Implications of the COVID-19 Pandemic on Immediate Breast Reconstruction Access.

AIMS: As a result of COVID-19, there have been restrictions on surgical interventions across Canada. Immediate breast reconstruction (IBR), while an essential component of cancer care, is classified as elective surgery and therefore has been restricted in access over the course of the pandemic. The purpose of this study was to compare wait times for breast cancer patients undergoing surgical intervention for IBR before and since the COVID-19 pandemic. METHODS: This was a retrospective cross-sectional study of consecutive patients who underwent IBR between July 2018 and October 2021 by 5 plastic surgeons at a single Canadian health center. Wait times to consultation and surgical intervention between pre- and post-COVID cohorts were analyzed. RESULTS: A total of 161 patients met inclusion criteria. For ablative surgery, there was no difference in wait times to surgical oncology consultation (14.0 ± 12.3 vs 14.0 ± 11.0 days, P = 0.991) and surgical intervention with IBR (41.0 ± 49.8 vs 35.0 ± 58.0 days, P = 0.621) between the pre- and post-COVID cohorts. For breast reconstruction, while time to consultation with plastic surgery (12.5 ± 14.8 vs 11.0 ± 12.8 days, P = 0.775) remained unchanged, usage of autologous techniques was reduced [n = 13 (16%) vs n = 2 (2%), P = 0.006], and time to second-stage alloplastic reconstruction increased (230 ± 102 vs 325 ± 224 days, P = 0.044) post-COVID. CONCLUSIONS: Swift adoption of evidence driven protocols has resulted in comparable wait times for breast cancer ablative procedures. However, utilization of autologous techniques and wait times to second-stage reconstructions have increased.

Management of patients requiring reconstructive breast surgery during the COVID-19 pandemic: recommendations from the BC Regional Breast Reconstruction Network.

Summary: The COVID-19 pandemic has caused unprecedented challenges in health care, threatening access and delivery of medical services across all sectors. Patients with breast cancer desiring breast reconstruction require timely interdisciplinary care; resource limitations threaten access to this elective reconstructive element of cancer care. An expert panel was convened to identify challenges, recommend preliminary solutions, and identify important future directions in anticipation of prolonged restrictions. This paper presents consensus recommendations for care of breast cancer reconstruction patients during the pandemic based on expert opinion from the BC Breast Reconstruction Network.

Recurrent Breast Cerebrospinal Fluid Pseudocyst: A Complication of Ventriculoperitoneal Shunt Placement.

Ventriculoperitoneal (VP) shunt complications involving the breast are rare, with the majority involving the formation of a cerebrospinal fluid pseudocyst. We present the case of a 22-year-old woman with recurrent cerebrospinal fluid pseudocyst secondary to fracture of a VP shunt at the time of breast surgery for breast asymmetry. We review the literature on this topic and present our case that highlights the need of the breast surgeon to take into account the position of VP shunts placed at birth. Shunts placed on the chest wall may result in breast asymmetry requiring surgery in the adolescent. Shunts in place since birth may be at greater risk of fracture during breast implant placement due to manipulation of a calcified and fragile shunt leading to formation of a cerebrospinal fluid pseudocyst.

Autologous Breast Reconstruction in Women Older Than 65 Years Versus Women Younger Than 65 Years: A Multi-Center Analysis.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson χ² and analysis of variance tests were used. Given the number of analyses, a more conservative α of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

Predictors of Mastectomy Flap Necrosis in Patients Undergoing Immediate Breast Reconstruction: A Review of 718 Patients.

