AJ, Chaker SC, Holan CA, Hung YC, Montorfano L, Mubang RN, Olsson SE, Bishay AE, Vijayasekaran A, Martinez-Jorge J, Slater ED, Lineaweaver WC. Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter? Aesthet Surg J 2024; 44:612-622. [PMID: 38284419 DOI: 10.1093/asj/sjad385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/30/2024] Open
Abstract
The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement. LEVEL OF EVIDENCE: 3
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Gombaut C, Bakovic M, Tran HV, Goldman J, Wallace S, Ranganath B. Simultaneous Free Flap Breast Reconstruction Combined With Contralateral Mastopexy or Breast Reduction: A Propensity-Matched National Surgical Quality Improvement Program Study on Postoperative Outcomes. Ann Plast Surg 2024; 92:S234-S240. [PMID: 38556680 DOI: 10.1097/sap.0000000000003816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can increase patient satisfaction and minimize the need for a second procedure. Surgeon concerns of increases in operative time, postoperative complications, and final breast symmetry may decrease the likelihood of these procedures being done concurrently. This study analyzed postoperative outcomes of simultaneous contralateral mastopexy or breast reduction with free flap breast reconstruction. METHODS By using the American College of Surgeons National Surgical Quality Improvement Program database (2010-2020), we analyzed 2 patient cohorts undergoing (A) free flap breast reconstruction only and (B) free flap breast reconstruction combined with contralateral mastopexy or breast reduction. The preoperative variables assessed included demographic data, comorbidities, and perioperative data. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 602 free flap breast reconstruction patients and 621 with concurrent contralateral operation patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. RESULTS We identified 11,308 cases who underwent microsurgical free flap breast reconstruction from the American College of Surgeons National Surgical Quality Improvement Program database from the beginning of 2010 to the end of 2020. A total of 621 patients underwent a free flap breast reconstruction combined with contralateral mastopexy or breast reduction. After propensity score matching, there were no significant differences in patient characteristics, perioperative variables or postoperative medical complications between the 2 cohorts. CONCLUSIONS Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can be performed safely and effectively without an increase in postoperative complication rates. This can improve surgeon competence in offering this combination of procedures as an option to breast cancer survivors, leading to better patient outcomes in terms of symmetrical and aesthetically pleasing results, reduced costs, and elimination of the need for a second operation.
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Affiliation(s)
- Cindy Gombaut
- From the George Washington School of Medicine and Health Sciences, Washington, DC
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Bucher F, Vogt PM, Krezdorn N, Dastagir K. Free Tissue Transfer for Reconstruction After Bilateral Skin Sparing Mastectomy-A Systematic Review. Ann Plast Surg 2024; 92:469-473. [PMID: 38470816 DOI: 10.1097/sap.0000000000003828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
BACKGROUND Breast cancer is the most commonly diagnosed malignant neoplasia in females worldwide. Overall survival and patients' choice for bilateral mastectomy have increased. It is therefore important to offer breast reconstructive procedures to improve patient quality of life and self-esteem. The aim of this systematic literature review is to quantify the outcome and sustainability of bilateral breast reconstruction using autologous, vascularized free tissue transfer. METHODS A systematic literature review of PubMed, Cochrane, and the Web of Science databases was performed. A total of 5879 citations were identified, and 12 studies met the inclusion criteria. RESULTS A total of 1316 patients were included, with a mean age of 47.2 years. Overall, 32.5% of patients experienced a complication after breast reconstruction. If reported, 7.45% of patients experienced major complications, while 20.7% had minor complications.The following flaps were used for breast reconstruction, in order of reducing frequency: DIEP (45.45%), TRAM (22.73%), SIEA (9.09%), SGAP (9.09%), TUG (4.55%), TMG (4.55%), and LD/MLD (4.55%). CONCLUSIONS Current studies indicate that bilateral breast reconstruction using autologous, vascularized free tissue transfer is a safe procedure for postmastectomy reconstruction and offers stable long-term results. This is particularly in comparison to implant-based breast reconstruction.
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Affiliation(s)
- Florian Bucher
- From the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
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7
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Fijany AJ, Chaker SC, Hung YC, Zago I, Friedlich N, Olsson SE, Holan CA, Montorfano L, Mubang RN, Givechian KB, Boctor MJ, Pekarev M, Martinez-Jorge J, Slater ED. Complication Profiles of Smooth vs Textured Tissue Expanders in Breast Reconstruction: A Systematic Review and Meta-Analysis. Aesthet Surg J 2024; 44:383-393. [PMID: 37757895 DOI: 10.1093/asj/sjad319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/19/2023] [Accepted: 09/23/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders. OBJECTIVES We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs). METHODS A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis. RESULTS A total of 5 articles met inclusion criteria, representing 1709 patients in the STE cohort and 1716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days.Our meta-analysis found no differences in all surgical outcomes except for explantation risk. STE use was associated with increased odds of explantation by over 50% compared to TTE use (odds ratio = 1.53; 95% CI = 1.15 to 2.02; P = .003). CONCLUSIONS Overall, STEs and TTEs had similar complication profiles. However, STEs had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single case of BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL. LEVEL OF EVIDENCE: 4
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Barnes LL, Lem M, Patterson A, Segal R, Holland MC, Lentz R, Sbitany H, Piper M. Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction. Plast Reconstr Surg 2024; 153:553-566. [PMID: 37166039 DOI: 10.1097/prs.0000000000010621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase. METHODS The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point. RESULTS A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively. CONCLUSIONS Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Laura L Barnes
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Melinda Lem
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Anne Patterson
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | | | - Michael C Holland
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Rachel Lentz
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
- Division of Plastic and Reconstructive Surgery, University of Washington
| | - Hani Sbitany
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai
| | - Merisa Piper
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
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Xu J, Zhu XM, Ng KC, Alhefzi MM, Avram R, Coroneos CJ. Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis. J Reconstr Microsurg 2024. [PMID: 38267008 DOI: 10.1055/a-2253-6099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
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.
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Affiliation(s)
- Joshua Xu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Xi Ming Zhu
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kimberly C Ng
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Ronen Avram
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Christopher J Coroneos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Shah V, Soh CL, Chhatwal K, Kucharczak J, Airapetyan AA, Avavde D, Torabi S, Mackenzie A, Miller G, Vardanyan R, Arjomandi Rad A, Malawana J. Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges. Minerva Surg 2024; 79:73-81. [PMID: 38381032 DOI: 10.23736/s2724-5691.23.10111-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
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.
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Affiliation(s)
- Viraj Shah
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Chien L Soh
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Karanjot Chhatwal
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | | | - Arkady A Airapetyan
- Department of Research and Academia, National Institute of Health, Yerevan, Armenia
| | - Dani Avavde
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Saeed Torabi
- Department of Anesthesia, University Hospital Cologne, Cologne, Germany
| | - Alexandra Mackenzie
- Department of Emergency Surgery, Chelsea and Westminster Hospital NHS Trust, London, UK
| | - George Miller
- Research Unit, The Healthcare Leadership Academy, London, UK
- Center for Digital Health and Education Research (CoDHER), University of Central Lancashire Medical School, Preston, UK
| | - Robert Vardanyan
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK -
| | - Arian Arjomandi Rad
- Research Unit, The Healthcare Leadership Academy, London, UK
- Center for Digital Health and Education Research (CoDHER), University of Central Lancashire Medical School, Preston, UK
- Clinical Academic Graduate School, The University of Oxford, Oxford, UK
| | - Johann Malawana
- Research Unit, The Healthcare Leadership Academy, London, UK
- Center for Digital Health and Education Research (CoDHER), University of Central Lancashire Medical School, Preston, UK
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Wong AWJ, Kuo WL, Cheong DCF, Tsai HP, Kao SW, Chen CF, Huang JJ. Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study. Int J Surg 2024; 110:645-653. [PMID: 38000051 PMCID: PMC10871604 DOI: 10.1097/js9.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/22/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies. METHODS There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy. RESULTS The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups. CONCLUSION With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.
