A National Snapshot of Patient-Reported Outcomes Comparing Types of Abdominal Flaps for Breast Reconstruction.

BACKGROUND: This study aimed to identify differences in patient-reported abdominal well-being, satisfaction, and quality of life in women with muscle-preserving free abdominal versus pedicle transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction. METHODS: Women with a history of breast cancer surgery were recruited from the Army of Women foundation to take the BREAST-Q and a background questionnaire. Descriptive statistics and regression analyses were used to compare abdominal physical well-being, breast satisfaction, chest physical, psychosocial well-being, and sexual well-being in women undergoing free versus pedicle TRAM flaps. RESULTS: Of 657 women, 273 (41 percent) underwent free flap surgery and 384 (58 percent) underwent pedicle TRAM flap surgery. Compared with unilateral pedicle TRAM flaps, those with unilateral free flaps scored an average of 9.5 points higher (95 percent CI, 5.4 to 13.6; p < 0.0001) and those with bilateral free flaps reported no difference in physical well-being of the abdomen. Compared with bilateral pedicle TRAM flaps, the following groups scored higher in physical well-being of the abdomen: unilateral free flaps, an average of 17.4 (95 percent CI, 11.5 to 23.3; p < 0.0001); bilateral free flaps, an average of 6.8 (95 percent CI, 0.3 to 13.3; p = 0.04); and unilateral pedicle TRAM flaps, an average of 7.9 (95 percent CI, 2.4 to 13.4; p = 0.005) higher. Women with bilateral pedicle flaps reported sexual well-being scores 7.4 (95 percent CI, 0.6 to 14.3; p = 0.03) and 6.8 (95 percent CI, 0.3 to 13.2; p = 0.04) points lower than those with unilateral free and unilateral pedicle flaps. CONCLUSIONS: Muscle-preserving techniques result in improved abdominal wall function and decreased morbidity compared with pedicle TRAM flap reconstruction. These data highlight the importance of offering patients the option of microsurgical techniques.

Patient-Reported Outcomes After Choice for Contralateral Prophylactic Mastectomy.

PURPOSE: The rate of contralateral prophylactic mastectomies (CPMs) continues to rise, although there is little evidence to support improvement in quality of life (QOL) with CPM. We sought to ascertain whether patient-reported outcomes and, more specifically, QOL differed according to receipt of CPM. METHODS: Volunteers recruited from the Army of Women with a history of breast cancer surgery took an electronically administered survey, which included the BREAST-Q, a well-validated breast surgery outcomes patient-reporting tool, and demographic and treatment-related questions. Descriptive statistics, hypothesis testing, and regression analysis were used to evaluate the association of CPM with four BREAST-Q QOL domains. RESULTS: A total of 7,619 women completed questionnaires; of those eligible, 3,977 had a mastectomy and 1,598 reported receipt of CPM. Women undergoing CPM were younger than those who did not choose CPM. On unadjusted analysis, mean breast satisfaction was higher in the CPM group (60.4 v 57.9, P < .001) and mean physical well-being was lower in the CPM group (74.6 v 76.6, P < .001). On multivariable analysis, the CPM group continued to report higher breast satisfaction (P = .046) and psychosocial well-being (P = .017), but no difference was reported in the no-CPM group in the other QOL domains. CONCLUSION: Choice for CPM was associated with an improvement in breast satisfaction and psychosocial well-being. However, the magnitude of the effect may be too small to be clinically meaningful. Such patient-reported outcomes data are important to consider when counseling women contemplating CPM as part of their breast cancer treatment.

Facial Fractures in the Aging Population.

BACKGROUND: As the U.S. population ages and life expectancy increases, the number of elderly patients seeking trauma care and treatment for facial fractures will increase. Understanding age-related differences in the pattern, cause, and management of these fractures is essential for improving care. METHODS: A retrospective review of adults presenting to a Level I trauma center was performed to evaluate age-related differences in facial fractures. Descriptive statistics were used to compare fracture number, type, cause of injury, management, and adverse events between elderly (older than 64 years) and younger cohorts (aged 18 to 64 years). Logistic regression was used to evaluate the effect of age on fracture type while controlling for potential confounding variables. RESULTS: Two thousand twenty-three adult patients sustained a facial fracture from 2001 to 2011. Two hundred nine patients were elderly and 1814 were younger. Regarding cause of injury, older patients were more likely to fall and younger patients were more likely to be injured through assaults, motor vehicle collisions, or sports (p < 0.0001). Elderly patients sustained a higher incidence of maxillary (16.3 percent versus 11.4 percent; p = 0.0401), nasal (54.1 percent versus 45.3 percent; p = 0.0156), and orbital floor fractures (28.2 percent versus 18.1 percent; p = 0.004) and a lower incidence of mandible fractures (10.1 percent versus 21.3 percent; p = 0.0001). The elderly had significantly less operative intervention (24.9 percent versus 43 percent; p < 0.0001) and were less likely to experience complications (5.3 percent versus 10.5 percent; p = 0.0162). CONCLUSION: Elderly patients tend to suffer from less severe facial fractures, requiring less need for operative intervention, likely secondary to low-energy mechanisms of injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A national snapshot of satisfaction with breast cancer procedures.