BACKGROUND: Mastectomy flap necrosis (MFN) after mastectomy and immediate breast reconstruction can compromise postsurgical recovery, lead to additional surgeries, and compromise aesthetic outcome. The objective of this study was to determine if there is a difference in the rate of MFN in patients undergoing immediate alloplastic versus immediate autologous breast reconstruction. The secondary objective was to identify additional patient and surgical factors that may influence the rate of MFN. METHODS: A retrospective chart review of patients who underwent immediate breast reconstruction between 2003 and 2011 in the University of British Columbia Breast Program was performed. Demographic, oncologic, reconstructive, and surgical data were compiled. RESULTS: Approximately 404 alloplastic and 314 autologous patients were reviewed. The overall rate of MFN was 12.9%. There was a trend toward a higher MFN rate in the autologous patient group (15.2% vs 11.6%, P = 0.095). After controlling for age, body mass index (BMI), smoking status, preoperative breast radiation, surgery duration, cancer side, mastectomy type, and postoperative chemotherapy, no association was found between reconstruction type and MFN. BMI greater than 30, smoking status, and preoperative radiation were independent predictors of MFN. Surgical factors including longer duration of surgery and Wise pattern mastectomy incision were also found to be associated with increased odds of MFN. CONCLUSION: We found no difference in the rate of MFN when comparing immediate alloplastic and autologous reconstruction methods. A number of patient and surgical factors were found to be predictors of MFN. The results of this large, retrospective study will help surgeons to tailor their reconstruction based on a patient's risk factors to minimize the incidence of MFN.

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.

Skin-sparing mastectomy and immediate autologous breast reconstruction in locally advanced breast cancer patients: a UBC perspective.

PURPOSE: To describe the clinical outcomes of patients with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy and preoperative radiotherapy, followed by skin-sparing mastectomy (SSM) and immediate autologous breast reconstruction (IABR). METHODS: A retrospective review of 30 LABC patients who underwent SSM and IABR between 1997 to 2007 was performed. Data were drawn from patient records and the University of British Columbia (UBC) Breast Reconstruction and British Columbia Cancer Agency databases. RESULTS: All 30 patients received neoadjuvant chemotherapy, preoperative radiotherapy, SSM, and IABR. Fifteen patients (50%) had stage IIIA disease, 13 (43%) stage IIIB, and 2 (6.7%) stage IIIC. Reconstruction types included the pedicled transverse rectus myocutaneous flap (n = 24), the latissimus dorsi flap (n = 5), and a combination of transverse rectus myocutaneous and latissimus dorsi flap (n = 1). The median follow-up was 3.51 years (range 1-9.4 years). Local complications included mastectomy flap necrosis (n = 3), partial flap necrosis (n = 1), fat necrosis (n = 1), seroma (n = 3), infection (n = 2), and flap fibrosis (n = 1). The incidence of donor site complications was 20%. Overall 5-year actuarial locoregional relapse-free, distant relapse-free, and disease-specific survival rates were 80, 65, and 68%, respectively. Excellent or good physician-rated aesthetic results were achieved in 66% of patients. CONCLUSIONS: The UBC protocol avoids irradiation of the autologous breast reconstruction. Outcomes compare with findings from similar studies with respect to local recurrence, distant relapse, overall survival, and surgical complication rates. Neoadjuvant chemotherapy and preoperative radiotherapy in LABC patients desiring autologous breast reconstruction can be considered a safe option.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting?

Breast cancer susceptibility gene (BRCA) mutation carriers have an increased risk of breast cancer. Mitigation of this risk can be achieved via surveillance or prophylactic mastectomy with or without breast reconstruction. Those that choose surgery expect to reduce their chance of developing cancer. The purpose of this study was to determine the incidence of patients developing breast cancer prior to surgery and to identify modifiable contributing factors within the patient journey. This is a historical cohort study of all BRCA mutation carriers identified through the British Columbia Cancer Hereditary Cancer Program between 2000 and 2012. Patients were divided into two groups: surveillance (S) and prophylactic mastectomy with immediate breast reconstruction (PM/IBR). The incidence of cancer, time to PM/IBR and patient journeys were analyzed. A total of 333 women were identified. The time to surgery from mutation disclosure was a median of 31 (5.3, 75.7) months. During this period, 6% of patients developed breast cancer compared with a 14% incidence of breast cancer in patients choosing surveillance. The majority of time to surgery was attributed to the period between mutation disclosure and the decision to proceed with surgery. Strategies to facilitate decision-making as well as wait list prioritization and dedicated operative time should be targeted to this population to decrease the number of women developing an interval cancer prior to surgery.

The surgical management of granulomatous mastitis.

