Implant breast reconstruction and radiation: a multicenter analysis of long-term health-related quality of life and satisfaction.

BACKGROUND: Indications for radiotherapy in breast cancer treatment are expanding. Long-term satisfaction and health-related quality of life (HR-QOL), important outcomes after alloplastic breast reconstruction and radiation, have not been measured in irradiated patients by using a condition-specific, validated patient-reported outcomes instrument. The aim was to evaluate patient satisfaction and HR-QOL in patients with implant breast reconstruction and radiotherapy. METHODS: A multicenter cross-sectional survey of patients who underwent implant-based breast reconstruction from three centers in the United States and Canada, with and without radiation, was performed. Satisfaction with breasts, satisfaction with outcome, psychosocial well-being, sexual well-being, and physical well-being outcomes were evaluated using the BREAST-Q(©) (Reconstruction Module). Multivariable analysis was performed to evaluate the effect of radiotherapy on patient satisfaction with breasts with adjustment by patient and treatment characteristics. RESULTS: The response rate was 71 %, with 633 completed questionnaires returned. Mean follow-up was 3.3 years for irradiated patients (n = 219) and 3.7 years for nonirradiated patients (n = 414). Patients with radiation had significantly lower satisfaction with breasts (58.3 vs. 64.0; p < 0.01), satisfaction with outcome (66.8 vs. 71.4; p < 0.01), psychosocial well-being (66.7 vs. 70.9; p < 0.01), sexual well-being (47.0 vs. 52.3; p < 0.01), and physical well-being (71.8 vs. 75.1; p < 0.01) compared with nonirradiated patients. Multivariable analysis confirmed the negative effect of radiotherapy on satisfaction with breasts (ß = -2.6; p = 0.03) when adjusted for patient and treatment factors. CONCLUSIONS: Radiotherapy has a negative effect on HR-QOL and satisfaction with breasts in patients with implant reconstruction compared with nonirradiated patients. The information provided here can inform decision-making and help set appropriate expectations for patients undergoing implant breast reconstruction and radiation.

Professional burnout among US plastic surgeons: results of a national survey.

PURPOSE: Little is known about professional burnout among plastic surgeons. Our purpose is to describe its prevalence among a large national sample of plastic surgeons and identify contributing factors. METHODS: A mailed, self-administered survey was sent to 708 plastic surgeons who were randomly sampled from the American Society of Plastic Surgeons national membership (71% response rate). The dependent variable was professional burnout, measured by 3 subscales from the validated Maslach Burnout Inventory-Human Services Survey. "High" scores in either the emotional exhaustion or depersonalization subscale categories predict professional burnout. The independent variables included surgeon sociodemographic and professional characteristics. χ was used for the bivariate analyses. RESULTS: Nearly one third (29%) of surgeons scored high in subscale categories predictive of professional burnout. Factors associated with high emotional exhaustion scores included surgeon age, 40-50 years (P = 0.03); fair/poor physician health (P < 0.01); ER call (P < 0.01); >60 work hours per week (P = 0.03); primarily reconstructive practice (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). Factors associated with high depersonalization scores included fair/poor physician health (P= 0.01); ER call (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). CONCLUSIONS: Nearly one third of plastic surgeons have signs of professional burnout. Middle-aged surgeons and those in poor health are most at risk; along with those who have a reconstructive rather than cosmetic practice, long work hours, ER call responsibility, a nonacademic setting. and group as compared to solo practice. These data have important implications for future workforce shortages and health care quality.

The choice for breast cancer surgery: can women accurately predict postoperative quality of life and disease-related stigma?

