Patient involvement in the decision-making process improves satisfaction and quality of life in postmastectomy breast reconstruction.

BACKGROUND: The patient-physician relationship has evolved from the paternalistic, physician-dominant model to the shared-decision-making and informed-consumerist model. The level of patient involvement in this decision-making process can potentially influence patient satisfaction and quality of life. In this study, patient-physician decision models are evaluated in patients undergoing postmastectomy breast reconstruction. METHODS: All women who underwent breast reconstruction at an academic hospital from 1999-2007 were identified. Patients meeting inclusion criteria were mailed questionnaires at a minimum of 1 y postoperatively with questions about decision making, satisfaction, and quality of life. RESULTS: There were 707 women eligible for our study and 465 completed surveys (68% response rate). Patients were divided into one of three groups: paternalistic (n = 18), informed-consumerist (n = 307), shared (n = 140). There were differences in overall general satisfaction (P = 0.034), specifically comparing the informed group to the paternalistic group (66.7% versus 38.9%, P = 0.020) and the shared to the paternalistic group (69.3% versus 38.9%, P = 0.016). There were no differences in aesthetic satisfaction. There were differences found in the SF-12 physical component summary score across all groups (P = 0.033), and a difference was found between the informed and paternalistic groups (P < 0.05). There were no differences in the mental component score (P = 0.42). CONCLUSIONS: Women undergoing breast reconstruction predominantly used the informed model of decision making. Patients who adopted a more active role, whether using an informed or shared approach, had higher general patient satisfaction and physical component summary scores compared with patients whose decision making was paternalistic.

Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction.

The purpose of this study was to evaluate complications and patient satisfaction after pedicled transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap reconstruction at a single institution. There were 346 patients identified from 1999 to 2006 who underwent 197 pedicled TRAM and 217 DIEP flap reconstructions. Flap complication rates were similar between groups, whereas pedicled TRAM reconstructions had higher rates of abdominal bulge (9.5% vs. 2.3%, P = 0.0071) and hernias (3.9% vs. 0%, P = 0.0052). DIEP flap patients had significantly higher general satisfaction (81.7% vs. 70.2%, P = 0.0395), whereas aesthetic satisfaction was similar between groups. Furthermore, DIEP flap patients, particularly those undergoing bilateral reconstructions, were more likely to choose the same type of reconstruction compared with pedicled TRAM patients (92.5% vs. 80.7%, P = 0.0113). Understanding the differences in complications and satisfaction will help physicians and patients make informed decisions about abdominal-based autologous breast reconstruction.

The impact of nipple reconstruction on patient satisfaction in breast reconstruction.

BACKGROUND: Nipple reconstruction is an integral part of the breast reconstruction process, as patients associate this stage with closure while providing a sense of completeness. This study evaluates the effect of nipple reconstruction on patient satisfaction with breast reconstruction. METHODS: All patients at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected retrospectively while aesthetic and general satisfaction was evaluated by an administered survey. Patients with nipple reconstruction at the time of survey were compared to patients without nipple reconstruction. RESULTS: Nine hundred two breast reconstructions were performed in 696 patients; 490 patients underwent nipple reconstruction and 206 did not. Autologous reconstruction predominated in patients with and without nipple reconstruction (61.8% and 54.8%, respectively). There were no significant differences in individual and overall total complications between groups. Patients with nipple reconstruction had significantly higher general (72.2% vs 52.8%, P<0.0001) and aesthetic (70.5% vs 46.5%, P<0.0001) satisfaction scores compared to patients without nipple reconstruction. These results were seen in unilateral and bilateral breast reconstruction. Across reconstructive techniques, patients with nipple reconstruction had higher aesthetic satisfaction. Patient satisfaction scores in all individual survey questions were statistically higher in patients with nipple reconstruction. CONCLUSIONS: Patients with breast reconstruction who undergo nipple reconstruction have higher general and aesthetic satisfaction compared to breast reconstruction alone. These differences were observed in both unilateral and bilateral reconstruction. Patients should be fully counseled about potential benefits nipple reconstruction can provide to all forms of breast reconstruction.

Management of complicated wounds of the extremities with scapular fascial free flaps.