Granulomatous mastitis is an inflammatory breast condition of unknown etiology. Management remains controversial and treatment algorithms are lacking from the literature. Few resources exist that discuss breast reconstruction following extirpation. This descriptive case series reviews the clinicopathologic features of granulomatous mastitis.We describe the surgical management undertaken at our institution including General and Plastic Surgery procedures. Eleven clinical charts and histologic slides of biopsy specimens were reviewed in our health region between 1992 and 2007. Demographic data, clinical presentation, and radiologic findings were tabulated. Treatment consisted of empirical antibiotics and surgical excision. Procedures performed included incision and drainage (n = 8), excisional biopsy (n = 15), partial mastectomy (n = 5), partial mastectomy with reduction mammaplasty (n = 2), and mastectomy with TRAM flap reconstruction (n = 1).Treatment was successful in all but one case. Multiple surgeries for recurrent lesions were often required to achieve final remission. Following extirpation, we recommend delayed breast reconstruction to monitor for recurrence.

Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature.

PURPOSE: The primary objective of this systematic review was to identify and analyze the outcomes measures that have been used to evaluate postoperative results following surgery for cubital tunnel syndrome. The secondary objective was to compare the postoperative results among patients evaluated using patient-satisfaction instruments to those evaluated using surgeon-reported scales. METHODS: Computerized database searches of MEDLINE, EMBASE, and MEDLINE In-Process were performed. Studies involving adults with cubital tunnel syndrome in whom the surgical intervention was simple decompression, anterior transposition (subcutaneous, submuscular or intramuscular), endoscopic decompression, or medial epicondylectomy were included. A systematic review was performed that included randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series. RESULTS: This systematic review of the literature identified 42 studies that satisfied the inclusion criteria. The authors identified 21 health outcomes measures used in cubital tunnel studies. These consisted of 2 generic instruments; 10 symptom-specific, author-reported instruments; 3 symptom-specific, patient-reported instruments; and 6 patient questionnaires. No measure demonstrated adequate development or validation for use in its target population. Available data revealed a consistently high level of patient satisfaction following simple decompression or submuscular transposition (65% to 92%). The results of the author-reported, symptom-specific scales varied widely and showed no obvious association with patient satisfaction. The variation in reporting of results prevented statistical comparisons between author-reported results and patient-reported results. CONCLUSIONS: To the best of our knowledge, this is the first systematic review to delineate the outcomes measures used to evaluate the treatment of cubital tunnel syndrome. Our results show that reliable, reproducible, and valid outcomes measures are lacking from the surgical literature. A standardized assessment protocol for ulnar neuropathy is required for future comparison trials. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis.

PURPOSE: Optimal surgical management of cubital tunnel syndrome remains uncertain despite the publication of numerous case series, observational studies, systematic reviews, and, in recent years, randomized controlled studies. The purpose of this meta-analysis was to compare simple decompression to anterior transposition of the ulnar nerve for the treatment of this condition, using comparative trials and randomized controlled trials. METHODS: Computerized database searches of MEDLINE, EMBASE, Cochrane Central, and all relevant surgical archives were performed. Studies involving adults with cubital tunnel syndrome in whom surgical intervention was simple decompression or anterior transposition (subcutaneous or submuscular) were included. Analysis was limited to randomized controlled trials and comparative observational studies. Included studies were assessed for quality, heterogeneity, and publication bias. Odds ratios of clinical improvement comparing simple decompression to anterior transposition (submuscular or subcutaneous) were calculated for each study. RESULTS: Ten studies involving a total of 449 simple decompressions, 342 subcutaneous transpositions, and 115 submuscular transpositions were included. There was little evidence of publication bias or statistical study heterogeneity. Odds of improvement with simple decompression versus anterior transposition were 0.751, 95% confidence interval (0.542, 1.040). Subanalyses on the basis of transposition technique (subcutaneous or submuscular) and study quality did not render a statistically significant result. CONCLUSIONS: This report represents the best cumulative evidence to date examining the surgical management of cubital tunnel syndrome. In this study, we found no statistically significant difference, but rather a trend toward an improved clinical outcome with transposition of the ulnar nerve as opposed to simple decompression. Additional prospective, randomized studies that use reproducible preoperative and postoperative objective measures might add statistical power to this finding.

