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BACKGROUND: Little is known about disparities in oncoplastic breast surgery delivery. METHODS: The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy. RESULTS: We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001). CONCLUSION: Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.
Subject(s)
Breast Neoplasms , Healthcare Disparities , Mammaplasty , Mastectomy, Segmental , Humans , Female , Breast Neoplasms/surgery , Breast Neoplasms/economics , Middle Aged , Mastectomy, Segmental/statistics & numerical data , Mastectomy, Segmental/economics , Mammaplasty/economics , Mammaplasty/statistics & numerical data , Mammaplasty/methods , Healthcare Disparities/statistics & numerical data , Massachusetts , United States , Aged , Adult , Insurance, Health , Practice Patterns, Physicians'/statistics & numerical data , Practice Patterns, Physicians'/economics , Follow-Up Studies , PrognosisABSTRACT
BACKGROUND: Little is known about practice patterns and payments for immediate lymphatic reconstruction (ILR). This study aims to evaluate trends in ILR delivery and billing practices. METHODS: We queried the Massachusetts All-Payer Claims Database between 2016 and 2020 for patients who underwent lumpectomy or mastectomy with axillary lymph node dissection for oncologic indications. We further identified patients who underwent lymphovenous bypass on the same date as tumor resection. We used ZIP code data to analyze the geographic distribution of ILR procedures and calculated physician payments for these procedures, adjusting for inflation. We used multivariable logistic regression to identify variables, which predicted receipt of ILR. RESULTS: In total, 2862 patients underwent axillary lymph node dissection over the study period. Of these, 53 patients underwent ILR. Patients who underwent ILR were younger (55.1 vs 59.3 years, P = 0.023). There were no significant differences in obesity, diabetes, or smoking history between the two groups. A greater percentage of patients who underwent ILR had radiation (83% vs 67%, P = 0.027). In multivariable regression, patients residing in a county neighboring Boston had 3.32-fold higher odds of undergoing ILR (95% confidence interval: 1.76-6.25; P < 0.001), while obesity, radiation therapy, and taxane-based chemotherapy were not significant predictors. Payments for ILR varied widely. CONCLUSIONS: In Massachusetts, patients were more likely to undergo ILR if they resided near Boston. Thus, many patients with the highest known risk for breast cancer-related lymphedema may face barriers accessing ILR. Greater awareness about referring high-risk patients to plastic surgeons is needed.
Subject(s)
Breast Neoplasms , Lymph Node Excision , Humans , Middle Aged , Female , Massachusetts , Breast Neoplasms/surgery , Breast Neoplasms/economics , Lymph Node Excision/economics , Mastectomy/economics , Retrospective Studies , Healthcare Disparities/economics , Healthcare Disparities/statistics & numerical data , Aged , Adult , Axilla/surgery , Mastectomy, Segmental/economics , Practice Patterns, Physicians'/economics , Practice Patterns, Physicians'/statistics & numerical dataABSTRACT
Background: Rippling remains one of the most common complications following prepectoral implant-based reconstruction (IBR). Objectives: The purpose of this study was to assess how implant cohesivity, a measure of elasticity and form stability, affects the incidence of rippling in prepectoral IBR. Methods: We performed a retrospective cohort study of 2-stage prepectoral IBR performed between January 2020 and June 2022 at the Brigham and Women's Hospital and Dana-Farber Cancer Institute, comparing outcomes in patients who received Allergan Natrelle least cohesive, moderately cohesive, and most cohesive silicone gel implants. Outcomes of interest were rippling and reoperation for fat grafting. Results: A total of 129 patients were identified, of whom 52 had the least cohesive implants, 24 had the moderately cohesive implants, and 53 patients had the most cohesive implants. The mean follow-up time was 463 (±220) days. A decreased incidence of rippling was seen with moderately cohesive (odds ratio [OR] 0.30, P < .05) and most cohesive (OR 0.39, P < .05) implants. Third stage reoperation for fat grafting was less frequent in patients with the most cohesive implant (OR 0.07, P < .05). In subgroup analyses, the patients with the most cohesive implant, who did not receive fat grafting at the time of initial implant placement, did not require reoperation for fat grafting (0%). Conclusions: The use of highly cohesive implants in prepectoral IBR is associated with decreased rippling and fewer reoperations for fat grafting.