Management of complicated open wounds of the extremities represents a reconstructive challenge. The goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissues for optimal restoration of its form and function. We present our experience with the use of scapular fascial free flaps in the reconstruction of complicated open wounds of the extremities. During the period 2001 to 2009, a total of 12 reconstructions utilizing scapular fascial free flaps were performed: nine for upper extremity wounds and three for lower extremity wounds. Two flaps failed: in one case due to intractable vasospasm, in the other case due to lack of adequate recipient vessels. In the ten successful cases, good functional and aesthetic outcomes were achieved. Based on our experience, we conclude that the scapular fascial free flap, although technically demanding, could be considered as the flap of choice for reconstruction of complicated open wounds of the extremities; it provides ample thin and well vascularized soft tissue coverage with restoration of function and a natural contour of the extremity.

Postmastectomy breast reconstruction after previous lumpectomy and radiation therapy: analysis of complications and satisfaction.

BACKGROUND: Lumpectomy and radiation therapy (breast conservation therapy [BCT]) are common treatments for early-stage breast cancer. However, many of these patients will require a subsequent salvage mastectomy and reconstruction after a locoregional recurrence. This study examines whether prior BCT leads to higher rates of complications and dissatisfaction with subsequent mastectomy and breast reconstruction. METHODS: All women undergoing initial breast reconstruction at an academic institution were identified (1999-2006). Women who had undergone prior BCT were compared with women without prior BCT. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered. Rates of complications, as well as general and aesthetic satisfaction, were compared between the 2 groups. Multiple logistic regression was used to analyze the effects of prior BCT, age, comorbidities, reconstruction type, and time between radiation and reconstruction. RESULTS: Overall, 532 women underwent 802 reconstructions, of whom 113 women (137 reconstructions) had prior BCT. Prior BCT did not correlate with higher complication rates (odds ratio [OR] = 1.09, P = 0.690), or lower general or aesthetic satisfaction (OR = 0.84, P = 0.559; OR = 0.91, P = 0.723, respectively); however, there was an increased rate of mastectomy skin flap loss (12.4% vs. 6.8%, P = 0.024). Increasing age was the most significant risk factor for complications and dissatisfaction. CONCLUSION: Radiation in the setting of BCT did not increase overall rates of complications or dissatisfaction with subsequent breast reconstruction in our patient population. These patients, however, had a higher incidence of mastectomy skin flap loss. These findings are important for preoperative counseling and intraoperative planning in patients with prior lumpectomy and radiation.

Breast cancer recurrence following postmastectomy reconstruction compared to mastectomy with no reconstruction.

BACKGROUND: Continuing advances in breast reconstruction have provided surgeons with a multitude of reconstructive options. Concerns remain, however, about the effects of the various reconstructive methods on ultimate oncologic outcome. This study compares incidence, detection, and management of recurrent breast cancer in a large series of patients treated with mastectomy alone or with mastectomy and various forms of reconstruction. METHODS: A retrospective analysis was performed on all patients who underwent mastectomy and/or immediate reconstruction for breast cancer at our institution between January 1999 and December 2006. The 921 patients were divided into 2 groups: mastectomy and reconstruction (n = 494) and mastectomy alone (n = 427). All modern reconstructive methods were included. Patients were followed for a mean of 4.5 years. RESULTS: The total incidence of recurrence-locoregional and/or distant-was 5.9% in patients who had mastectomy with reconstruction and 11.5% in patients who had mastectomy alone (P < 0.0023). The incidence of locoregional recurrence only was 2.2% in patients who had mastectomy with reconstruction and 4.0% in patients who had mastectomy alone (P = 0.1220). Of the 11 reconstructed patients with a locoregional recurrence, all recurrences were detected by self or clinical examination. Median time to detection was the same in both groups: 1.6 years (P = 0.5471). CONCLUSIONS: Reconstruction with a variety of methods does not adversely affect the incidence or time to detection of recurrent breast cancer. Further, our data point to an important role for physical examination in tumor surveillance after mastectomy and reconstruction.

Computer-based learning module increases shared decision making in breast reconstruction.