Preoperative and Postoperative Assessment of Rectus Abdominis Muscle Size and Function following DIEP Flap Surgery.

BACKGROUND: Prospective evaluation of rectus abdominis muscle function after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is limited. Elimination of muscle harvest with this procedure is theoretically associated with preservation of rectus abdominis function and minimization of abdominal wall morbidity. In this study, the authors evaluate the change in rectus abdominis muscle size and function after DIEP flap surgery. METHODS: Patients undergoing unilateral DIEP flap surgery were recruited prospectively. Using computed tomography, the change in preoperative to postoperative rectus abdominis muscle size was compared between the operative side rectus abdominis muscle and the contralateral, nonoperative control rectus abdominis. Postoperative muscle integrity and contractility were evaluated using ultrasound by comparing the change in rectus abdominis muscle dimensions between contractile and relaxed states. The BREAST-Q was used to score patients' subjective satisfaction. Clinical and radiographic hernia rates were also calculated. RESULTS: Analysis of 26 paired rectus abdominis muscles revealed no significant change in muscle size from preoperative to postoperative values. Furthermore, dimensional change from contractile to relaxed states postoperatively was similar for paired operative and nonoperative rectus abdominis muscles. BREAST-Q scores indicated a high degree of satisfaction in abdominal well-being, breast satisfaction, and surgical experience domains. There were no clinical or radiographic abdominal wall hernias noted. CONCLUSIONS: The DIEP flap is an effective surgical procedure with minimal abdominal wall morbidity that is associated with no measurable loss in rectus abdominis size and contractile function postoperatively. Patients are highly satisfied with their abdominal function postoperatively using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evidence-Based Medicine: Alloplastic Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction. SUMMARY: There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Evidence-Based Medicine: Autologous Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. SUMMARY: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

A Review of 101 Consecutive Subcutaneous Mastectomies and Male Chest Contouring Using the Concentric Circular and Free Nipple Graft Techniques in Female-to-Male Transgender Patients.

BACKGROUND: Many techniques exist for subcutaneous mastectomy in female-to-male transgender patients. The authors review outcomes for two techniques and present an algorithm to aid surgeons in technique selection. METHODS: One hundred one consecutive female-to-male transgender patients undergoing subcutaneous mastectomy using the concentric circular or free nipple graft technique were retrospectively reviewed. An algorithm for procedure selection was created using classification and regression tree analysis. Aesthetic results (nipple-areola complex, scar, and chest contour) were also independently reviewed. RESULTS: Two hundred two subcutaneous mastectomies were performed (concentric circular, 92 breasts; free nipple graft, 110 breasts). The overall complication rate was 21.3 percent, with 6.4 percent requiring operative intervention (free nipple graft, 1 percent; concentric circular, 13 percent; p < 0.001). The overall revision rate was 23.8 percent (free nipple graft, 12.7 percent; concentric circular, 37.0 percent; p < 0.001). In the concentric circular group, there were 3.3 times the odds of total complications (p = 0.03) and 4.0 times the odds of revision surgery (p < 0.001). Mean aesthetic scores for the concentric circular technique were superior to free nipple graft for scar (3.39 versus 2.62; p < 0.001) and contour (3.82 versus 3.34; p < 0.001). CONCLUSIONS: In patients who meet selection criteria, the concentric circular technique is preferred because of fewer scars, improved aesthetic contour, and potential for retained nipple sensation. These patients must be counseled regarding the higher rate of complications and revisions. It was determined that smokers and those with a nipple-to-inframammary fold distance greater than 7 cm or nipple-to-inframammary fold distance less than 7 cm and a body mass index greater than 27 kg/m should undergo the free nipple graft technique because of the increased risk of complications with the concentric circular technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods.

BACKGROUND: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs. METHODS: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected. RESULTS: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders. CONCLUSIONS: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review.