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BACKGROUND: Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers. METHODS: Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes. RESULTS: There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients. CONCLUSION: Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.
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BACKGROUND: Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population. METHODS: Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy. RESULTS: Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors. CONCLUSION: Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.
Subject(s)
Breast Neoplasms , Inflammatory Breast Neoplasms , Lymphedema , Humans , Middle Aged , Female , Breast Neoplasms/surgery , Breast Neoplasms/pathology , Inflammatory Breast Neoplasms/complications , Inflammatory Breast Neoplasms/surgery , Prospective Studies , Lymphedema/etiology , Lymphedema/surgery , Lymph Node Excision/adverse effects , Risk Factors , Obesity/complications , Axilla/surgery , Sentinel Lymph Node Biopsy/adverse effectsABSTRACT
Many plastic surgery residency programs adapted to the COVID-19 pandemic by implementing virtual grand rounds. This study aimed to assess the impact of virtual grand rounds and how attendees perceived virtual grand rounds to inform future programmatic planning. Methods: This was a quality improvement initiative involving a cross-sectional survey and retrospective review of administrative records for the 2017-2018 (in-person) and 2021-2022 (virtual) academic years for two academic plastic surgery training programs in Boston, MA. Respondents were residents, fellows, and faculty within the two multisite plastic surgery residency training programs. Results: There were 39 respondents (51% faculty, 41% residents, and 8% fellows). There was no evidence of different preferences for the format of future grand rounds (P = 0.08), with most preferring hybrid, defined as in person for speakers and others who could attend. Most respondents indicated a more accessible learning environment (86.8%) and lack of in-person interaction (82.1%) as reasons for liking and not liking virtual grand rounds, respectively. Excluding outliers, attendance in 2021-2022 was on average 7.4% points greater than that in 2017-2018 (P < 0.001), or six to seven more individuals at each session. There were significantly more out-of-state speakers in 2021-2022 (84%) as compared to 2017-2018 (28%) (P = 0.0008). Conclusions: Virtual grand rounds improved attendance and the geographic diversity of speakers. Attendees preferred a hybrid format for future grand rounds, citing advantages and disadvantages to both in-person and virtual formats.
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BACKGROUND: There is a need to better understand the financial toxicity of surgery on patients. Recent data demonstrated that plastic surgeons seldom discuss out-of-pocket costs with patients. Not much is known regarding the public perceptions of out-of-pocket cost communication in reconstructive and cosmetic breast surgery. METHODS: A cross-sectional survey was administered to adult women in the United States from November 2021 to December 2021 using Amazon Mechanical Turk. Perceptions regarding cost communication in plastic surgery were gathered. Incomplete responses were excluded. Multivariable models were used to identify predictors of responses. RESULTS: There were 512 complete responses. Respondents had a mean age of 37.4 years. The majority strongly agreed or agreed that plastic surgeons should discuss out-of-pocket costs with patients undergoing implant-based breast reconstruction (85%), plastic surgeons should know the impact of surgery on patients' financial well-being (78%), and discussing costs was the most important aspect of the appointment (70%). Respondents who were unsure of their insurance status had lower odds of strongly agreeing or agreeing that surgeons should discuss out-of-pocket costs for autologous reconstruction (OR 0.12, CI 0.02-0.58, p = 0.01) and cosmetic breast augmentation (OR 0.14, CI 0.03-0.65, p = 0.01). Privately insured respondents had greater odds of strongly agreeing or agreeing to both, respectively (OR 2.21, CI 1.32-3.82, p < 0.01; OR 1.94, CI 1.17-3.31, p = 0.01) CONCLUSION: Many laywomen support the cost communication in plastic surgery and believe that plastic surgeons should know the impact of surgery on the patients' financial well-being, with variability among the sociodemographic groups. Plastic surgeons should strongly consider discussing costs with patients undergoing breast surgery.