BACKGROUND: Shared decision making (SDM) combines evidence-based medicine with individual patient preferences. Patients who are actively engaged in their own health care management with their physicians have been shown to experience not only increased compliance, but also higher satisfaction and better outcomes. We hypothesize that a computer-based learning module for breast reconstruction increases patient involvement in the decision-making process. MATERIALS AND METHODS: Women who underwent either immediate or delayed breast reconstruction at an academic teaching hospital from 2004 to 2007 were identified. Patients meeting inclusion criteria were mailed questionnaires on demographics, informational resources, and decision-making processes. Questionnaire results were divided into 2 groups for analysis: patients who received a standard surgeon consultation and patients who were shown a computer-based decision aid in addition to the standard consultation. RESULTS: There were 358 women eligible for our study. A total of 255 patients (75.9%) responded to the survey; 168 patients were shown the computer-based decision aid and 87 patients were not. Patients who used the computer-based learning module reported a greater role in choosing the type of reconstruction (P < .001). Additionally, these patients reported a greater number of reconstructive options offered to them (P < .001) and were more satisfied with the amount of information provided by their reconstructive surgeon (P = .049). CONCLUSIONS: A computer-based learning module allows patients to assimilate information and actively participate in choosing type of breast reconstruction. Use of this educational modality represents a simple and effective way to improve the shared decision-making process.

Postmastectomy radiation therapy and breast reconstruction: an analysis of complications and patient satisfaction.

The indications for postmastectomy radiotherapy (PMRT) have expanded over the past decade. This study examines PMRT and reconstruction compared with a control group without radiotherapy. There were 919 reconstructed breasts identified (1999-2006) and separated into 3 groups: mastectomy with PMRT before reconstruction (n = 57), immediate reconstruction then PMRT (n = 59), and reconstruction without PMRT (n = 665). A validated questionnaire assessed patient satisfaction (response rate 73.7%). Overall complication rates for patients undergoing PMRT (before and after reconstruction) were higher than that of the controls (39.66% vs. 23.16%, P < 0.001). Immediate reconstruction before PMRT had increased overall and late (>90 days) complication rates, compared with controls (47.46% vs. 23.16%, P < 0.001; 33.90% vs. 15.59%, P < 0.001, respectively); however general and aesthetic satisfaction was similar. In contrast, PMRT before reconstruction has similar complication rates and general satisfaction with controls, but decreased aesthetic satisfaction (50% vs. 66.88%, P < 0.035).

Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation.

The purpose of this study is to describe our experience with nipple-sparing mastectomy and immediate reconstruction, with particular attention to patient satisfaction, aesthetic results, and nipple sensation. Immediate reconstruction was performed on 17 breasts in 10 patients, using either implants or autologous tissue flaps. Assessment of outcomes was performed through patient interviews, a self-reported patient satisfaction survey and review of postoperative photographs. Short-term complications included partial loss of the nipple-areolar complex requiring debridement (n = 3) and removal of the nipple-areolar complex (n = 2) for occult ductal carcinoma in situ. While all patients with completed breast reconstructions were satisfied with their general reconstructive experience, 6 of 9 patients were aesthetically satisfied with their breast reconstruction. Postoperative nipple sensation was reported in 75% of patients, although sensation was low (mean of 2.8 of 10). As nipple-sparing mastectomy is becoming an increasing patient preference, preoperative discussion needs to address expectations, aesthetic satisfaction, and long-term cancer control.

Autologous fat grafting: a technique for stabilization of the microvascular pedicle in DIEP flap reconstruction.

Proper orientation of the microvascular pedicle is essential to ensure a high success rate in microvascular surgery. The inset of a deep inferior epigastric perforator (DIEP) flap breast reconstruction can sometimes be problematic given the long vascular pedicle, the acute takeoff from an internal mammary anastomosis, and the positioning of the flap on top of the vascular pedicle. In the postoperative period, the flap can also shift as the patient's activity level increases. We present a technique where nonvascularized autologous fat grafts are used to stabilize and cushion the vascular pedicle. Over a 14-month period, 117 consecutive DIEP flaps were performed to the internal mammary vessels with autologous fat grafting to the microvascular pedicle. Six flaps (5.1%) were explored during the immediate postoperative period for anastomotic compromise. Only one total flap failure (0.8%) was observed during this time. We had no direct complications related to the fat grafts. The use of nonvascularized autologous fat grafts is a simple and safe technique for stabilization of a microvascular pedicle. It should be considered in DIEP flap breast reconstruction and other microvascular cases where the vascular pedicle might be compressed by adjacent structures.

Randomized Controlled Trial of Antiseptic Hand Hygiene Methods in an Outpatient Surgery Clinic.