BACKGROUND: To make an informed choice, breast cancer patients facing surgery must imagine the effect of surgery on their future life experiences. However, the accuracy of patient predictions of postoperative quality of life (QoL) and disease-related stigma is not well understood. MATERIALS AND METHODS: Four groups of breast cancer patients at the University of Michigan Medical Center were surveyed by mail and interview (response rate 76.3%): (1) preoperative (N = 59), (2) mastectomy (N = 146), (3) mastectomy with reconstruction (N = 250), and (4) breast conservation (N = 705). Subjects rated their QoL (1 = lowest, 100 = highest) and stigma (1 = lowest, 5 = highest) and estimated QoL and stigma associated with mastectomy alone, mastectomy with reconstruction, and breast conserving surgery (BCS). Mean scores were compared using linear regression controlling for age, race, partnered status, and income. RESULTS: Preoperatively, women inaccurately predicted postoperative QoL and stigma for all surgical options, particularly for mastectomy. Preoperative patients underestimated the postoperative QoL for mastectomy alone (predicted: 56.8 vs actual: 83.7; P < .001). Preoperative patients underestimated QoL following mastectomy following reconstruction (predicted: 73.4 vs actual: 83.9; P < .001) and BCS (predicted: 72.2 vs actual: 88.6; P < .001). Additionally, preoperative patients overestimated stigma related to mastectomy (predicted: 3.25 vs actual: 2.43; P < .001). Finally, preoperative women overestimated stigma related to mastectomy with reconstruction (predicted: 2.54 vs actual: 2.03; P < .001) and BCS (predicted: 1.90 vs actual: 1.76; P < .001). CONCLUSION: Predicting QoL and stigma following breast cancer surgery is challenging for patients facing a diagnosis for surgery. Identifying strategies to better inform patients of surgical outcomes can improve the decision-making process.

Receipt of delayed breast reconstruction after mastectomy: do women revisit the decision?

BACKGROUND: Postmastectomy breast reconstruction is an important component of breast cancer care, but few receive it at the time of the mastectomy. Virtually nothing is known about receipt of reconstruction after initial cancer therapy and why treatment might be delayed. MATERIALS AND METHODS: A 5-year follow-up survey was mailed to a population-based cohort of mastectomy-treated breast cancer patients who were initially surveyed at time of diagnosis in 2002 and reported to the Los Angeles and Detroit SEER registries (N = 645, response rate 60%). Outcomes were receipt of reconstruction (immediate [IR], delayed [DR], or none) and patient appraisal of their treatment decisions. RESULTS: About one-third (35.9%) had IR, 11.5% had DR, and 52.6% had no reconstruction. One-third delayed reconstruction because they focused more on other cancer interventions, and nearly half were concerned about surgical complications and interference with cancer surveillance. Two-thirds of those with no reconstruction said that the procedure was not important to them. A large proportion of all patients were satisfied with their reconstruction decision-making (89.4% IR, 78.4% DR, 80.4% no reconstruction, P = NS). However, only 59.3% of those with no reconstruction felt that they were adequately informed about their reconstructive options (vs 82.7% IR and 78.4% DR, P < .01). CONCLUSIONS: There was modest uptake of breast reconstruction after initial cancer treatment. Factors associated with delayed reconstruction were primarily related to uncertainty about the procedure, concern about cancer surveillance, and low priority. Those without reconstruction demonstrated significant informational needs, which should be addressed with future research efforts.

Understanding the Basics of Restrictive Covenants in Employment Agreements.

BACKGROUND: Restrictive covenants are common in contractual agreements involving physicians and need careful consideration to minimize potential conflict during the term of the contract and on physician departure from a group practice or hospital system. METHODS: A general overview of the different components of restrictive covenants is provided, including specific information related to noncompetes, nonsolicitations, and nondisclosure agreements. RESULTS: In general, states will uphold restrictive covenants if the elements of the noncompete are reasonable regarding geographic distance restrictions (e.g., <20 air miles), time restrictions (e.g., <2 years), and scope of services. However, states vary considerably in the interpretation of restrictive covenants. Other components of the contract, such as alternative dispute resolution (mediation and/or arbitration) and buy-out clauses (i.e., liquidated damages provisions), should be considered at the time the agreement is negotiated. CONCLUSIONS: States are balancing the protection of business interests with the protection of free trade. It is important that physicians seek counsel with an experienced health care attorney with respect to restrictive covenants in his or her specific state. A simple, well-written, and reasonable restrictive covenant can often help limit legal conflict and expense.

Does it matter where you go for breast surgery?: attending surgeon's influence on variation in receipt of mastectomy for breast cancer.