Subject(s)
Breast Neoplasms , Mammaplasty , Surgery, Plastic , Adult , Humans , Female , United States , Cross-Sectional Studies , Public Opinion , Mammaplasty/methods , CommunicationABSTRACT
BRIEF SUMMARY: As value-based care gains traction in response to towering healthcare expenditures and issues of healthcare inequity, hospital capacity, and labor shortages, it is important to consider how a value-based approach can be achieved in plastic surgery. Value is defined as outcomes divided by costs across entire cycles of care. Drawing on previous studies and policies, this paper identifies key opportunities in plastic surgery to move the levers of costs and outcomes to deliver higher-value care. Specifically, outcomes in plastic surgery should include conventional measures of complication rates as well as patient-reported outcome measures in order to drive quality improvement and benchmark payments. Meanwhile, cost reduction in plastic surgery can be achieved through value-based payment reform, efficient workflows, evidence-based and cost-conscious selection of medical devices, and greater use of out-patient surgical facilities. Lastly, we discuss how the diminished presence of third-party payers in aesthetic surgery exemplifies the cost-conscious and patient-centered nature of value-based plastic surgery. To lead in future health policy and care delivery reform, plastic surgeons should strive for high-value care, remain open to new ways of care delivery, and understand how plastic surgery fits into overall health care delivery.
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BACKGROUND: Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM. METHODS: Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission. RESULTS: Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01). CONCLUSIONS: The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.
Subject(s)
Breast Neoplasms , Mastectomy, Modified Radical , Humans , Aged , United States , Female , Breast Neoplasms/surgery , Mastectomy/adverse effects , Medicare , Hospitalization , Patient Readmission , Retrospective Studies , Ambulatory Surgical Procedures/adverse effectsABSTRACT
BACKGROUND: The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion. METHODS: A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3). RESULTS: A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p < 0.05). Major complications occurred in 10% of patients. There was no significant difference in the development of major complications between the three groups (p = 0.57). Although not statistically significant, the probability of any major complication peaked 2 to 6 months after PMRT completion. CONCLUSION: There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.
Subject(s)
Breast Neoplasms , Mammaplasty , Humans , Female , Breast Neoplasms/complications , Mastectomy , Treatment Outcome , Retrospective Studies , Follow-Up Studies , Radiotherapy, Adjuvant/adverse effects , Mammaplasty/methods , Postoperative Complications/etiologyABSTRACT
BACKGROUND: Sensation after autologous breast reconstruction is an increasingly important outcome. Several studies demonstrated improved sensation with flap neurotization but utilized heterogenous measures and follow-up intervals. This review evaluates sensory outcomes after neurotization using uniform, objective outcome measurements. METHODS: PubMed/Medline and Embase databases were queried for articles published between January 1990 and January 2022. Inclusion criteria included studies with free flap tissue transfer breast reconstruction patients and use of Semmes-Weinstein Monofilaments (SWM) to quantify return of sensation after either neurotization or no neurotization. Reviews, case reports, and studies utilizing implants or pedicled flaps were excluded. RESULTS: Overall, 513 articles were screened. Eleven articles met inclusion criteria for a total of 474 patients. There were 254 non-neurotized patients included as controls (Group A) and 220 neurotized patients (Group B). Mean follow-up time was similar in both groups (22.06 months vs. 22.78 months, p > 0.05). There was no significant difference in age (Group A = 49.97 years vs. Group B = 42.47 years) or BMI (Group A = 25.48 vs. Group B = 25.97) between groups. More patients in group B received radiation therapy (Group B = 32.72% vs. Group A = 20.86%, p > 0.05). Patients that received neurotization had lower mean pressure thresholds (Group A = 38.85 gm/mm2 vs. Group B = 6.69 gm/mm2 , p = 0.053) than comorbidity-matched controls. CONCLUSION: Neurotization has been shown to be a safe and feasible option for enhancing return of sensation after breast reconstruction. Future studies with standardized, long-term follow-up will further elucidate the pattern of breast sensation return and the impact of neurotization.