PURPOSE: Women with early-stage breast cancer face the complex decision to undergo one of three equally effective oncologic surgical strategies: breast-conservation surgery with radiation (BCS), mastectomy, or mastectomy with breast reconstruction. With comparable oncologic outcomes and survival rates, evaluations of satisfaction with these procedures are needed to facilitate the decision-making process and to optimize long-term health. METHODS: Women recruited from the Army of Women with a history of breast cancer surgery took electronically administered surgery-specific surveys, including the BREAST-Q© and a background survey evaluating patient-, disease-, and procedure-specific factors. Descriptive statistics and regression analysis were used to evaluate the effect of procedure type on breast satisfaction scores. RESULTS: Overall, 7,619 women completed the questionnaires. Linear regression revealed that women who underwent abdominal flap, or buttock or thigh flap reconstruction reported the highest breast satisfaction score, scoring an average of 5.6 points and 14.4 points higher than BCS, respectively (p < 0.0001 and p = 0.027, respectively). No difference in satisfaction was observed in women who underwent latissimus dorsi flap reconstruction compared with those who underwent BCS. Women who underwent implant reconstruction reported scores 8.6 points lower than BCS (p < 0.0001). Those with mastectomies without reconstruction or complex surgical histories scored, on average, 10 points lower than BCS (p < 0.0001). CONCLUSION: Women who underwent autologous tissue reconstruction reported the highest breast satisfaction, while women undergoing mastectomy without reconstruction reported the lowest satisfaction. These findings emphasize the value of patient-reported outcome measures as an important guide to decision making in breast surgery and underscore the importance of multidisciplinary participation early in the surgical decision-making process.

Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons.

BACKGROUND: Concern exists that plastic surgeons are performing fewer autologous and microsurgical breast reconstructions, despite superior long-term outcomes. The authors describe the proportion of U.S. plastic surgeons performing these procedures and evaluate motivating factors and perceived barriers. METHODS: A random national sample of American Society of Plastic Surgeons members was surveyed (n = 325; response rate, 76 percent). Surgeon and practice characteristics were assessed, and two multiple logistic regression models were created to evaluate factors associated with (1) high-volume autologous providers and (2) microsurgical providers. Qualitative assessments of motivating factors and barriers to microsurgery were also performed. RESULTS: Fewer than one-fifth of plastic surgeons perform autologous procedures for more than 50 percent of their breast cancer patients, and only one-quarter perform any microsurgical breast reconstruction. Independent predictors of a high-volume autologous practice include involvement with resident education (odds ratio, 2.57; 95 percent CI, 1.26 to 5.24) and a microsurgical fellowship (odds ratio, 2.09; 95 percent CI, 1.04 to 4.27). Predictors of microsurgical breast reconstruction include involvement with resident education (odds ratio, 6.8; 95 percent CI, 3.32 to 13.91), microsurgical fellowship (odds ratio, 2.4; 95 percent CI, 1.16 to 4.95), and high breast reconstruction volume (odds ratio, 6.68; 95 percent CI, 1.76 to 25.27). The primary motivator for microsurgery is superior outcomes, and the primary deterrents are time and reimbursement. CONCLUSIONS: The proportion of U.S. plastic surgeons with a high-volume autologous or microsurgical breast reconstruction practice is low. Involvement with resident education appears to facilitate both, whereas time constraints and reimbursement are primary deterrents. Future efforts should focus on improving the feasibility and accessibility of all types of breast reconstruction.

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

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

Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement.