BACKGROUND: There are few studies that compare the deep inferior epigastric artery perforator (DIEP) flap to the pedicled transverse rectus abdominis myocutaneous (pTRAM) flap for use in reconstructive breast surgery. The authors examined four factors that aid in decision-making: donor-site morbidity, need for surgery related to abdominal morbidity, operative time, and complications. METHODS: This is a retrospective review of patients undergoing breast reconstruction using the DIEP or pTRAM flap at the University of British Columbia between 2002 and 2013. The authors compared operative time and abdomen- and flap-related complications in both groups. RESULTS: Reconstruction was performed in 507 patients; 25.6 percent received DIEP flaps (n = 183 breasts) and 74.4 percent underwent pTRAM flap surgery (n = 444 breasts). Pedicled TRAM flap patients were more likely to require abdominal closure with mesh (44.2 percent versus 8.1 percent; p < 0.001); 21.2 percent of them had a postoperative bulge and/or hernia versus 3.1 percent of DIEP flap patients; and 12.7 percent of pTRAM flap patients required surgery for hernia/bulge. Controlling for confounders, there were five times the odds of a hernia/bulge in the pTRAM flap group. DIEP flap surgery was 234 minutes longer than pTRAM flap surgery. CONCLUSIONS: The benefits of the pTRAM flap may be offset by the need to correct abdominal wall complications. DIEP flap reconstruction had lower donor complications but increased operative time. A cost analysis is needed to determine the most economical procedure. CLINCIAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q.

BACKGROUND: Reimbursement has been recognized as a physician barrier to autologous reconstruction. Autologous reconstructions are more expensive than prosthetic reconstructions, but provide greater health-related quality of life. The authors' hypothesis is that autologous tissue reconstructions are cost-effective compared with prosthetic techniques when considering health-related quality of life and patient satisfaction. METHODS: A cost-effectiveness analysis from the payer perspective, including patient input, was performed for unilateral and bilateral reconstructions with deep inferior epigastric perforator (DIEP) flaps and implants. The effectiveness measure was derived using the BREAST-Q and interpreted as the cost for obtaining 1 year of perfect breast health-related quality-adjusted life-year. Costs were obtained from the 2010 Nationwide Inpatient Sample. The incremental cost-effectiveness ratio was generated. A sensitivity analysis for age and stage at diagnosis was performed. RESULTS: BREAST-Q scores from 309 patients with implants and 217 DIEP flap reconstructions were included. The additional cost for obtaining 1 year of perfect breast-related health for a unilateral DIEP flap compared with implant reconstruction was $11,941. For bilateral DIEP flaps compared with implant reconstructions, the cost for an additional breast health-related quality-adjusted life-year was $28,017. The sensitivity analysis demonstrated that the cost for an additional breast health-related quality-adjusted life-year for DIEP flaps compared with implants was less for younger patients and earlier stage breast cancer. CONCLUSIONS: DIEP flaps are cost-effective compared with implants, especially for unilateral reconstructions. Cost-effectiveness of autologous techniques is maximized in women with longer life expectancy. Patient-reported outcomes findings can be incorporated into cost-effectiveness analyses to demonstrate the relative value of reconstructive procedures.

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective.

BACKGROUND: An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant. METHODS: Patients who had their tissue expander irradiated before implant exchange were identified. Complications, capsular contracture, revision surgery, and autologous salvage rates of irradiated patients were compared with a control group of nonirradiated patients. RESULTS: Immediate two-stage tissue expander/implant reconstruction was initiated in 604 patients, with 113 irradiated breasts meeting inclusion criteria. Three hundred thirty-nine nonirradiated breasts constituted the control group. There was a 4.2 increased odds of major complications in the irradiated group, after adjusting for plastic surgeon, age, body mass index, smoking, chemotherapy, and cancerous breast (OR, 4.2; p=0.001). The grade III and IV capsular contracture rate was significantly higher in the irradiated group compared with the control group (21.7 percent versus 10 percent; p<0.008). The revision rate in the control group was higher compared with the irradiated group (30.2 percent versus 20.9 percent; p<0.001). CONCLUSIONS: Postmastectomy irradiation to the tissue expander is associated with high complications; however, these patients have an acceptable capsular contracture rate that compares favorably with other implant-based radiotherapy algorithms. Revision rates were less than expected in irradiated breasts. This study suggests that immediate tissue expander/implant reconstruction is a reasonable surgical option in the setting of postmastectomy radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.