Subject(s)
Free Tissue Flaps , Mammaplasty , Nerve Transfer , Humans , Middle Aged , Mammaplasty/adverse effects , Sensation/physiology , Breast/surgery , Free Tissue Flaps/surgeryABSTRACT
Climate change poses significant threats to human health and society. Although healthcare will bear a large burden of the downstream effects of climate change, the healthcare industry is simultaneously a major contributor to climate change. Within hospitals, surgery is one of the most energy-intensive practices. There is a growing body of literature describing ways to mitigate and adapt to climate change in surgery. However, there is a need to better understand the unique implications for each surgical subspecialty. This review contextualizes plastic and reconstructive surgery within the climate change discussion. In particular, this review highlights the specific ways in which plastic surgery may affect climate change and how climate change may affect plastic surgery. In light of growing public demand for change and greater alignment between industries and nations with regard to climate change solutions, we also offer a conceptual framework to guide further work in this burgeoning field of research.
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The US Food and Drug Administration (FDA) issued a boxed warning on breast implants in October 2021, requiring communication of certain risks to patients. This study assessed how this boxed warning may impact public perceptions of breast implants. Methods: A cross-sectional survey was administered to adult women in the United States in December 2021 using Amazon Mechanical Turk to assess perceptions of breast implant risks communicated in the FDA-issued guidance. Sociodemographic predictors of responses were identified using multivariable models. Results: There were 494 complete responses. Respondents had a mean age of 36.9 years, and 80% had an associate's degree or higher. At baseline, most would consider receiving implants for reconstructive or cosmetic purposes (65%). Some were unsure or indicated that it is not possible to undergo mammograms after receiving implants (42%). After provided information in the FDA guidance, the majority strongly agreed or agreed that they were less likely to receive implants knowing the risk of anaplastic large cell lymphoma (75%), because implants contain chemicals/heavy metals (74%), and because implants are not lifetime devices (68%), with greater odds among Hispanic respondents (OR, 2.35; P < 0.01) and lower odds among higher-income respondents (OR, 0.64; P = 0.03). Conclusions: There are misconceptions with regard to breast implant-associated risks. Despite most laywomen indicating that they would consider receiving implants at baseline, the risks communicated in the 2021 FDA boxed warning may make patients less likely to receive implants, with variability among different sociodemographic populations.
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Healthcare has a major impact on climate change, and surgery is among the most energy-intensive hospital practices. Although most Americans believe climate change is happening, little is known regarding public awareness of the impact of healthcare on climate change and how this may impact perceptions of plastic surgery. Methods: A cross-sectional survey was administered to adults in the United States using Amazon Mechanical Turk in December 2021 to assess public perceptions of climate change, healthcare, and plastic surgery. Incomplete responses were excluded from analysis. Multivariable logistic regression models were used to determine predictors of responses. Results: There were 890 complete responses. Most participants strongly agreed or agreed that climate change is happening (89%). Fewer believed that healthcare has an impact on climate change (62%), with greater odds among respondents with an associate's degree or higher (odds ratio 2.8, P < 0.001). After they were given information about the impact of healthcare on climate change, most respondents were more worried about the effects of cosmetic plastic surgery (64%). Many respondents would be willing to engage in personal climate change mitigation measures if undergoing surgery and pay higher professional fees to support sustainable hospital practices. Conclusions: Most Americans believe climate change is happening, but fewer believe healthcare has an impact on climate change. Knowledge regarding the impact of healthcare and surgery on climate change may make patients more worried about the effects of plastic surgery on climate change, but patients may be willing to personally mitigate climate impacts of surgery.