BACKGROUND: Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon's influence on the variation in receipt of these procedures. OBJECTIVES: To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer. METHODS: Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment. RESULTS: Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th-95th percentile, 9%-65%) then for mastectomy (median, 18%; 5th-95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%). CONCLUSION: Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.

Measuring Outcomes in Cosmetic Abdominoplasty: The BODY-Q.

The BODY-Q is a condition-specific patient-reported outcome measure that enables a comprehensive assessment of outcomes that are specific to patients undergoing body contouring procedures such as abdominoplasty. The BODY-Q scales were designed to be responsive to the effects of abdominoplasty on health-related quality of life and appearance outcomes. The BODY-Q covers a range of content domains, and the independently functioning scales enable surgeons to tailor the BODY-Q to their needs. The application of the BODY-Q in cosmetic clinics internationally may give rise to better understanding of abdominoplasty outcomes and optimize the care delivered to patients undergoing these procedures.

A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction.

Perforator flap breast reconstruction potentially offers patients greater postoperative abdominal strength compared with traditional TRAM techniques. Our purpose was to perform a systemic review of the published literature regarding abdominal wall function following breast reconstruction and compare outcomes between pedicle TRAM, free TRAM, and perforator flap procedures. We used the MEDLINE, EMBASE, CINAHL, the Cochrane Network, and HAPI databases from January 1966 through November 1, 2007 to identify potentially relevant studies. Inclusion criteria included studies that evaluated subjective or objective functional abdominal outcomes for postmastectomy patients receiving either pedicle TRAM, free TRAM, or deep inferior epigastric perforator (DIEP) flaps. All study designs were included in the review-prospective studies, cross-sectional studies, and retrospective case series. Our search yielded 20 studies on abdominal wall function after autogenous tissue breast reconstruction. Objective measures of abdominal wall function using isometric dynamometry revealed that pedicle TRAM patients experienced up to a 23% deficit, whereas free TRAM patients experienced up to an 18% deficit in trunk flexion. For trunk extension, pedicle TRAM patients experienced up to a 14% deficit, whereas free TRAM patients experienced minimal to no deficits. However, none of the comparative studies of pedicle and free TRAM procedures found significant differences in abdominal wall function between the 2 groups. Studies that compared free TRAM to DIEP flaps found significantly higher flexion abilities in the DIEP groups, with one study reporting an advantage in measures of extension for DIEP flaps. Functional deficits assessed by physiotherapy measures revealed that patients with pedicle TRAM reconstructions experienced the greatest deficit in rectus and oblique muscle function (up to 53%). Free TRAM groups experienced minimal deficit in rectus muscle function, whereas DIEP flaps returned to baseline for both rectus and oblique muscle function. Subjective measures of abdominal wall function were similar across unipedicle TRAM, free TRAM, and DIEP flap procedures. Patients with bilateral pedicle TRAM reconstruction suffered up to a 40% deficit in trunk flexion and up to a 9% deficit in trunk extension. Patients with bilateral pedicle or free TRAM reconstruction also experienced a significant decrease in the ability to perform sit-ups and a significant decrease in activities of daily living, recreational, and laborious activities. With the exception of those who had bipedicled TRAM or bilateral free TRAM procedures, most women reported return to their preoperative function without a decrease in their ability to perform activities of daily living. Although some studies report an objective advantage of DIEP flaps, this does not appear to translate to detriments in the performance of activities of daily living. However, the current data have limitations in study design and generalizability. A multicenter, longitudinal study is needed to assess objective and subjective outcomes in patients with pedicle TRAM, free TRAM, and perforator flaps using standardized and validated measures.

The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction.