INTRODUCTION: Outpatient wound care plays an integral part in any plastic surgery practice. However, compliance with hand hygiene measures has shown to be low, due to skin irritation and lack of time. The objective of this trial was to determine whether single-use, long-acting antiseptics can be as effective as standard multiple-use hand hygiene methods in an outpatient surgical setting. MATERIALS AND METHODS: A prospective, randomized controlled trial was performed in the authors' outpatient plastic surgery clinic at Rutgers New Jersey Medical School, Newark, NJ to compare the efficacy of an ethyl alcohol-based sanitizer (Avagard D Instant Hand Aniseptic, 3M Health Care, St. Paul, MN), a benzalkonium chloride-based sanitizer (Soft & Shield, Bioderm Technologies, Inc, Trenton, NJ, distributed by NAPP Technologies, Hackensack, NJ ), and soap and- water handwashing. Subjects included clinic personnel, who were followed throughout the course of a 3-hour clinic session with hourly hand bacterial counts taken. RESULTS: During the course of the trial, 95 subjects completed the clinic session utilizing 1 of the hand hygiene methods (36 ethyl alcohol-based sanitizer, 38 benzalkonium chloride-based sanitizer, and 21 soap-and-water handwashing). There was no difference between hand bacterial counts using the different methods at 4 hourly time points (P greater than 0.05). Hand bacterial counts increased significantly over the 3-hour clinic session with the ethyl alcohol-based sanitizer (9.24 to 21.90 CFU, P less than 0.05), benzalkonium chloride-based sanitizer (6.69 to 21.59 CFU, P less than 0.05), and soap-and-water handwashing (8.43 to 22.75 CFU, P less than 0.05). CONCLUSION: There does not appear to be any difference in efficacy between single-use, long-acting sanitizer, and standard multiple-use hand hygiene methods. Hand bacterial counts increased significantly over the course of the 3-hour clinic session regardless of the hand hygiene measure used. Hand condition of subjects was improved with the ethyl alcohol-based sanitizer and the benzalkonium chloride-based sanitizer compared with soap-and-water handwashing.

Complications following expander/implant breast reconstruction utilizing acellular dermal matrix: a systematic review and meta-analysis.

BACKGROUND: The recent increase in popularity of acellular dermal matrix assistance in immediate expander/implant breast reconstruction has led to variety of viewpoints. Many studies are published indicating an increase in complications with the use of acellular dermal matrix, while others indicate there is no increase in complications. METHODS: This meta-analysis utilizes information from available studies that directly compare one specific type of acellular dermal matrix with traditional methods of immediate expander/implant breast reconstruction. Eight studies were found through a meticulous literature search that met these criteria. RESULTS: There was more than a 2-fold increase in the number of infections and explanations in the acellular dermal matrix group compared to the control. There was a 3-fold increase in seroma formation in the acellular dermal matrix group compared to the control. There was a significant difference of intraoperative fill volumes between the acellular dermal matrix group compared to the control. CONCLUSIONS: This study illustrates that after pooling all available date regarding the use of acellular dermal matrix in immediate expander/implant breast reconstruction there appears to be an increased rate of complications. However, the increased intraoperative fill volume may lead to ultimately greater patient satisfaction.

Patient satisfaction in unilateral and bilateral breast reconstruction [outcomes article].

BACKGROUND: The goal of reconstruction after mastectomy is to provide a long-term and symmetric reconstruction. Providing symmetry entails different decision making when faced with a unilateral or bilateral reconstruction. In unilateral reconstruction, the goal is to match the contralateral breast; however, in bilateral reconstruction, symmetry between the reconstructed breasts is more important. The purpose of this study was to examine patient satisfaction between unilateral and bilateral reconstruction. METHODS: All women at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected. A survey was administered examining general and aesthetic satisfaction. Patients with unilateral reconstruction were identified and compared with patients with bilateral reconstruction. Additional analysis was performed based on the type of reconstruction, including autologous, autologous with implant, and tissue expander/implant-based reconstruction. RESULTS: Overall, 702 women underwent 910 breast reconstructions (494 unilateral, 416 bilateral). Patients in the bilateral reconstruction group were more likely to have prophylactic mastectomy and immediate reconstruction. Complication rates were similar between unilateral and bilateral reconstruction. Patient satisfaction was highest in unilateral patients with autologous compared with implant reconstruction (general satisfaction, 73.9 versus 40.9 percent, p < 0.0001; aesthetic satisfaction, 72.3 versus 43.2 percent, p < 0.0001). Bilateral reconstruction had similar general and aesthetic satisfaction scores across autologous, autologous with implant, and implant-based reconstruction. CONCLUSIONS: Patients undergoing unilateral reconstruction have the highest satisfaction with autologous reconstruction. As symmetry between reconstructed breasts is essential for patient satisfaction in bilateral reconstruction, it is important to use the same type of reconstruction, whether autologous or implant-based.