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BACKGROUND: Superficial inguinal (groin) vascularized lymph node transplantation is the most common option for the treatment of lymphedema, particularly in combination with free abdominal flap breast reconstruction. This study examines the utility of single-photon emission computed tomographic (SPECT/CT) lymphoscintigraphy for lower extremity reverse lymphatic mapping in presurgical planning for groin vascularized lymph node transplantation and appraises the physiologic lymphatic drainage to the superficial inguinal lymph nodes. METHODS: All patients who underwent bilateral lower extremity SPECT/CT reverse lymphatic mapping over a 5-year period were included. Retrospective case note analysis was performed to collect demographic, surgical, and outcomes data. RESULTS: The study included 84 patients; 56 of these subsequently underwent groin vascularized lymph node transplantation (58 flaps). Fifty-four of these flaps were combined with free abdominal flaps for breast reconstruction (55 flaps). Using SPECT/CT reverse lymphatic mapping investigation of 168 inguinal regions, drainage to at least one superficial inguinal region was visualized in 38.1 percent of patients; in 13.1 percent, drainage was visualized to both superficial inguinal regions. Using this information for presurgical planning, groin vascularized lymph node flap harvest was performed from the contralateral side in 57 of 58 cases (98.3 percent) using intraoperative gamma probe guidance, and no patient developed donor lower extremity lymphedema during follow-up (mean ± SD, 34.5 ± 15.4 months). CONCLUSIONS: The authors' use of presurgical SPECT/CT reverse lymphatic mapping together with limited flap dissection and intraoperative gamma probe guidance resulted in no clinical cases of iatrogenic donor lower extremity lymphedema. The high incidence of drainage from the lower extremity to the superficial inguinal region mandates the use of reverse lymphatic mapping when performing groin vascularized lymph node transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Subject(s)
Groin , Lymphedema , Groin/surgery , Humans , Lymph Node Excision/adverse effects , Lymph Nodes/diagnostic imaging , Lymph Nodes/pathology , Lymphedema/diagnostic imaging , Lymphedema/etiology , Lymphedema/surgery , Retrospective Studies , Tomography, Emission-Computed, Single-Photon/adverse effectsSubject(s)
Breast Cancer Lymphedema , Breast Neoplasms , Lymphedema , Female , Humans , Patient SelectionABSTRACT
Background: Women undergoing autologous reconstruction (AR) after mastectomy for breast cancer and their surgeons must make decisions regarding timing of the AR and choose among various flap types. We conducted a systematic review to evaluate the comparative benefits and harms of (1) timing of AR relative to chemotherapy and radiation therapy, and (2) various flap types for AR. Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods. Results: We screened 15,936 citations. Twelve mostly high risk of bias studies, including three randomized controlled trials and nine nonrandomized comparative studies met criteria (total N = 31,833 patients). No studies addressed timing of AR relative to chemotherapy or radiation therapy. Six flap types were compared, but conclusions were feasible for only the comparison between transverse rectus abdominus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. The choice of either flap may result in comparable patient satisfaction with breasts and comparable risk of necrosis (low SoE for both outcomes), but TRAM flaps probably pose a greater risk of harm to the area of flap harvest (abdominal bulge/hernia and need for surgical repair) (moderate SoE). Conclusions: Evidence regarding details for AR is mostly of low SoE. New high-quality research among diverse populations of women is needed for the issue of timing of AR and for comparisons among flap types.
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Women undergoing implant-based reconstruction (IBR) after mastectomy for breast cancer have numerous options, including timing of IBR relative to radiation and chemotherapy, implant materials, anatomic planes, and use of human acellular dermal matrices. We conducted a systematic review to evaluate these options. Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias and strength of evidence (SoE) using standard methods. Results: We screened 15,936 citations. Thirty-six mostly high or moderate risk of bias studies (48,419 patients) met criteria. Timing of IBR before or after radiation may result in comparable physical, psychosocial, and sexual well-being, and satisfaction with breasts (all low SoE), and probably comparable risks of implant failure/loss or explantation (moderate SoE). No studies addressed timing relative to chemotherapy. Silicone and saline implants may result in clinically comparable satisfaction with breasts (low SoE). Whether the implant is in the prepectoral or total submuscular plane may not impact risk of infections (low SoE). Acellular dermal matrix use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections (low SoE). Risks of seroma and unplanned repeat surgeries for revision are probably comparable (moderate SoE), and risk of necrosis may be comparable with or without human acellular dermal matrices (low SoE). Conclusions: Evidence regarding IBR options is mostly of low SoE. New high-quality research is needed, especially for timing, implant materials, and anatomic planes of implant placement.