Although experimental evidence suggests that the preliminary surgical delay procedure physiologically improves the circulation of the TRAM flap, there are no published controlled studies evaluating the clinical outcomes associated with this procedure. The purpose of this study was to evaluate the efficacy of the surgical flap delay versus no delay in consecutive patients having pedicle TRAM breast reconstruction. This was a retrospective cohort study of breast cancer patients at the University of Michigan who had pedicle TRAM reconstruction between January 2004 and March 2008. Prior to September 2005, all patients had pedicle TRAM reconstruction without the delay procedure. Starting in September 2005, all patients had the delay procedure prior to TRAM flap reconstruction. Descriptive statistics were used to compare demographic data, comorbidities, and complication rates between the 2 cohorts. Regression analysis was used to determine the effects of the surgical delay procedure on the incidence of flap ischemia and major and minor complications while controlling for patient and treatment level factors. Eighty-seven postmastectomy breast cancer patients had unipedicle TRAM flap reconstruction, in which 112 flaps were used to reconstruct breasts. The nondelay cohort consisted of 42 consecutive patients (51 flaps) and the delay cohort consisted of 45 consecutive patients (61 flaps). Of the patients without the surgical delay procedure 17.6% experienced at least one ischemic complication of the flap compared with 6.6% of those who were surgically delayed (P = 0.082). When controlling for patient and treatment level factors, the delay procedure was found to significantly decrease the incidence of flap ischemia (OR = 0.21, P = 0.018). In addition, there were no significant differences in the incidence of major or minor complication rates in the surgically delayed versus nondelayed groups (P = 0.247, P = 0.486, respectively). When patient and treatment level factors were taken into consideration, undergoing the delay procedure also did not increase the incidence of having a major or minor complication. These data support the use of the preliminary surgical delay procedure to decrease ischemic complications of the flap in pedicle TRAM postmastectomy breast reconstruction.

Surgeon recommendations and receipt of mastectomy for treatment of breast cancer.

CONTEXT: There is concern that mastectomy is overused in the United States. OBJECTIVES: To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS). DESIGN, SETTING, AND PATIENTS: A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other). MAIN OUTCOME MEASURES: The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS. RESULTS: Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001). CONCLUSION: Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study.

OBJECTIVE: To prospectively evaluate the psychosocial outcomes and body image of patients 2 years postmastectomy reconstruction using a multicenter, multisurgeon approach. BACKGROUND: Although breast reconstruction has been shown to confer significant psychosocial benefits in breast cancer patients at year 1 postreconstruction, we considered the possibility that psychosocial outcomes may remain in a state of flux for years after surgery. METHODS: Patients were recruited as part of the Michigan Breast Reconstruction Outcome Study, a 12 center, 23 surgeon prospective cohort study of mastectomy reconstruction patients. Two-sided paired sample t tests were used to compare change scores for the various psychosocial subscales. Multiple regression analysis was used to determine whether the magnitude of the change score varied by procedure type. RESULTS: Preoperative and postoperative year 2 surveys were received from 173 patients; 116 with immediate and 57 with delayed reconstruction. For the immediate reconstruction cohort, significant improvements were observed in all psychosocial subscales except for body image. This occurred essentially independent of procedure type. In the cohort with delayed reconstruction, significant change scores were observed only in body image. Women with transverse rectus abdominis musculocutaneous flaps had significantly greater gains in body image scores (P = 0.003 and P = 0.034, respectively) when compared with expander/implants. CONCLUSIONS: General psychosocial benefits and body image gains continued to manifest at 2 years postmastectomy reconstruction. In addition, procedure type had a surprisingly limited effect on psychosocial well being. With outcomes evolving beyond year 1, these data support the need for additional longitudinal breast reconstruction outcome studies.

Predictors of re-excision among women undergoing breast-conserving surgery for cancer.