Impact of complications on patient satisfaction in breast reconstruction.

BACKGROUND: The development of a complication after surgery can be difficult for both patient and surgeon. With a growing body of literature evaluating patient satisfaction after breast reconstruction, few studies directly focus on the impact of surgical complications on satisfaction. This study analyzed the effect of complications on general and aesthetic satisfaction after breast reconstruction. METHODS: All women at an academic institution undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and history of complications were collected. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered examining general and aesthetic satisfaction. Patients with complications were compared with patients with no complications. RESULTS: Overall, 716 women underwent 932 reconstructions; 233 patients had a complication. Patient demographics and response rate were similar between the two groups (overall response rate 75.4 percent). Development of a complication correlated with increased odds of aesthetic dissatisfaction (odds ratio = 1.61, p = 0.047). Other predictors of dissatisfaction were older age, reconstruction with an implant, and a longer time interval between reconstruction and survey, while autologous reconstruction was a predictor of satisfaction. Among patients with a complication, implant reconstruction and mastectomy for prophylaxis were significant predictors of dissatisfaction. CONCLUSIONS: Aesthetic satisfaction after breast reconstruction is lower in patients developing a complication, older patients, and those receiving an implant reconstruction. Furthermore, patients with a prophylactic mastectomy are more likely than those with a therapeutic mastectomy to be dissatisfied when complications arise. These relationships are important, as measures to improve quality and decrease complications can directly improve patient satisfaction.

The lateral chest wall: a separate aesthetic unit in breast surgery.

BACKGROUND: The lateral chest wall is an aesthetic unit often overlooked in breast surgery. Abnormalities are often seen in candidates for aesthetic and reconstructive breast surgery and in the massive weight loss population. Preoperative evaluation of the lateral chest wall is necessary to address this area properly. These deformities are intimately associated with the final outcome of any breast operation. METHODS: To better define deformities of the lateral chest wall, a series of 522 patients who had aesthetic or reconstructive breast surgery was reviewed retrospectively. The preoperative and postoperative photographs were evaluated by two surgeons independently. Any surgical approaches used to correct lateral chest wall deformities were documented. RESULTS: In evaluating the lateral chest wall, the authors identified three subunit areas that need to be addressed to maximize aesthetic result: the axilla, the lateral breast, and the chest wall. Deficiency and excess of skin and fat contribute to any deformities in this region; deficiency or excess was found in 39 percent of patients. These deformities, when identified, were surgically addressed in 40 percent of patients, as management strategies included transfer of autologous tissue, fat injection, liposuction, or direct excision. CONCLUSIONS: Lateral chest wall deformities are often found among breast surgery candidates and can affect the final outcome. This area should be treated as a separate aesthetic unit from the breast. Patients with deficiency or excess should be counseled appropriately, as proper treatment may require procedures in addition to the primary breast procedure. The classification system presented can serve as a guideline for management of deformities in this region.

Impact of sequencing of postmastectomy radiotherapy and breast reconstruction on timing and rate of complications and patient satisfaction.

PURPOSE: There are few long-term studies of how the sequencing of postmastectomy radiotherapy (PMRT) and breast reconstruction (BR) affects the time to development of complications or patient satisfaction with BR. We therefore studied this issue. METHODS AND MATERIALS: One hundred thirteen women who underwent BR at Beth Israel Deaconess Medical Center (Boston, MA) from 1999-2006 and also received PMRT were included. Complications requiring surgery were categorized as early (within 90 days of BR) or late. The median length of follow-up after BR was 46.5 months. Patients' general and esthetic satisfaction was assessed with a validated questionnaire. RESULTS: Complications occurred among 32% of 57 women receiving PMRT before BR and 44% of 57 patients having BR before PMRT (p = 0.176). Early complications were more frequent in patients who had PMRT first (18%) than for those with BR first (11%) (p = 0.210); conversely, late complication rates in the two groups were 14% and 33%, respectively (p = 0.009). General satisfaction was comparable between the PMRT-first and BR-first groups (68% and 68%, respectively; p = 0.995); esthetic satisfaction rates were also similar (50% and 62%, respectively; p = 0.238). CONCLUSIONS: The sequencing of PMRT and BR did not have a substantial impact on the total risk of complications or patients' general and esthetic satisfaction. However, early complications tended to develop in patients having PMRT first, whereas patients having BR first had a higher risk of late complications. Additional study of the effects of sequencing of PMRT on particular types of reconstructions may help devise strategies for reducing these risks.

Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction.

BACKGROUND: The potential for donor-site morbidity associated with bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has led to the popularization of deep inferior epigastric artery perforator (DIEP) flap reconstruction. This study compares postoperative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction. METHODS: One hundred five women with bilateral pedicled TRAM flaps were compared with 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Postoperative follow-up data were obtained through Short Form-36, Functional Assessment of Cancer Therapy-Breast, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys. RESULTS: The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data were otherwise similar. Abdominal hernias occurred in three TRAM patients (2.9 percent) and in no DIEP patients, whereas abdominal bulges occurred in three TRAM patients (2.9 percent) and four DIEP patients (6.9 percent); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Postoperative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the Medical Outcome Study Short Form-36 subjective energy category (p = 0.01) and mean Functional Assessment of Cancer Therapy-Breast score (p = 0.01). CONCLUSIONS: This study suggests no significant differences in donor-site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction.

Sociodemographics, referral patterns, and Internet use for decision-making in microsurgical breast reconstruction.

BACKGROUND: Increasing numbers of patients are choosing to undergo microsurgical breast reconstruction. Currently, no information is available about the sociodemographic profile, referral patterns, or decision-making process of women who choose this reconstructive modality. METHODS: All women who underwent breast reconstruction at a single institution between 2004 and 2007 were surveyed regarding demographic information, referral patterns, and decision-making processes. For data analysis, the cohort was separated by reconstructive method: nonmicrosurgical reconstruction (i.e., implant, latissimus, and pedicled transverse rectus abdominis musculocutaneous flaps) or microsurgical reconstruction (i.e., free transverse rectus abdominis musculocutaneous, deep inferior epigastric artery perforator, superficial inferior epigastric artery, and superior gluteal artery perforator flaps). RESULTS: Overall, 332 women were surveyed, with a response rate of 77 percent. Patients who underwent microsurgical reconstruction were more likely to be 40 to 49 years old (p = 0.014), whereas nonmicrosurgical patients were clustered at the extremes of age. Microsurgery patients self-referred to a reconstructive surgeon, whereas other patients were sent by surgical oncologists (p < 0.001). The Internet was an important decision-making aid to help microsurgery patients identify their reconstructive modality (p < 0.001). Compared with nonmicrosurgical counterparts, microsurgery patients were independent decision-makers and more active in choosing their reconstructive procedure (p = 0.001). CONCLUSIONS: Microsurgical breast reconstruction is highly sought after by a subset of patients with breast cancer. These patients are independent decision-makers in their health care choices. They use the Internet to learn about breast reconstruction techniques and are more likely to self-refer to a reconstructive surgeon. It remains unclear how many patients would choose microsurgical reconstruction if offered more widely or if awareness of the procedure were greater.

Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques.

BACKGROUND: Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction. METHODS: All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. RESULTS: Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198). CONCLUSIONS: Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Postoperative Pain Management in DIEP Flap Breast Reconstruction: Identification of Patients With Poor Pain Control.

OBJECTIVE: Adequate control of postoperative pain directly improves patient satisfaction and outcomes, and timely identification of patients with poorly controlled pain is essential. Pain management protocols are best studied in patients recovering from the same operation. In our institution, the postoperative pain regimen for patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction is standardized using patient-controlled analgesia (PCA) followed by conversion to oral narcotics. From this uniform population, we were able to identify a subgroup of patients with poor pain control. METHODS: Over a 44-month period, 179 consecutive patients underwent DIEP flap breast reconstruction with 242 flaps performed. A retrospective chart review recorded PCA usage, visual analog scale pain scores, and length of stay. RESULTS: Pain management with PCA after DIEP flap breast reconstruction was uniformly controlled. Most patients (74.9%) required PCA usage in the first 2 days with conversion to oral analgesics. A subgroup of patients (25.1%) continued to require PCA usage on the third postoperative day. These "nonresponder" patients had a higher visual analog scale score on the first postoperative day, higher total intravenous morphine use, and a longer length of stay (all, P < .05). A multivariate analysis revealed more nonresponders among patients undergoing immediate breast reconstruction (P < .05); however, all other factors analyzed had no correlation. CONCLUSION: We report a subgroup of patients with poor pain control after DIEP flap breast reconstruction. This group of patients required a longer course of pain management and subsequently a longer hospital stay. Pain management protocols that identify these patients promptly can allow for appropriate modifications.