PURPOSE: Healthy, viable mastectomy skin is a critical factor in the outcome of immediate breast reconstruction. Unfortunately, mastectomy skin viability can be problematic and intraoperative assessment is unreliable. For this reason, we have modified our approach to immediate transverse rectus abdominus myocutaneous flap (TRAM) reconstruction. Instead of completing the reconstruction with a definitive inset at the time of the mastectomy, the TRAM flap is left intact and buried beneath the mastectomy skin for 3 to 5 days. This falls within the normal period of postoperative hospitalization, and at this point, the viability of the mastectomy skin is clear. Ischemic skin is debrided and replaced with healthy TRAM skin, and nipple reconstruction can be performed at the time of this interval inset. The purpose of this study was to review a large case series of patients who underwent an interval inset of their TRAM flap in the setting of immediate skin-sparing mastectomy. METHODS: Retrospective chart data were obtained for all TRAM patients who underwent immediate postmastectomy breast reconstruction by a single surgeon during a 5-year period. Data were collected on procedures, complications, margin status, and number of immediate versus delayed nipple reconstructions. RESULTS: There were 63 patients who underwent immediate TRAM reconstruction with interval inset of the flap. This included 25 bilateral cases, for a total of 89 flaps. Interval insets were performed an average of 3.9 days after the TRAM. Twenty-seven percent (17/63) required replacement of nonviable mastectomy skin with TRAM skin and had no nipple reconstruction; 4.8% (3/63) had additional skin taken because of residual tumor close to or at the mastectomy margins. Seventy-three percent of patients (46/63) had a nipple reconstruction with minimal or no mastectomy skin loss. CONCLUSION: We present the interval inset of TRAM flaps during the normal period of postoperative hospitalization as a technical refinement to optimize cosmetic outcomes. Mastectomy skin viability can be more easily assessed and necrotic or ischemic skin replaced with TRAM skin as needed. This avoids the need for prolonged dressing changes or a compromised aesthetic result from skin loss. When there is no major skin loss, the nipple reconstruction can be performed concurrently with the inset. These refinements optimize the appearance of the reconstructed breast and reduce the need for future surgeries. In addition, the surgical oncologist has the opportunity to excise close or positive margins as indicated by pathologic findings. Thus, the benefits of the interval inset of TRAM flaps are shared by the reconstructive surgeon, the surgical oncologist, and most importantly, the patient.

Ipsilateral pedicle TRAM flaps for breast reconstruction: are they as safe as contralateral techniques?

INTRODUCTION: Many surgeons are using the ipsilateral rotation of the TRAM flap because of easier flap insetting and improved aesthetic outcomes; however studies evaluating these techniques are limited to case series without groups for comparison. Our purpose was to evaluate the safety of the ipsilateral technique through a retrospective cohort study. METHODS: We retrospectively evaluated consecutive contralateral and ipsilateral TRAM flaps for mastectomy breast reconstruction. The incidence of ischemia-related flap complications and the incidence of major and minor complications were compared between the two groups. Multiple logistic regression was used to assess the effect of rotation type on complication rates, while controlling for potential confounding variables. RESULTS: Comparing 58 ipsilateral to 32 contralateral pedicle TRAM patients, the rate of a major complication was 20.7% and 28.1%, respectively, p=0.425; a minor complication was 50.0% vs. 34.4%, respectively, p=0.153; and total ischemic-related flap complications were 22.4% and 25.0% respectively, p=0.781. When controlling for potential confounders, the type of pedicle TRAM flap did not have a significant effect on the above complications. Advanced patient age was significantly correlated with an increased incidence of major complications (OR=1.09, p=0.031) and ischemic flap complications (OR=1.11, p=0.016). CONCLUSION: The ipsilateral pedicle TRAM flap appears as safe as the contralateral technique for breast reconstruction. Given the increased pedicle length and preservation of both the medial inframammary fold and xiphoid subunit, we believe that the ipsilateral technique is preferred over the contralateral rotation.

The impact of obesity on patient satisfaction with breast reconstruction.

BACKGROUND: As the U.S. population becomes increasingly overweight, a growing number of patients with body mass indexes greater than 30 are seeking mastectomy reconstruction. The authors' purpose was to prospectively evaluate the effect of body mass index on patient satisfaction with breast reconstruction. METHODS: Women undergoing first-time breast reconstruction at one of 12 centers in the United States and Canada were surveyed preoperatively and at postoperative year 1. Satisfaction was evaluated with two scales assessing general and aesthetic satisfaction. Using Centers for Disease Control and Prevention criteria, patients were classified as normal weight, overweight, or obese. Logistic regressions evaluated the effects of body mass index on patient satisfaction with expander/implant, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap techniques while controlling for patient age and timing of reconstruction. RESULTS: Data were available for a total of 262 patients. Patient body mass index had a significant effect on aesthetic satisfaction, particularly among patients undergoing expander/implant procedures. Compared with normal weight individuals, obese patients with expander/implants were significantly less satisfied aesthetically (odds ratio, 0.14, p = 0.02). However, there was no significant difference between obese and normal weight patients in aesthetic satisfaction with TRAM flap reconstruction. Finally, body mass index had no significant effects on general satisfaction for either expander/implant or TRAM flap technique. CONCLUSION: Although previous investigators have reported relatively high complication rates and modest aesthetic results for breast reconstruction in overweight and obese women, the authors' study suggests that patient satisfaction with reconstruction is surprisingly high in this population, particularly in cases of autogenous tissue reconstruction.