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Affiliation(s)
- Allen Wei-Jiat Wong
- Departments of Plastic and Reconstructive Surgery
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - Wen-Ling Kuo
- General Surgery
- Center for Tissue Engineering
- College of Medicine, Chang Gung University, Taoyuan
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - David Chon-Fok Cheong
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Hsiu-Pei Tsai
- General Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Shu-Wei Kao
- Departments of Plastic and Reconstructive Surgery
| | - Chia-Fang Chen
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Jung-Ju Huang
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
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Mahrhofer M, Schwaiger K, Fierdel F, Russe E, Hitzl W, Schoeller T, Wechselberger G, Weitgasser L. Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale. Aesthet Surg J 2024; 44:NP168-NP176. [PMID: 37738426 DOI: 10.1093/asj/sjad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 09/24/2023] Open
Abstract
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
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Yanaga H, Koga M, Nishina H, Tanaka Y, Yanaga K. Successful fat-only whole breast reconstruction using cultured mature adipocytes and conditioned medium containing MCP-1. Sci Rep 2023; 13:18998. [PMID: 37923755 PMCID: PMC10624668 DOI: 10.1038/s41598-023-45169-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023] Open
Abstract
A mastectomy is a curative treatment for breast cancer. It causes breast and soft tissue deficits, resulting in a chest with poor vascularity. Autologous tissue breast reconstruction is commonly associated with donor site morbidity. Breast implants are another reconstruction alternative, but they are associated with infection, rupture, and the need for replacement. Autologous aspirated fat grafting has appeared as an ideal breast reconstruction method, but low graft viability and high resorption remain as the main shortcomings. We developed a novel method for fat-only grafts using cultured mature adipocytes (CMAs) mixed with their condition medium. Twenty-five mastectomy patients, aged 32-72 years, received a mixed grafting of CMAs, MCP1-containing condition medium, and fat grafts for total breast reconstruction. In follow-up periods of 24-75 months, MRI analysis showed full thickness fat-engraftment. The cell proliferation marker Ki67 was negative in post-transplant biopsy specimens from all patients. Aesthetic full breast morphology was achieved, patient satisfaction was evaluated 1 year and 3-6 years after surgery. All grafts were confirmed safe, demonstrating high reliability and long-term sustainability.
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Affiliation(s)
- Hiroko Yanaga
- Yanaga Clinic and Tissue Culture Laboratory, 1-2-12 Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan.
| | - Mika Koga
- Yanaga Clinic and Tissue Culture Laboratory, 1-2-12 Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan
| | - Hiromichi Nishina
- Yanaga Clinic and Tissue Culture Laboratory, 1-2-12 Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan
| | - Yoshio Tanaka
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kida-gun, Kagawa, 761-0793, Japan
| | - Katsu Yanaga
- Yanaga Clinic and Tissue Culture Laboratory, 1-2-12 Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan
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14
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Hassan AM, Biaggi-Ondina A, Asaad M, Morris N, Liu J, Selber JC, Butler CE. Artificial Intelligence Modeling to Predict Periprosthetic Infection and Explantation following Implant-Based Reconstruction. Plast Reconstr Surg 2023; 152:929-938. [PMID: 36862958 DOI: 10.1097/prs.0000000000010345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Despite improvements in prosthesis design and surgical techniques, periprosthetic infection and explantation rates following implant-based reconstruction (IBR) remain relatively high. Artificial intelligence is an extremely powerful predictive tool that involves machine learning (ML) algorithms. We sought to develop, validate, and evaluate the use of ML algorithms to predict complications of IBR. METHODS A comprehensive review of patients who underwent IBR from January of 2018 to December of 2019 was conducted. Nine supervised ML algorithms were developed to predict periprosthetic infection and explantation. Patient data were randomly divided into training (80%) and testing (20%) sets. RESULTS The authors identified 481 patients (694 reconstructions) with a mean ± SD age of 50.0 ± 11.5 years, mean ± SD body mass index of 26.7 ± 4.8 kg/m 2 , and median follow-up time of 16.1 months (range, 11.9 to 3.2 months). Periprosthetic infection developed in 113 of the reconstructions (16.3%), and explantation was required with 82 (11.8%) of them. ML demonstrated good discriminatory performance in predicting periprosthetic infection and explantation (area under the receiver operating characteristic curve, 0.73 and 0.78, respectively), and identified nine and 12 significant predictors of periprosthetic infection and explantation, respectively. CONCLUSIONS ML algorithms trained using readily available perioperative clinical data accurately predict periprosthetic infection and explantation following IBR. The authors' findings support incorporating ML models into perioperative assessment of patients undergoing IBR to provide data-driven, patient-specific risk assessment to aid individualized patient counseling, shared decision-making, and presurgical optimization.
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Affiliation(s)
- Abbas M Hassan
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
| | - Andrea Biaggi-Ondina
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
| | - Malke Asaad
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
| | - Natalie Morris
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
| | - Jun Liu
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
| | - Jesse C Selber
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
| | - Charles E Butler
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center
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15
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Chow AL, Luthringer MM, Van Kouwenberg EA, Agag RL, Sinkin JC. Same-Day Mastectomy and Immediate Prosthetic Breast Reconstruction: A 12-Year National Database Analysis and Early Postoperative Outcomes. Plast Reconstr Surg 2023; 152:578e-589e. [PMID: 36862949 DOI: 10.1097/prs.0000000000010348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Coronavirus disease of 2019 and rising health care costs have incentivized shorter hospital stays after mastectomies with immediate prosthetic reconstruction. The purpose of this study was to compare postoperative outcomes following same-day and non-same-day mastectomy with immediate prosthetic reconstruction. METHODS A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2019 was performed. Patients who underwent mastectomies and immediate reconstruction with tissue expanders or implants were selected and grouped based on length of stay. Univariate analysis and multivariate regression were performed to compare 30-day postoperative outcomes between length-of-stay groups. RESULTS A total of 45,451 patients were included: 1508 had same-day surgery (SDS) and 43,942 were admitted for 1 or more night (non-SDS). There was no significant difference in overall 30-day postoperative complications between SDS and non-SDS following immediate prosthetic reconstruction. SDS was not a predictor of complications (OR, 1.1; P = 0.346), whereas tissue expander reconstruction decreased odds of morbidity compared with direct-to-implant reconstruction (OR, 0.77; P < 0.001). Among patients who had SDS, smoking was significantly associated with early complications on multivariate analysis (OR, 1.85; P = 0.010). CONCLUSIONS This study provides an up-to-date assessment of the safety of mastectomies with immediate prosthetic breast reconstruction that captures recent advancements. Postoperative complication rates are similar between same-day discharge and at least 1-night stay, suggesting that same-day procedures may be safe for appropriately selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Amanda L Chow
- From the Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School
| | - Margaret M Luthringer
- From the Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School
| | - Emily A Van Kouwenberg
- Division of Plastic and Reconstructive Surgery, Rutgers Robert Wood Johnson Medical School
| | - Richard L Agag
- Division of Plastic and Reconstructive Surgery, Rutgers Robert Wood Johnson Medical School
| | - Jeremy C Sinkin
- Division of Plastic and Reconstructive Surgery, Rutgers Robert Wood Johnson Medical School
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16
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Martineau J, Scampa M, Viscardi JA, Giordano S, Kalbermatten DF, Oranges CM. Inferior gluteal artery perforator (IGAP) flap in autologous breast reconstruction: A proportional meta-analysis of surgical outcomes. J Plast Reconstr Aesthet Surg 2023; 84:147-156. [PMID: 37329748 DOI: 10.1016/j.bjps.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/30/2023] [Accepted: 05/15/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The inferior gluteal artery perforator (IGAP) flap is an alternative technique for autologous breast reconstruction. In contrast to other commonly used techniques, there is a paucity of literature on the safety and efficacy of the IGAP flap. The aim of this study was to perform a systematic literature review and meta-analysis of postoperative outcomes and complications associated with the IGAP in autologous breast reconstructions to validate its safety. METHODS A systematic review of literature was performed following PRISMA guidelines. Articles reporting post-operative outcomes of IGAP flaps in autologous breast reconstruction were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions with 95% confidence intervals (CIs). RESULTS Seven studies met the inclusion criteria, which represented a total of 239 IGAP flaps in 181 patients The total flap loss rate was 3% (95% CI 0-8%), partial flap loss rate was 2% (95% CI 0-4%), haematoma rate was 3% (95% CI 0-7%), overall donor-site complication rate was 15% (95% CI 5-28%), overall recipient-site complication rate was 24% (95% CI 15-34%), and the overall complication rate was 40% (95% CI 23-58%). CONCLUSIONS This meta-analysis provides comprehensive knowledge on the safety and efficacy of the IGAP flap in autologous breast reconstruction. It evidences the IGAP flap in autologous breast reconstruction's overall safety and validates its role as an effective option in breast reconstruction.