BACKGROUND: Up to 60% of breast cancer patients who undergo breast-conserving surgery (BCS) require re-excision to obtain clear margins, causing delays in adjuvant treatment and poor aesthetic results. However, patient and treatment-related factors associated with re-excision are not well defined. METHODS: We surveyed all women undergoing breast conserving surgery between January 2002 and May 2006 regarding their breast disease (n = 714, response rate = 79.5%). The medical record was reviewed to determine the receipt of re-excision lumpectomy following BCS, and obtain tumor stage, histology, and biopsy method (surgical versus needle biopsy). Patient age, breast size, tumor location in the breast, and receipt of chemotherapy were self-reported. Logistic regression was used to determine significant predictors of re-excision lumpectomy. RESULTS: In this sample, 51.4% of women required only one breast excision, 41.9% required two breast excisions, and 6.6% required three breast excisions. Overall, 10.8% of women required a mastectomy following initial attempt at BCS. Factors significantly correlated with re-excision lumpectomy included smaller breast size (A cup: OR = 2.7; 95%CI: 1.32-5.52; B cup: 1.63; 95%CI: 1.02-2.62), lobular histology (OR = 1.93; 95%CI: 1.15-3.25), and receipt of surgical biopsy (OR = 3.35; 95%CI: 2.24-5.02). Women who received adjuvant chemotherapy (OR = 2.49; 95%CI: 1.19-5.22) were more likely to require re-excision compared with women who received neoadjuvant chemotherapy. CONCLUSIONS: Re-excision lumpectomy is common, and is significantly correlated with smaller breast size, lobular histology, surgical biopsy, and chemotherapy timing. Attention to these risk factors can improve the quality of care delivered to BCS patients by decreasing the cost and morbidity associated with multiple re-excision procedures.

Latina patient perspectives about informed treatment decision making for breast cancer.

OBJECTIVE: To evaluate Latina breast cancer patient perspectives regarding informed decision making related to surgical treatment decision making for breast cancer. METHODS: 2030 women with non-metastatic breast cancer diagnosed from 8/05 to 5/06 and reported to the Los Angeles metropolitan SEER registries were mailed a survey shortly after surgical treatment. Latina and African-American women were over-sampled. We conducted regression of four decision outcome to evaluate associations between race/ethnicity, demographic and clinical factors, and mechanistic variables (i.e., health literacy) and decision outcomes. RESULTS: Our analytic sample was 877 women: 24.5% Latina-Spanish speaking (Latina-SP), 20.5% Latina-English speaking, 24% African-American and 26.6% Caucasian. Approximately 28% of women in each ethnic group reported a surgeon-based, 36% a shared, and 36% a patient-based surgery decision. Spanish-preferent Latina women had the greatest odds of high decision dissatisfaction and regret controlling for other factors (OR 5.5, 95% CI: 2.9, 10.5 and OR 4.1, 95% CI: 2.2, 8.0, respectively). Low health literacy was independently associated with dissatisfaction and regret (OR 5.6, 95% CI: 2.9, 11.1 and OR 3.5, 95% CI 1.8, 7.1, respectively) and slightly attenuated associations between Latina-SP ethnicity and decision outcomes. CONCLUSION: Despite similar clinical outcomes, patients report very different experiences with treatment decision making. Latina women, especially those who prefer Spanish, are vulnerable to poor breast cancer treatment decision outcomes. PRACTICE IMPLICATIONS: Providers need to be aware of the role of ethnicity, acculturation and literacy in breast cancer treatment discussions.

Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study.

BACKGROUND: Previously, we found patient satisfaction with breast reconstruction at postoperative year 1 significantly higher in the autogenous tissue compared with the expander/implant population. But breast reconstructive procedures have different "aging" processes, and the point at which outcomes stabilize is unclear. So we evaluated patient satisfaction with breast reconstruction at postoperative year 2 and compared the results with those from our previous study. STUDY DESIGN: As part of the Michigan Breast Reconstruction Outcomes Study, women undergoing mastectomy reconstruction (including expander/implants and pedicle and free transverse rectus abdominis musculocutaneous flaps [TRAM]) were prospectively evaluated. Preoperatively and at postoperative years 1 and 2, women completed a questionnaire that collected a variety of validated health status information. The postoperative questionnaire had an additional seven items assessing both general and esthetic satisfaction as separate subscales. To assess the effects of procedure on satisfaction and control for possible confounding, multiple logistic regression was used. RESULTS: At year 2, patients with TRAM flaps (both free and pedicle) continued to have higher levels of esthetic satisfaction compared with expander/implant patients (odds ratio 2.8, p < 0.01). But no significant differences were appreciated in esthetic satisfaction between women with free and pedicle TRAM flaps. In regard to general satisfaction, the type of reconstruction (expander/implant, pedicle TRAM, and free TRAM) had no statistically significant effect. CONCLUSIONS: At postoperative year 2, procedural differences initially found in women's general satisfaction with breast reconstruction diminish. Specifically, women with pedicle TRAM flaps, free TRAM flaps, and expander/implants had similar levels of general satisfaction. But at year 2, patients continue to be more esthetically satisfied with autogenous tissue than with expander/implant reconstructions.

