Outcomes in Deep Inferior Epigastric Perforator Flap and Implant-Based Reconstruction: Does Age Really Matter?

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

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

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

Longitudinal analysis of long-term outcomes of abdominal flap-based microsurgical reconstruction and two-stage prosthetic reconstruction

Two-stage tissue expander/implant (TE/I) and deep inferior epigastric perforator (DIEP) flaps are the two main pillars of breast reconstruction. This study aimed to conduct a longitudinal analysis of long-term outcomes after immediate DIEP- and TE/I-based reconstruction. This retrospective cohort study included patients with breast cancer who underwent immediate DIEP- or TE/I-based reconstruction between 2012 and 2017. The cumulative incidence of major complications, defined as unplanned reoperation/readmission due to complications, was analyzed by the reconstruction modality and its independent association. In total, 1,474 cases (1,162 TE/I and 312 DIEP cases) were analyzed, with a median follow-up of 58 months. The 5-year cumulative incidence of major complications was significantly higher in the TE/I group (10.3% vs. 4.7%). On the multivariable analyses, the use of DIEP flap was associated with a significantly reduced risk of major complications compared to that of TE/I. A more prominent association was observed in the analysis of patients who received adjuvant radiotherapy. Restricting analysis to those who received adjuvant chemotherapy revealed no differences between the two groups. The rate of reoperation/readmission for improving aesthetic outcomes was similar in the two groups. Long-term risks for unexpected reoperation/readmission may differ between DIEP- and TE/I-based immediate reconstruction.

Are Large Intraoperative Fill Volumes Associated With Increased Complications After Tissue Expander Placement?

Background

With the increased adoption of skin-sparing mastectomies, immediate 2-stage breast reconstruction is a common option for breast cancer patients. During the first stage of the procedure with tissue expander placement, higher intraoperative percent fill has been identified as a risk factor for complications. However, the postoperative outcomes of higher intraoperative fill volumes are not well established. The authors sought to evaluate if a higher initial intraoperative tissue expander fill volume is associated with higher complication rates in patients undergoing immediate breast reconstruction with tissue expander placement.

Methods

A retrospective review of patients who underwent immediate breast reconstruction with a tissue expander placement from 2016 to 2018 was conducted. Patient demographics and perioperative data were recorded. Large intraoperative fill was defined as saline fill volume greater than 350 mL. The primary outcome evaluated was skin and nipple necrosis. Secondary outcomes were major infections, minor infections, seroma, and hematoma.

Results

A total of 147 breasts in 86 patients were included. Mean intraoperative fill volume was 246.4 ± 106.6 mL. Thirty-five tissue expanders were filled with greater than 350 mL of saline intraoperatively. Patients with large intraoperative fill volume were older (mean age, 52.6 vs 47.9 years; P = .04), had a higher mean body mass index (BMI; 33.2 vs 25.9 kg/m²; P < .0001), and had larger preoperative breast anthropometrics (P < .0001). During a mean follow-up period of 20.1 months (range, 3-55 months), 9 breasts were noted to have skin/nipple necrosis. After multivariate analysis, large tissue expander fill volume was not a significant predictor of skin or nipple necrosis (P = .62). Hypertension and anticoagulant use were associated with increased skin and nipple necrosis (P = .04 and P = .03, respectively). Large fill volume was not associated with statistically significant increases in rates of other complications like major infections, minor infections, seroma, or hematoma.

Conclusions

Larger fill volumes are often required and benefit patients with higher BMI or bra sizes. This also reduces the number of postoperative fills required. In this patient population, larger intraoperative tissue expander saline fill volume (greater than 350 mL) was not associated with increased postoperative complications. After careful patient selection and perfusion evaluation, larger fill volumes may be considered a safe option to improve the aesthetic outcomes in patients with high BMI.