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Affiliation(s)
- Jérôme Martineau
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Matteo Scampa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Juan A Viscardi
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Salvatore Giordano
- Department of General and Plastic Surgery, Turku University Hospital, University of Turku, 20521 Turku, Finland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Carlo M Oranges
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland.
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17
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Wederfoort JLM, Voeten N, Smeins NNPM, Hommes JE, Essers BAB, van der Hulst RRWJ, Piatkowski A. A Dutch randomized controlled study shows autologous fat transfer with pre-expansion is more cost-effective in the long term than implants. J Plast Reconstr Aesthet Surg 2023; 84:398-412. [PMID: 37399660 DOI: 10.1016/j.bjps.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/31/2023] [Accepted: 06/03/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND One in seven women will develop breast cancer, making it the most common female cancer worldwide. Consequently, breast cancer-related treatment, including breast reconstruction, impacts societal costs. Autologous fat transfer (AFT) is a relatively new breast reconstruction technique; however, several surgeries are necessary. This study investigates if AFT with pre-expansion is more cost-effective than implant-based reconstruction (IBR). METHODS Seven centers assigned patients randomly from 2015 to 2021 to evaluate costs and EQ-5D-5L quality-adjusted life years (QALY) of AFT vs. IBR at 12 months postoperative. Costs were calculated, including direct costs related to treatment and PROductivity and DISease Questionnaire, to estimate productivity loss (indirect costs). Sensitivity analyses were performed for 10- and 30 years to estimate costs for patients replacing or explanting their breast implants over time. RESULTS A total of 152 women, of which 91 received AFT (mean age 49.3) and 80 IBR (mean age 49.1). The mean EQ-5D-5L QALY in the AFT group was 0.83, compared with the IBR group of 0.79. Total costs for AFT at 12 months postoperative were higher than IBR (incremental cost: €6763.59). Sensitivity analyses for 10- and 30-year scenarios showed mean incremental costs of respectively €2586.56 and €680.22. CONCLUSION Mean EQ-5D-5L QALY and costs were higher for AFT over the first year after reconstruction. However, these costs were low; therefore, AFT was estimated to be more cost-effective over the 10- and 30-year period since no additional surgeries are necessary for this group. Larger cohorts are required to confirm AFT is more cost-effective in the long term.
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Affiliation(s)
- J L M Wederfoort
- Department of Plastic-, Reconstructive-, and Hand Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | - N Voeten
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - N N P M Smeins
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - J E Hommes
- Department of Plastic-, Reconstructive-, and Hand Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - B A B Essers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, the Netherlands
| | - R R W J van der Hulst
- Department of Plastic-, Reconstructive-, and Hand Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - A Piatkowski
- Department of Plastic-, Reconstructive-, and Hand Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Plastic-, Reconstructive-, and Hand Surgery, Viecuri Medical Center, Venlo, the Netherlands
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18
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Hassan AM, Biaggi AP, Asaad M, Andejani DF, Liu J, Offodile Nd AC, Selber JC, Butler CE. Development and Assessment of Machine Learning Models for Individualized Risk Assessment of Mastectomy Skin Flap Necrosis. Ann Surg 2023; 278:e123-e130. [PMID: 35129476 DOI: 10.1097/sla.0000000000005386] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop, validate, and evaluate ML algorithms for predicting MSFN. BACKGROUND MSFN is a devastating complication that causes significant distress to patients and physicians by prolonging recovery time, compromising surgical outcomes, and delaying adjuvant therapy. METHODS We conducted comprehensive review of all consecutive patients who underwent mastectomy and immediate implant-based reconstruction from January 2018 to December 2019. Nine supervised ML algorithms were developed to predict MSFN. Patient data were partitioned into training (80%) and testing (20%) sets. RESULTS We identified 694 mastectomies with immediate implant-based reconstruction in 481 patients. The patients had a mean age of 50 ± 11.5 years, years, a mean body mass index of 26.7 ± 4.8 kg/m 2 , and a median follow-up time of 16.1 (range, 11.9-23.2) months. MSFN developed in 6% (n = 40) of patients. The random forest model demonstrated the best discriminatory performance (area under curve, 0.70), achieved a mean accuracy of 89% (95% confidence interval, 83-94), and identified 10 predictors of MSFN. Decision curve analysis demonstrated that ML models have a superior net benefit regardless of the probability threshold. Higher body mass index, older age, hypertension, subpectoral device placement, nipple-sparing mastectomy, axillary nodal dissection, and no acellular dermal matrix use were all independently associated with a higher risk of MSFN. CONCLUSIONS ML algorithms trained on readily available perioperative clinical data can accurately predict the occurrence of MSFN and aid in individualized patient counseling, preoperative optimization, and surgical planning to reduce the risk of this devastating complication.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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19
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Barnes LL, Patterson A, Lem M, Holland MC, Lentz R, Sbitany H, Piper ML. Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy. Ann Plast Surg 2023; 90:432-436. [PMID: 37146309 DOI: 10.1097/sap.0000000000003539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. METHODS We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. RESULTS One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. CONCLUSIONS Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.
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Affiliation(s)
- Laura L Barnes
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | - Anne Patterson
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | | | - Michael C Holland
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
| | | | - Hani Sbitany
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Merisa L Piper
- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco
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20
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Abdou SA, Charipova K, Song DH. Modern Approaches to Pedicled Latissimus Dorsi Flap Breast Reconstruction with Immediate Fat Transfer. Clin Plast Surg 2023; 50:259-265. [PMID: 36813404 DOI: 10.1016/j.cps.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The latissimus dorsi flap with immediate fat transfer is a viable option for fully autologous breast reconstruction in patients who are not candidates for free flap reconstruction. Technical modifications described in this article allow for high-volume and efficient fat grafting at the time of reconstruction to augment the flap and mitigate complications associated with the use of an implant.
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Affiliation(s)
- Salma A Abdou
- Department of Plastic Surgery, MedStar Plastic and Reconstructive Surgery, Washington, DC, USA
| | - Karina Charipova
- Department of Plastic Surgery, MedStar Plastic and Reconstructive Surgery, Washington, DC, USA
| | - David H Song
- Department of Plastic Surgery, MedStar Plastic and Reconstructive Surgery, Washington, DC, USA.
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21
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Schoberleitner I, Augustin A, Egle D, Brunner C, Amort B, Zelger B, Brunner A, Wolfram D. Is It All about Surface Topography? An Intra-Individual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction. J Clin Med 2023; 12:jcm12041315. [PMID: 36835850 PMCID: PMC9967160 DOI: 10.3390/jcm12041315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
The most common long-term complication of silicone breast implants (SMI) remains capsular fibrosis. The etiology of this exaggerated implant encapsulation is multifactorial but primarily induced by the host response towards the foreign material silicone. Identified risk factors include specific implant topographies. Of note, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has only been observed in response to textured surface implants. We hypothesize that reduction of SMI surface roughness causes less host response and, hence, better cosmetic outcomes with fewer complications for the patient. A total of 7 patients received the routinely used CPX®4 breast expander (~60 µM Ra) and the novel SmoothSilk® (~4 µM Ra), fixed prepectoral with a titanized mesh pocket and randomized to the left or right breast after bilateral prophylactic NSME (nipple-sparing mastectomy). We aimed to compare the postoperative outcome regarding capsule thickness, seroma formation, rippling, implant dislocation as well as comfortability and practicability. Our analysis shows that surface roughness is an influential parameter in controlling fibrotic implant encapsulation. Compared intra-individually for the first time in patients, our data confirm an improved biocompatibility with minor capsule formation around SmoothSilk® implants with an average shell roughness of 4 µM and in addition an amplification of host response by titanized implant pockets.