Breast reconstruction.

During the last century, breast reconstruction after mastectomy has become an important part of comprehensive treatment for patients who have breast cancer. Breast reconstruction initially was created to reduce complications of mastectomy and to diminish chest wall deformities. Now, however, it is known that reconstruction also can improve the psychosocial well-being and quality of life of patients who have breast cancer. This article reviews the techniques used for breast construction after breast surgery.

The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors.

The purpose of this study was to identify important sociodemographic factors affecting the utilization of immediate and early delayed postmastectomy breast reconstruction in the United States. Using the Surveillance, Epidemiology, and End Results (SEER) program, all cases of mastectomy-treated breast cancer that were reported to a SEER registry in 1998 were identified. Data were limited to reconstructions within the first 4 months postmastectomy, and logistic regression was used to analyze the effects of sociodemographic variables on reconstruction rates. Of the 10,406 mastectomy-treated breast cancer patients, 1607 (15 percent) underwent reconstruction within the first 4 months postmastectomy. Compared with women 45 to 54 years old, those 35 to 44 years old were significantly more likely to have breast reconstruction (OR = 1.52, p < 0.001), but women 55 to 64, 65 to 74, and 75 years and older were significantly less likely to have reconstruction (OR = 0.42, p < 0.001; OR = 0.16, p < 0.001; OR = 0.04, p < 0.001, respectively). Compared with Caucasian women, African American, Hispanic, and Asian women were significantly less likely to have reconstruction (OR = 0.48, p < 0.001; OR = 0.45, p < 0.001; OR = 0.29, p < 0.001, respectively). In addition, a four-fold difference in reconstruction rates existed in high-use versus low-use regions. With regard to the type of reconstruction, patients younger than 35 and 65 to 74 years old were significantly less likely to receive autogenous tissue reconstruction compared with women 45 to 54 years old (OR = 0.47, p = 0.047; OR p = 0.61, p = 0.031, respectively). However, African Americans were significantly more likely to receive autogenous tissue reconstructions compared with Caucasians (OR = 2.03, p = 0.021). According to these data, the utilization of immediate and early delayed breast reconstruction in the United States is low and is significantly influenced by patients' age, race, and geographic location. Further research is needed to evaluate the impact of provider bias, patient preference, and barriers to care on the utilization of breast reconstruction in the United States.

Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study.

In this study, the effects of procedure type, timing, and other clinical variables on complication rates in mastectomy reconstruction were prospectively evaluated. Using a prospective cohort design, women undergoing first-time, immediate or delayed breast reconstruction were recruited from 12 centers and 23 plastic surgeons. Complication data for expander/implant, pedicle transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap procedures were evaluated 2 years after surgery in 326 patients. For each patient, the total number of complications was recorded and the complication data were dichotomized in two ways: (1) total complications and (2) major complications (those requiring reoperation, rehospitalization, or nonperioperative intravenous antibiotic treatment). The effects of procedure type, timing, radiotherapy, chemotherapy, age, smoking, and body mass index on complication rates were analyzed using logistic regression. Immediate reconstructions had significantly higher total as well as major complication rates, compared with delayed procedures (p = 0.011 and 0.005, respectively). Furthermore, higher body mass indexes were associated with significantly higher total and major complication rates (p = 0.005 and p < 0.001, respectively). No significant effects on complication rates were noted for procedure type or for the other independent variables, although there was evidence of trends for higher total and major complication rates in implant patients who received radiotherapy and a trend for higher major complication rates in TRAM flap patients who received chemotherapy. It was concluded that (1) immediate reconstructions were associated with significantly higher complication rates than delayed procedures, and (2) procedure type had no significant effect on complication rates.