Comparative Analysis of Recurrence-Free Survival and Mortality in Postmastectomy Patients: Insights From Multidecade, Multiinstitutional Propensity Score Matching.

INTRODUCTION: Disparities in postmastectomy reconstructive care are widely acknowledged. However, there is limited understanding regarding the impact of reconstructive services on cancer recurrence and breast cancer-related mortality. Therefore, this study aims to examine how patient-specific factors and breast reconstruction status influence recurrence-free survival and mortality rates in breast cancer patients. METHODS: Retrospective chart review was performed to collect data on patients who underwent mastectomy at 2 institutions within the New York-Presbyterian system from 1979 to 2019. Sociodemographic information, medical history, and the treatment approach were recorded. Propensity score matching, logistic regression, unpaired t test, and chi-square test were used for statistical analysis. RESULTS: Overall, cancer recurrence occurred in 6.62% (317) of patients, with 16.8% (803) overall mortality rate. For patients who had relapsed disease, completion of the reconstruction sequence was correlated with an earlier detection of cancer recurrence and improved survival odds (P < 0.05). Stratified analysis of the reconstruction group alone showed mortality benefit among patients who underwent free flap procedures (P < 0.05). CONCLUSION: Patients undergoing breast reconstruction after mastectomy are likely to have better access to follow-up care and improved interfacing with the healthcare system. This may increase the speed at which cancer recurrence is detected. This study highlights the need for consistent plastic surgery referral and continued monitoring by all members of the breast cancer care team for cancer recurrence among patients.

A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest.

BACKGROUND: The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients. METHODS: This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications. RESULTS: Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87. CONCLUSION: This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

A Pilot Study Comparing Sensation in Buried Versus Nonburied Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: Neurotized deep inferior epigastic perforator (DIEP) flaps have been shown to improve sensory recovery after mastectomy and reconstruction. With the recent trend toward nipple-sparing mastectomies, sensation likely originates within the buried DIEP flap and then innervates the breast skin. In contrast, for patients undergoing skin-sparing mastectomies, the DIEP flap skin is preserved, brought up to the surface, and directly innervated. In this study, we aim to evaluate inner breast region sensation between patients whose DIEP flap is buried and whose DIEP flap skin is brought to the surface. METHODS: Seventy patients who underwent mastectomy with immediate reconstruction using the DIEP flap were prospectively identified. Of these, 60 patients underwent nipple-sparing mastectomy with buried DIEP flap reconstruction while 10 patients underwent skin-sparing mastectomy with nonburied DIEP flap reconstruction. Patients in both cohorts received nerve grafting using the 70 × 1-2-mm Avance Nerve Graft in identical fashion. Sensitivity evaluation was performed in five inner breast regions (corresponding to the nonburied DIEP flap area). RESULTS: In the buried DIEP cohort, at 6 months postoperatively, there was a statistically significant difference in inner breast region sensitivity measurements compared with baseline levels ( P < 0.001). In contrast, in the nonburied DIEP cohort, at 6 months postoperatively, sensation in the inner breast region was comparable with preoperative baseline levels ( P = 0.236). At 24 months postoperatively, inner breast region sensitivity measurements in both cohorts were comparable with preoperative baseline measurements ( P > 0.05). CONCLUSIONS: Neurotized DIEP flap skin raised directly to the surface confers earlier sensory recovery than buried DIEP flaps. In patients who undergo skin-sparing mastectomies with nonburied DIEP flap reconstruction, they can expect significantly better sensation in the inner regions of the breast at 6 months postoperatively. In patients who undergo nipple-sparing mastectomies with buried DIEP flap reconstruction, they can expect sensation in the inner breast to return to preoperative baseline levels at a later time point-beginning as early as 24 months postoperatively.

A Comparison Between Immediate and Babysitter Deep Inferior Epigastric Perforator Flap Breast Reconstruction in Postoperative Outcomes.