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Affiliation(s)
- Ines Schoberleitner
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Angela Augustin
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Daniel Egle
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Christine Brunner
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Birgit Amort
- Department of Radiology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Bettina Zelger
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Müllerstraße 44, A-6020 Innsbruck, Austria
| | - Andrea Brunner
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Müllerstraße 44, A-6020 Innsbruck, Austria
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-512-504-82050
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22
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Kim EK, Woo SH, Kim DY, Choi EJ, Min K, Lee TJ, Eom JS, Han HH. Loss to follow-up after direct-to-implant breast reconstruction. J Plast Surg Hand Surg 2023; 57:64-70. [PMID: 35012419 DOI: 10.1080/2000656x.2021.1981350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Loss to follow-up is inevitable in retrospective cohort studies, and patients are lost to follow-up after direct-to-implant reconstruction despite annual follow-up recommendation. We analyzed more than 500 patients to analyze the rate of loss to follow-up to plastic surgery and to investigate the factors affecting it. A retrospective review of patients who underwent direct-to-implant reconstruction between July 2008 and August 2016 was performed. Loss to follow-up to plastic surgery was defined as a difference of ≥24 months between the total and plastic surgery follow-up. The rate of loss to follow-up and associated factors including patients' demographics, surgery-related variables, oncological data, and early and late complications were analyzed. Of 631 patients who underwent direct-to-implant reconstruction, 551 patients continued visiting the hospital for breast cancer-related treatment. Of the 527 patients who were eligible for the study, 157 patients (29.8%) were lost to plastic surgery follow-up. Surgery-related variables, early complications, cancer stage, and adjuvant therapies were not significantly different. Younger age was significantly associated with loss to follow-up in univariate analysis. However, logistic regression revealed that a long total follow-up period, distant metastasis, and absence of late elective complications were significant factors contributing to follow-up loss. Late elective complications such as malposition, capsular contracture, and mastectomy flap thinning were more common in the follow-up group (48%) than in the loss to follow-up group (22%). Follow-up loss after direct-to-implant reconstruction was not associated with specific demographic or surgery-related variables, and postoperative courses significantly affected the loss to follow-up.
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Affiliation(s)
- Eun Key Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo Hyun Woo
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do Yeon Kim
- Plastic Surgery, Woori Plastic Surgery Clinic, Seoul, Republic of Korea
| | - Eun Jeong Choi
- Plastic Surgery, The Way Plastic Surgery Clinic, Seoul, Republic of Korea
| | - Kyunghyun Min
- Hanyang University Seoul Hospital, Hanyang University, Seoul, Republic of Korea
| | - Taik Jong Lee
- Uijeongbu Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Jin Sup Eom
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyun Ho Han
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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23
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Silva J, Carvalho F, Marques M. Direct-to-Implant Subcutaneous Breast Reconstruction: A Systematic Review of Complications and Patient's Quality of Life. Aesthetic Plast Surg 2023; 47:92-105. [PMID: 36097081 DOI: 10.1007/s00266-022-03068-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of direct-to-implant subcutaneous breast reconstruction has increased over the last years. The goal of this systematic review is to deliver an updated review of the safety of this technique and its impact on quality of life. We also compare subcutaneous vs submuscular complications, through meta-analysis. METHODS Literature review through PubMed and Cochrane Library databases were performed by PRISMA criteria. Thirty-nine studies met inclusion criteria for subcutaneous review and 15 studies met inclusion criteria for meta-analysis. All included studies were evaluated for complications and answers to the BREAST-Q. Data were analysed using Microsoft Excel, IBM SPSS, and Cochrane RevMan. RESULTS In 2863 patients and 3988 breasts that undergone direct to implant subcutaneous breast reconstruction, 8,21% had rippling, 5,64% seroma, 1,74% hematoma, 3,40% infection, 3,01% wound dehiscence, 3,93% skin necrosis, 3,34% nipple-areolar-complex (NAC) necrosis, 3,07% capsular contracture, 0,00% animation deformity, and 3,83% an implant removal. Meta-analysis showed a statistically significant decrease in the odds ratio of animation deformity, a but statistically significant higher odds ratio of rippling. Subcutaneous and submuscular reconstructions had similar BREAST-Q scores. CONCLUSIONS Direct-to-implant subcutaneous breast reconstruction does not harm the patient's quality of life, comparatively with submuscular, saving the pectoral muscle from dissection and preventing animation deformity, but increasing the risk of rippling. LEVEL OF EVIDENCE III 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 .
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Affiliation(s)
- José Silva
- Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Francisco Carvalho
- Department of Plastic and Reconstructive Surgery, Centro Hospitalar de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marisa Marques
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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24
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Stefura T, Rusinek J, Wątor J, Zagórski A, Zając M, Libondi G, Wysocki WM, Koziej M. Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients. J Plast Reconstr Aesthet Surg 2023; 77:346-358. [PMID: 36621238 DOI: 10.1016/j.bjps.2022.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/13/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR. METHODS A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research. RESULTS Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010). CONCLUSIONS The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.
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Affiliation(s)
| | - Jakub Rusinek
- Jagiellonian University Medical College, Cracow, Poland
| | - Julia Wątor
- Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | | | - Maciej Zając
- Jagiellonian University Medical College, Cracow, Poland
| | - Guido Libondi
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Cracow, Poland
| | - Wojciech M Wysocki
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Cracow, Poland; Chair of Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.
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25
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Hassan AM, Rajesh A, Asaad M, Jonas NA, Coert JH, Mehrara BJ, Butler CE. Artificial Intelligence and Machine Learning in Prediction of Surgical Complications: Current State, Applications, and Implications. Am Surg 2023; 89:25-30. [PMID: 35562124 PMCID: PMC9653510 DOI: 10.1177/00031348221101488] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Surgical complications pose significant challenges for surgeons, patients, and health care systems as they may result in patient distress, suboptimal outcomes, and higher health care costs. Artificial intelligence (AI)-driven models have revolutionized the field of surgery by accurately identifying patients at high risk of developing surgical complications and by overcoming several limitations associated with traditional statistics-based risk calculators. This article aims to provide an overview of AI in predicting surgical complications using common machine learning and deep learning algorithms and illustrates how this can be utilized to risk stratify patients preoperatively. This can form the basis for discussions on informed consent based on individualized patient factors in the future.
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Affiliation(s)
- Abbas M. Hassan
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aashish Rajesh
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Malke Asaad
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nelson A. Jonas
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J. Henk. Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Babak J. Mehrara
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles E. Butler
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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26
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Sampathkumar U, Bui T, Liu J, Nowroolizarki Z, Bordes MC, Hanson SE, Reece GP, Markey MK, Merchant FA. Objective Analysis of Breast Symmetry in Female Patients Undergoing Breast Reconstruction After Total Mastectomy. Aesthet Surg J Open Forum 2022; 5:ojac090. [PMID: 36654970 PMCID: PMC9836330 DOI: 10.1093/asjof/ojac090] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Satisfaction with the breast aesthetic outcome is an expectation of breast reconstruction surgery, which is an integral part of cancer treatment for many patients. We evaluated postreconstruction breast symmetry in 82 female patients using distance and volume measurements. Objectives Clinical factors, such as reconstruction type (implant-based and autologous reconstruction), laterality, timing of reconstruction (immediate, delayed, and sequential), radiation therapy (RT), and demographic factors (age, BMI, race, and ethnicity), were evaluated as predictors of postoperative symmetry. Matched preoperative and postoperative measurements for a subset of 46 patients were used to assess correlation between preoperative and postoperative symmetry. Methods We used standardized differences between the left and right breasts for the sternal notch to lowest visible point distance and breast volume as metrics for breast, positional symmetry, and volume symmetry, respectively. We performed statistical tests to compare symmetry between subgroups of patients based on reconstruction type, laterality, timing, RT, and demographics. Results Overall, reconstruction type, reconstruction timing, and RT were observed to be factors significantly associated with postoperative symmetry, with implant reconstructions and immediate reconstruction procedures, and no RT showing better postoperative breast volume symmetry. Subgroup analyses, for both reconstruction type and laterality, showed superior volume symmetry for the bilateral implant reconstructions. No correlation was observed between preoperative and postoperative breast symmetry. Demographic factors were not significant predictors of postreconstruction symmetry. Conclusions This comprehensive analysis examines multiple clinical factors in a single study and will help both patients and surgeons make informed decisions about reconstruction options at their disposal. Level of Evidence 3
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Affiliation(s)
| | - Thao Bui
- Department of Engineering Technology, University of Houston, Houston, TX, USA
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhale Nowroolizarki
- Department of Engineering Technology, University of Houston, Houston, TX, USA
| | - Mary Catherine Bordes
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Summer E Hanson
- Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Gregory P Reece
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mia K Markey
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Fatima A Merchant
- Department of Computer Science, University of Houston, Houston, TX, USA
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27
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Portnow LH, Majid S, Maduram A, Chesebro AL, Karimova EJ, Chung SH, Gombos EC. Breast Malignancies After Mastectomy With Autologous or Implant Reconstruction. JOURNAL OF BREAST IMAGING 2022; 4:649-660. [PMID: 38417000 DOI: 10.1093/jbi/wbac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Indexed: 03/01/2024]
Abstract
There are multiple indications for mastectomy for breast cancer, including extent of tumor, inability to achieve negative margins after re-excision, patient preference, or prevention in women with a high lifetime risk of breast cancer. Multiple types of autologous or implant reconstruction options are available for cosmesis. Although rare, breast cancers after mastectomy can occur, and it is important for both surgeons and radiologists to be aware of the associated risk factors, common locations, and classic imaging features of these malignancies. This article reviews the types of mastectomies, reconstruction options, and information about the location, presentation, and prognosis of cancers in the reconstructed breast.
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Affiliation(s)
- Leah H Portnow
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Sana Majid
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Amy Maduram
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Allyson L Chesebro
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - E Jane Karimova
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Stephanie H Chung
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Eva C Gombos
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
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28
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Santosa KB, Wang CS, Hu HM, Mullen CR, Brummett CM, Englesbe MJ, Bicket MC, Myers PL, Waljee JF. Opioid Coprescribing with Sedatives after Implant-Based Breast Reconstruction. Plast Reconstr Surg 2022; 150:1224e-1235e. [PMID: 36103669 PMCID: PMC9712174 DOI: 10.1097/prs.0000000000009726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Skeletal muscle relaxants and benzodiazepines are thought to mitigate against postoperative muscle contraction. The Centers for Disease Control and Prevention and the Food and Drug Administration warn against coprescribing them with opioids because of increased risks of overdose and death. The authors evaluated the frequency of coprescribing of opioids with skeletal muscle relaxants or benzodiazepines after implant-based reconstruction. METHODS The authors examined health care claims to identify women (18 to 64 years old) who underwent implant-based breast reconstruction between January of 2008 and June of 2019 to determine the frequency of coprescribing, factors associated with coprescribing opioids and skeletal muscle relaxants or benzodiazepines, and the impact on opioid refills within 90 days of reconstruction. RESULTS A total of 86.7 percent of women ( n = 7574) who had implant-based breast reconstruction filled an opioid prescription perioperatively. Of these, 27.7 percent of women filled prescriptions for opioids and benzodiazepines, 14.4 percent for opioids and skeletal muscle relaxants, and 2.4 percent for opioids, benzodiazepines, and skeletal muscle relaxants. Risk factors for coprescribing opioids and benzodiazepines included use of acellular dermal matrix, immediate reconstruction, and history of anxiety. Women who filled prescriptions for opioids and skeletal muscle relaxants, opioids and benzodiazepines, and opioids with skeletal muscle relaxants and benzodiazepines were significantly more likely to refill opioid prescriptions, even when controlling for preoperative opioid exposure. CONCLUSIONS Nearly half of women filled an opioid prescription with a benzodiazepine, skeletal muscle relaxant, or both after implant-based breast reconstruction. Coprescribing of opioids with skeletal muscle relaxants may potentiate opioid use after surgery and should be avoided given the risks of sedation. Identifying strategies that avoid sedatives to manage pain after breast reconstruction is critical to mitigate high-risk prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Christine S. Wang
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Hsou-Mei Hu
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN), University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Connor R. Mullen
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Chad M. Brummett
- Professor, Division of Pain Research, Department of Anesthesiology, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Michael J. Englesbe
- Professor of Surgery, Section of Transplantation, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Mark C. Bicket
- Assistant Professor, Division of Pain Research, Department of Anesthesiology University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Paige L. Myers
- Assistant Professor, Section of Plastic Surgery, Department of Surgery, University Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
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29
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Park M, Verma A, Madrigal J, Lee C, Koshki J, Festekjian J, Benharash P. Cost-volume analysis of deep inferior epigastric artery perforator flaps for breast reconstruction in the United States. Surgery 2022; 172:838-843. [PMID: 35710535 DOI: 10.1016/j.surg.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep inferior epigastric artery perforator flaps are increasingly utilized over other autologous methods of breast reconstruction. We evaluated the relationship between annual hospital volume and costs after breast reconstruction with the deep inferior epigastric artery perforator flap. METHODS All female patients undergoing elective implant or autologous tissue breast reconstruction were identified using the 2016-2019 Nationwide Readmission Database. Annual hospital volume of deep inferior epigastric artery perforator reconstructions was tabulated and modeled using restricted cubic splines. Institutions were categorized into high- and low-volume based on the inflection point of the spline between annual caseload and costs. The association between high volume status and costs, complications, length of stay, and 30-day nonelective readmission was assessed using multivariable regression. RESULTS Of an estimated 94,524 patients meeting inclusion criteria, 33,046 (34.6%) underwent deep inferior epigastric artery perforator flap reconstruction. Deep inferior epigastric artery perforator flap utilization increased from 31% in 2016 to 40% in 2019 (P < .001) among inpatient breast reconstructions. High-volume hospitals more frequently performed bilateral reconstructions (43.3 vs 37.7%, P = .021) but had similar rates of concurrent mastectomy (28.7 vs 30.6%, P = .46), relative to low-volume hospitals. The median cost of deep inferior epigastric artery perforator reconstruction was lower ($29,900 [interquartile range: 22,400-37,400] vs $31,600 [interquartile range: 22,500-44,900], P = .036) at high-volume hospitals compared to low-volume. On adjusted analysis, high-volume status was associated a $3,800 (95% confidence interval: -6,200 to -1,400) decrement in hospitalization costs, and reduced odds of perioperative complications (adjusted odd ratio: 0.68 95% confidence interval: 0.54-0.86). High-volume status was not associated with length of stay or likelihood of unplanned readmission. CONCLUSION The present study demonstrated an inverse cost-volume relationship in deep inferior epigastric artery perforator flap breast reconstruction. In line with goals of value-based health care delivery, our findings may inform referral patterns to suitable centers for deep inferior epigastric artery perforator breast reconstruction.
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Affiliation(s)
- Mina Park
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Cory Lee
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jessica Koshki
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jaco Festekjian
- Division of Plastic and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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30
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Yan M, Kuruoglu D, Boughey JC, Manrique OJ, Tran NV, Harless CA, Martinez-Jorge J, Nguyen MDT. Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation. Arch Plast Surg 2022; 49:346-351. [PMID: 35832147 PMCID: PMC9142228 DOI: 10.1055/s-0042-1744405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients.
Methods
A retrospective case–control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality.
Results
From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m
2
(SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%,
p
= 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%,
p
= 0.63), thromboembolism (5% vs. 0%,
p
= 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2],
p
= 0.85).
Conclusion
Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.
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Affiliation(s)
- Maria Yan
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Doga Kuruoglu
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Judy C. Boughey
- Division of Breast Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Oscar J. Manrique
- Division of Plastic Surgery, University of Rochester, Rochester, New York
| | - Nho V. Tran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Christin A. Harless
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jorys Martinez-Jorge
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minh-Doan T. Nguyen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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31
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Wu Young MY, Holoyda KA, Chang DW. Outcomes of progressive tension donor-site closure in abdominal-based autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:2991-2995. [PMID: 35717497 DOI: 10.1016/j.bjps.2022.04.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/18/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of progressive tension sutures (PTSs) for drain-free abdominoplasty closure has been well published in the esthetic literature and found to be effective at reducing abdominal drainage without a worse complication profile. This research aims to evaluate the outcomes of incorporating PTS into donor-site closures for abdominal-based breast reconstruction. METHODS A retrospective chart review was performed evaluating patients at the University of Chicago Medicine, who underwent autologous breast reconstruction and either PTS closure or standard abdominal closure between 2018 and 2021. RESULTS A total of 100 patients were included with 50 patients receiving PTS closure and 50 with traditional abdominal closures. Patient demographics, including age (p = 0.82), body mass index (BMI; p = 0.17), diabetes (p = 1.00), tobacco use (p = 0.15), and chemotherapy (p = 1.00) did not significantly differ. Total drain output over the first 72 h was significantly lower in the PTS group compared with the standard closure (SC) group (p = 0.00005). Mean duration of drain placement was shorter by 2 days in the PTS group, but this did not reach significance (p = 0.08). Overall complication rates were lower in the PTS group (p = 0.03), however, no difference was appreciated when separately assessing for seromas (p = 1.00), hematomas (p = 1.00), wound dehiscence (p = 0.58), or surgical-site infections (p = 1.00). More abdominal revisions were observed in the SC group, however, this did not reach significance (p = 0.15) CONCLUSION: The use of PTS with placement of a single drain is a safe option for donor-site closure, and is a compelling technique for patients undergoing abdominal-based breast reconstruction.