BACKGROUND: Delayed-immediate, or "babysitter," deep inferior epigastric perforator (DIEP) flap reconstruction, defined as immediate tissue expander or implant placement at the time of mastectomy followed by eventual exchange for DIEP flap, is becoming increasingly popular in breast cancer patients anticipated to receive adjuvant radiotherapy. In this study, we aim to compare delayed-immediate to immediate DIEP flap patients in postoperative outcomes including major complications and surgical site morbidity. METHODS: A retrospective cohort study between immediate and delayed-immediate DIEP flap patients was performed. Patient demographics, comorbidities, and preoperative cancer treatment were compared between the 2 cohorts. Clinical outcomes of interest included dehiscence, necrosis, and infection of the breast, abdomen, and umbilicus in the 90-day postoperative period as well as breast hematoma, anastomotic failure, flap loss, and venous thromboembolism. RESULTS: Of the 248 patients (443 breasts) included in this study, 193 women (344 breasts) and 55 women (99 breasts) were in the immediate and delayed-immediate cohorts, respectively. The 2 cohorts were comparable in age, body mass index, and comorbidities (P > 0.05). Despite significantly higher rates of preoperative cancer treatment (P < 0.05), delayed-immediate patients were not at an elevated risk for major complications. The 2 cohorts were also comparable in surgical site outcomes, with the exception of breast skin necrosis, which was significantly higher in incidence in the immediate cohort (16.0% vs 2.0%, P < 0.001). CONCLUSIONS: This study is the first to directly compare delayed-immediate to immediate DIEP flap reconstruction in postoperative outcomes. Our findings show that babysitter DIEP flaps are a safe option for patients, even in those expected to undergo breast irradiation preoperatively.

Is It Worth the Risk? Contralateral Prophylactic Mastectomy With Immediate Bilateral Breast Reconstruction.

BACKGROUND: An increasing number of women are choosing to undergo contralateral prophylactic mastectomy with immediate bilateral breast reconstruction. Operating on the contralateral noncancer side is not without its own set of risks. We sought to compare complication rates between the cancerous and contralateral prophylactic breasts. METHODS: A retrospective review was conducted of all patients undergoing immediate postmastectomy bilateral breast reconstruction for unilateral breast cancer between January 2008 and January 2019 at a single institution. Data were collected on patient demographics, cancer and adjuvant/neoadjuvant treatments, tumor, reconstruction, hospital stay, and complications. Complications were compared between the cancerous and the noncancerous breasts. RESULTS: One hundred sixty patients met the inclusion criteria of this study. Of these 160 patients, 33 (20.6%) had complications (major and minor) only to the cancerous breast, 7 (4.4%) had complications only to the noncancerous breast, and 7 (4.4%) had bilateral complications. Most patients underwent tissue expander/implant reconstruction (93.8%) with the rest (6.2%) undergoing abdominally based flap or latissimus dorsi flap reconstruction. Patients with complications were more likely to have hypertension, diabetes, exposure to radiation, and neoadjuvant chemotherapy. Complications included wound dehiscence, hematoma, cellulitis, seroma, capsular contracture, infected implant, and skin necrosis. Overall, there were significantly more complications to the cancerous breasts than the noncancerous breasts (P < 0.001). In addition, although exposure to radiation to the affected side significantly increased the likelihood of complications to that side (P < 0.0001), patients who were not exposed to any radiation were also more likely to have complications to the cancer side than to the noncancer side (P = 0.00065). However, after controlling for the effects of radiation, there was no significant difference in complications between the cancer side and the prophylactic side when stratifying by specific complications. CONCLUSIONS: Although contralateral prophylactic mastectomy with immediate bilateral reconstruction is not without added risk when compared with a unilateral procedure, this study shows that the incidence of complications to the noncancerous breast is less than that to the cancerous breast. This information can be used to help counsel patients with unilateral breast cancer on their treatment options and associated risks.

Radiation Oncology Applications in Plastic and Reconstructive Surgery: A Nonsystematic Review of Concepts and Principles.

SUMMARY: Careful consideration of radiotherapy can determine the success of reconstructive therapy. There is a broad spectrum of radiotherapy modalities, both benign and malignant. Delivery mechanisms differ in the physical design, setup, radiation source, administrable dosage, and mode of delivery. This range of options allows radiation oncologists to tailor individualized treatment; however, radiotherapy concepts can be challenging for nonspecialists. The purpose of this article is to review general radiation oncology concepts, including essential equipment and radiobiology, and provide plastic surgeons with a basic conceptual understanding to facilitate effective multidisciplinary collaboration with radiation oncologists.