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Affiliation(s)
- Mimi Y Wu Young
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine; Chicago, IL, USA
| | - Kathleen A Holoyda
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine; Chicago, IL, USA; Barton Health Plastic and Reconstructive Surgery, South Lake Tahoe, CA, USA
| | - David W Chang
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine; Chicago, IL, USA.
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32
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Rubenstein RN, Stern CS, Plotsker EL, Haglich K, Tadros AB, Mehrara BJ, Matros E, Nelson JA. Effects of COVID-19 on mastectomy and breast reconstruction rates: A national surgical sample. J Surg Oncol 2022; 126:205-213. [PMID: 35411946 PMCID: PMC9088456 DOI: 10.1002/jso.26889] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
Background The COVID‐19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive surgeries and restricting breast reconstruction options. We examined the effects of COVID‐19 on oncologic breast surgery and reconstruction rates during the first year of the pandemic. Methods Using the National Surgical Quality Improvement Program, we performed an observational examination of female surgical breast cancer patients from 2017 to 2020. We analyzed annual rates of lumpectomy, mastectomy (unilateral/contralateral prophylactic/bilateral prophylactic), and breast reconstruction (alloplastic/autologous) and compared 2019 and 2020 reconstruction cohorts to evaluate the effect of COVID‐19. Results From 2017 to 2020, 175 949 patients underwent lumpectomy or mastectomy with or without reconstruction. From 2019 to 2020, patient volume declined by 10.7%, unilateral mastectomy rates increased (70.5% to 71.9%, p = 0.003), and contralateral prophylactic mastectomy rates decreased. While overall reconstruction rates were unchanged, tissue expander reconstruction increased (64.0% to 68.4%, p < 0.001) and direct‐to‐implant and autologous reconstruction decreased. Outpatient alloplastic reconstruction increased (65.7% to 73.8%, p < 0.0001), and length of hospital stay decreased for all reconstruction patients (p < 0.0001). Conclusions In 2020, there was a nearly 11% decline in breast cancer surgeries, comparable mastectomy and reconstruction rates, increased use of outpatient alloplastic reconstruction, and significantly reduced in‐hospital time across all reconstruction types.
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Affiliation(s)
- Robyn N Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carrie S Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ethan L Plotsker
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn Haglich
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Audree B Tadros
- Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Breast Reconstruction during the COVID-19 Pandemic: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3852. [PMID: 34584831 PMCID: PMC8460228 DOI: 10.1097/gox.0000000000003852] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/16/2021] [Indexed: 12/13/2022]
Abstract
Introduction The COVID-19 pandemic posed unique challenges for breast reconstruction. Many professional organizations initially placed restrictions on breast reconstruction, leading surgeons to conceive innovative protocols for offering breast reconstruction. This study reviewed the current evidence on breast reconstruction during the COVID-19 pandemic to provide guidance for surgeons facing future crises. Methods The MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were searched for studies (1) describing implant and autologous breast reconstruction following mastectomy and (2) occurring during or pertaining to the COVID-19 pandemic. Results Of the 1347 studies identified, 26 were included. Studies discussed type of reconstruction (18, 69%), complications (11, 42%), timing of reconstruction (10, 38%), protocols (10, 38%), COVID-19 screening (7, 27%), and length of hospital stay (7, 27%). The type of reconstruction varied depending on the stage of the pandemic: early on, autologous breast reconstruction was halted to preserve resources, but was later resumed. Within implant-based reconstruction, direct-to-implant was favored over serial tissue expansion. Several protocols were developed, with many emphasizing multidisciplinary collaborations for patient selection, use of specialized measures to reduce risk of COVID-19 transmission, and optimization of same-day discharge. Complication rates following breast reconstruction were similar to pre-pandemic rates. Conclusions The COVID-19 pandemic has forever changed the landscape of breast reconstruction by raising important questions about delivery of care, cost, and resource utilization. The findings of this review may inform surgeons as they plan for similar future crises or strive for improved patient care and efficacy even during nonpandemic times.
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Objective photographic assessments and comparisons of immediate bilateral breast reconstruction using deep inferior epigastric perforator flaps and implants. Arch Plast Surg 2021; 48:473-482. [PMID: 34583431 PMCID: PMC8490115 DOI: 10.5999/aps.2020.02362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 07/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background The increasing number of bilateral breast cancer patients has been accompanied by a growing need for bilateral mastectomy with immediate reconstruction. However, little research has investigated the complications and aesthetic outcomes related to bilateral reconstruction. Therefore, we analyzed retrospective data comparing the outcomes of bilateral reconstruction using deep inferior epigastric perforator (DIEP) flaps or implants. Methods This study included 52 patients (24 DIEP group and 28 implant group) who underwent bilateral mastectomy with immediate reconstruction between 2010 and 2020. Patient demographics, surgical characteristics, and complications were recorded. The difference between the left and right position of the nipple-areolar complex with respect to the sternal notch point at the clavicle was measured, and breast symmetry was evaluated. Results The average weight of breasts reconstructed with DIEP flaps (417.43±152.50 g) was higher than that of breasts with implants. The hospitalization period and operation time were significantly longer in the DIEP group. Early complications were significantly more common in the implant group (36.53%) than in the DIEP group. The angles between the nipples and the horizontal line were 1.09°±0.71° and 1.75°±1.45° in the DIEP and implant groups, respectively. Conclusions Although the surgical burden is lower, breast reconstruction using implants requires greater attention with respect to implant positioning, asymmetry, and complications than DIEP flap reconstruction. DIEP flap reconstruction has a prolonged operation time and a high risk of flap failure, but yields excellent cosmetic results and does not require intensive follow-up. Patients should be consulted to determine the most suitable option for them.
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Huayllani MT, Torres-Guzman RA, Avila FR, Advani PP, Spaulding AC, Cochuyt JJ, Nguyen MDT, Lu X, Rinker BD, Forte AJ. Effect of health care disparities on procedure selection of autologous breast reconstruction in Florida. Breast Dis 2021; 41:75-80. [PMID: 34487016 DOI: 10.3233/bd-210004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Disparities in access to reconstructive surgery after breast cancer have been reported. We aim to evaluate demographic and socioeconomic factors influencing type of autologous breast reconstruction in Florida. METHODS We queried the Florida Inpatient Discharge Dataset to evaluate disparities in type of autologous breast reconstructive surgery between January 1, 2013, and September 30, 2017. Patients 18 years of age or older were included. Women younger than 65 years old on Medicare were excluded. Patients were categorized into three groups according to type of autologous reconstruction: latissimus dorsi pedicled flap (pedicled flap), free flap, or pedicled flap with implant (combined flap). Demographic and socioeconomic variables were evaluated. 𝜒2 and Mann-Whitney tests were used to estimate statistical significance. A multivariate logistic regression was performed to find independent associations. RESULTS Our results showed higher odds of reconstruction with free flap in Hispanic patients (odds ratio (OR), 1.66; 95% CI, 1.32-2.09; P < 0.0001) and patients with comorbidities (OR, 1.45; 95% CI, 1.23-1.71; P < 0.0001). However, patients treated in Central and South Florida were less likely to undergo free flap than combined and pedicled flap reconstructions compared with those treated in North Florida (P < 0.05). Patients insured by Medicaid and Medicare were less likely to undergo free flap than combined or pedicled flap reconstruction compared to patients with private insurance (P < 0.05). CONCLUSIONS Our study identified that race, region, insurance, and comorbidity are factors associated with type of autologous breast reconstruction in Florida.
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Affiliation(s)
| | | | | | - Pooja P Advani
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- Department of Health Science Research, Mayo Clinic, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Science Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Brian D Rinker
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
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Johnson L, Holcombe C, O'Donoghue JM, Jeevan R, Browne J, Fairbrother P, MacKenzie M, Gulliver-Clarke C, White P, Mohiuddin S, Hollingworth W, Potter S. Protocol for a national cohort study to explore the long-term clinical and patient-reported outcomes and cost-effectiveness of implant-based and autologous breast reconstruction after mastectomy for breast cancer: the brighter study. BMJ Open 2021; 11:e054055. [PMID: 34408062 PMCID: PMC8375757 DOI: 10.1136/bmjopen-2021-054055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Breast reconstruction (BR) is offered to improve quality of life for women with breast cancer undergoing mastectomy. As most women will be long-term breast cancer survivors, high-quality information regarding the long-term outcomes of different BR procedures is essential to support informed decision-making. As different techniques vary considerably in cost, policymakers also require high-quality cost-effectiveness evidence to inform care. The Brighter study aims to explore the long-term clinical and patient-reported outcomes (PROs) of implant-based and autologous BR and use health economic modelling to compare the long-term cost-effectiveness of different reconstructive techniques. METHODS AND ANALYSIS Women undergoing mastectomy and/or BR following a diagnosis of breast cancer between 1 January 2008 and 31 March 2009 will be identified from hospital episode statistics (HES). Surviving women will be contacted and invited to complete validated PRO measures including the BREAST-Q, EQ-5D-5L and ICECAP-A, or opt out of having their data included in the HES analysis. Long-term clinical outcomes will be explored using HES data. The primary outcome will be rates of revisional surgery between implant-based and autologous procedures. Secondary outcomes will include rates of secondary reconstruction and reconstruction failure. The long-term PROs of implant-based and autologous reconstruction will be compared using BREAST-Q, EQ-5D-5L and ICECAP-A scores. Multivariable regression will be used to examine the relationship between long-term outcomes, patient comorbidities, sociodemographic and treatment factors. A Markov model will be developed using HES and PRO data and published literature to compare the relative long-term cost-effectiveness of implant-based and autologous BR. ETHICS AND DISSEMINATION The Brighter study has been approved by the South-West -Central Bristol Research Ethics Committee (20/SW/0020), and the Confidentiality Advisory Group (20/CAG/0021). Results will be published in peer-reviewed journals and presented at national meetings. We will work with the professional associations, charities and patient groups to disseminate the results.
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Affiliation(s)
- Leigh Johnson
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Joe M O'Donoghue
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Ranjeet Jeevan
- Manchester University NHS Foundation Trust, Manchester, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | | | | | | | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | - Syed Mohiuddin
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | | | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
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Understanding the Relationship between Breast Reconstruction Subtype and Risk of Financial Toxicity: A Single-Institution Pilot Study. Plast Reconstr Surg 2021; 148:1e-11e. [PMID: 34181599 DOI: 10.1097/prs.0000000000008015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of breast reconstruction on financial toxicity remains poorly understood despite growing awareness. The authors sought to illustrate the relationship between breast reconstruction subtypes and the risk of financial toxicity. METHODS The authors conducted a single-institution cross-sectional survey of all female breast cancer patients undergoing any form of breast reconstruction between January of 2018 and June of 2019. Financial toxicity was measured by means of the validated Comprehensive Score for Financial Toxicity instrument. Demographics, clinical course, and coping strategies were abstracted from a purpose-built survey and electronic medical records. Multivariable linear regression was performed to identify associations with financial toxicity. RESULTS The authors' analytical sample was 350 patients. One hundred eighty-four (52.6 percent) underwent oncoplastic reconstruction, 126 (36 percent) underwent implant-based reconstruction, and 40 (11.4 percent) underwent autologous reconstruction. Oncoplastic reconstruction recipients were older, had a higher body mass index, and were more likely to have supplemental insurance and receive adjuvant hormonal therapy. No significant differences in the risk of financial toxicity were uncovered across breast reconstruction subtypes (p = 0.53). Protective factors against financial toxicity were use of supplemental insurance (p = 0.0003) and escalating annual household income greater than $40,000 (p < 0.0001). Receipt of radiation therapy was positively associated with worsening financial toxicity (-2.69; 95 CI percent, -5.22 to -0.15). Financial coping strategies were prevalent across breast reconstruction subtypes. CONCLUSIONS Breast reconstruction subtype does not differentially impact the risk of financial toxicity. Increasing income and supplemental insurance were found to be protective, whereas receipt of radiation therapy was positively associated with financial toxicity. Prospective, multicenter studies are needed to identify the main drivers of out-of-pocket costs and financial toxicity in breast cancer care.
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Validating machine learning approaches for prediction of donor related complication in microsurgical breast reconstruction: a retrospective cohort study. Sci Rep 2021; 11:5615. [PMID: 33692412 PMCID: PMC7946880 DOI: 10.1038/s41598-021-85155-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/24/2021] [Indexed: 12/02/2022] Open
Abstract
Autologous reconstruction using abdominal flaps remains the most popular method for breast reconstruction worldwide. We aimed to evaluate a prediction model using machine-learning methods and to determine which factors increase abdominal flap donor site complications with logistic regression. We evaluated the predictive ability of different machine learning packages, reviewing a cohort of breast reconstruction patients who underwent abdominal flaps. We analyzed 13 treatment variables for effects on the abdominal donor site complication rates. To overcome data imbalances, random over sampling example (ROSE) method was used. Data were divided into training and testing sets. Prediction accuracy, sensitivity, specificity, and predictive power (AUC) were measured by applying neuralnet, nnet, and RSNNS machine learning packages. A total of 568 patients were analyzed. The supervised learning package that performed the most effective prediction was neuralnet. Factors that significantly affected donor-related complication was size of the fascial defect, history of diabetes, muscle sparing type, and presence or absence of adjuvant chemotherapy. The risk cutoff value for fascial defect was 37.5 cm2. High-risk group complication rates analyzed by statistical method were significant compared to the low-risk group (26% vs 1.7%). These results may help surgeons to achieve better surgical outcomes and reduce postoperative burden.
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Heidekrueger PI, Moellhoff N, Horch RE, Lohmeyer JA, Marx M, Heitmann C, Fansa H, Geenen M, Gabka CJ, Handstein S, Prantl L, von Fritschen U. Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany-A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions. J Clin Med 2021; 10:jcm10051016. [PMID: 33801419 PMCID: PMC7958631 DOI: 10.3390/jcm10051016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/20/2022] Open
Abstract
While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.
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Affiliation(s)
- Paul I. Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany
- Correspondence: (P.I.H.); (L.P.); (U.v.F.); Tel.: +49-941-944-6763 (L.P.)
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany;
| | - Jörn A. Lohmeyer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, 20259 Hamburg, Germany;
| | - Mario Marx
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, 01445 Radebeul, Germany;
| | | | - Hisham Fansa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Breast Centre Spital Zollikerberg, 8125 Zollikerberg, Switzerland;
| | - Matthias Geenen
- Department of Reconstructive Surgery, Lubinus Clinic Kiel, 24106 Kiel, Germany;
| | - Christian J. Gabka
- Nymphenburg Clinic for Plastic and Aesthetic Surgery, 80636 Munich, Germany;
| | - Steffen Handstein
- Department of Plastic, Reconstructive, and Breast Surgery, Municipal Hospital Goerlitz, 02828 Görlitz, Germany;
| | - Lukas Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany
- Correspondence: (P.I.H.); (L.P.); (U.v.F.); Tel.: +49-941-944-6763 (L.P.)
| | - Uwe von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, 14165 Berlin, Germany
- Correspondence: (P.I.H.); (L.P.); (U.v.F.); Tel.: +49-941-944-6763 (L.P.)
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Yang G, Chang JS, Shin KH, Kim JH, Park W, Kim H, Kim K, Lee IJ, Yoon WS, Cha J, Lee KC, Kim JH, Choi JH, Ahn SJ, Ha B, Lee SY, Lee DS, Lee J, Shin SO, Kim YB. Post-mastectomy radiation therapy in breast reconstruction: a patterns of care study of the Korean Radiation Oncology Group. Radiat Oncol J 2020; 38:236-243. [PMID: 33389980 PMCID: PMC7785842 DOI: 10.3857/roj.2020.00738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/15/2020] [Accepted: 11/25/2020] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The details of breast reconstruction and radiation therapy (RT) vary between institutions; therefore, we sought to investigate the practice patterns of radiation oncologists who specialize in breast cancer. MATERIALS AND METHODS We identified the practice patterns and inter-hospital variations from a multi-center cohort of women with breast cancer who underwent post-mastectomy RT (PMRT) to the reconstructed breast at 16 institutions between 2015 and 2016. The institutions were requested to contour the target volume and produce RT plans for one representative case with five different clinical scenarios and answer questionnaires which elicited infrastructural information. We assessed the inter-institutional variations in RT in terms of the target, normal organ delineation, and dose-volume histograms. RESULTS Three hundred fourteen patients were included; 99% of them underwent immediate reconstruction. The most irradiated material was tissue expander (36.9%) followed by transverse rectus abdominis musculocutaneous flap (23.9%) and silicone implant (12.1%). In prosthetic-based reconstruction with tissue expander, most patients received PMRT following partial deflation. Conventional fractionation and hypofractionation RT were used in 66.6% and 33.4% patients, respectively (commonest: 40.05 Gy in 15 fractions [17.5%]). Furthermore, 15.6% of the patients received boost RT and 53.5% were treated with bolus. Overall, 15 physicians responded to the questionnaires and six submitted their contours and RT plans. There was a significant variability in target delineations and RT plans between physicians, and between clinical scenarios. CONCLUSION Adjuvant RT following post-mastectomy reconstruction has become a common practice in Korea. The details vary significantly between institutions, which highlights an urgent need for standard protocol in this clinical setting.
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Affiliation(s)
- Gowoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Korea University Ansan Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jihye Cha
- Department of Radiation Oncology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyu-Chan Lee
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Hwa Choi
- Department of Radiation Oncology, Chung-Ang University Hospital, Seoul, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Boram Ha
- Department of Radiation Oncology, Hallym University Dongtan Sacred Heart Hospital, Hwasung, Korea
| | - Sun Young Lee
- Department of Radiation Oncology, Chonbuk National University Hospital, Jeonju, Korea
| | - Dong Soo Lee
- Department of Radiation Oncology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Sei One Shin
- Department of Radiation Oncology, Andong Medical Group Andong Hospital, Andong, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Kouwenberg CAE, Mureau MAM, Kranenburg LW, Rakhorst H, de Leeuw D, Klem TMAL, Koppert LB, Ramos IC, Busschbach JJ. Cost-utility analysis of four common surgical treatment pathways for breast cancer. Eur J Surg Oncol 2020; 47:1299-1308. [PMID: 33349523 DOI: 10.1016/j.ejso.2020.11.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/10/2020] [Accepted: 11/20/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim was to evaluate the cost-utility of four common surgical treatment pathways for breast cancer: mastectomy, breast-conserving therapy (BCT), implant breast reconstruction (BR) and autologous-BR. METHODS Patient-level healthcare consumption data and results of a large quality of life (QoL) study from five Dutch hospitals were combined. The cost-effectiveness was assessed in terms of incremental costs and quality adjusted life years (QALYs) over a 10-year follow-up period. Costs were assessed from a healthcare provider perspective. RESULTS BCT resulted in comparable QoL with lower costs compared to implant-BR and autologous-BR and showed better QoL with higher costs than mastectomy (€17,246/QALY). QoL outcomes and costs of especially autologous-BR were affected by the relatively high occurrence of complications. If reconstruction following mastectomy was performed, implant-BR was more cost-effective than autologous-BR. CONCLUSION The occurrence of complications had a substantial effect on costs and QoL outcomes of different surgical pathways for breast cancer. When this was taken into account, BCT was most the cost-effective treatment. Even with higher costs and a higher risk of complications, implant-BR and autologous-BR remained cost-effective over mastectomy. This pleas for adapting surgical pathways to individual patient preferences in the trade-off between the risks of complications and expected outcomes.
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Affiliation(s)
- Casimir A E Kouwenberg
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
| | - Marc A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Leonieke W Kranenburg
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Hinne Rakhorst
- Department of Plastic, Reconstructive and Hand Surgery, Hospital Medisch Spectrum Twente/ Hospital Group Twente, Enschede, the Netherlands
| | - Daniëlle de Leeuw
- Department of Surgery, Hospital Group Twente, Almelo, the Netherlands
| | - Taco M A L Klem
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Isaac Corro Ramos
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jan J Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients. Plast Reconstr Surg Glob Open 2020; 8:e3166. [PMID: 33173682 PMCID: PMC7647645 DOI: 10.1097/gox.0000000000003166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/07/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m2] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap. METHODS A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated. RESULTS Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m2, including 12 patients with BMI > 50 kg/m2. Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively. CONCLUSIONS These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.
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Ganesh Kumar N, Kung TA. Guidelines for breast reconstruction during the COVID-19 pandemic: Are we considering enough evidence? Breast J 2020; 26:2108-2109. [PMID: 32794328 PMCID: PMC7436389 DOI: 10.1111/tbj.14015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/04/2022]
Affiliation(s)
- Nishant Ganesh Kumar
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore A Kung
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Mandelbaum AD, Thompson CK, Attai DJ, Baker JL, Slack G, DiNome ML, Benharash P, Lee MK. National Trends in Immediate Breast Reconstruction: An Analysis of Implant-Based Versus Autologous Reconstruction After Mastectomy. Ann Surg Oncol 2020; 27:4777-4785. [PMID: 32712889 DOI: 10.1245/s10434-020-08903-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/19/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Many factors affect access to immediate breast reconstruction (IR) after mastectomy. The present study was performed to assess trends, outcomes, and predictors of IR techniques using a nationally representative cohort. METHODS The 2009-2014 National Inpatient Sample (NIS) was used to identify adult women who underwent inpatient mastectomy with IR. Patients were compared by type of reconstruction: implant-based IR versus autologous reconstruction (AR). AR was classified as a microsurgical or pedicled flap procedure. Incidence, outcomes, and predictors were assessed using Chi squared univariate tests and multivariable logistic regression analyses. RESULTS Of 194,073 women who underwent IR, 136,668 (70.4%) received implant-based IR and 57,405 (29.6%) received AR. Of those who underwent AR procedures, 31,336 (54.6%) received microsurgical flaps and 26,680 (46.5%) received pedicled flaps. Utilization of deep inferior epigastric perforator (DIEP) flaps increased significantly (28.6-42.5% of AR, P < 0.001). Predictors of AR were Black race [adjusted odds ratio (AOR) = 1.46, P < 0.001], lower Elixhauser Comorbidity Index (AOR = 1.25, P < 0.001), private insurance (AOR = 1.07, P = 0.030), body mass index (BMI) ≥ 30 kg/m2 (AOR = 1.38, P < 0.001), urban teaching hospital designation (AOR = 1.77, P < 0.001), and high hospital volume (AOR = 3.11, P < 0.001). Similar factors were associated with the use of microsurgical flaps. AR and microsurgical flaps were associated with higher rates of acute inpatient complications, resource utilization and length of stay (LOS) compared with implant-based IR and pedicled flaps, respectively. CONCLUSION Implant-based IR remains the most common type of IR, although rates of microsurgical AR are on the rise. Follow-up of complications, costs, and quality-of-life measures may show that AR provides long-term high-value care despite upfront morbidity, cost, and use of hospital resources.
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Affiliation(s)
- Ava D Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Carlie K Thompson
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Deanna J Attai
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Jennifer L Baker
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Ginger Slack
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Maggie L DiNome
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Minna K Lee
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA.
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Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare? Plast Reconstr Surg 2020; 146:494e-495e. [PMID: 32639425 DOI: 10.1097/prs.0000000000007176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Discussion: Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare? Plast Reconstr Surg 2020; 145:312-314. [DOI: 10.1097/prs.0000000000006498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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