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Breast Reconstruction: ‘A Process Not a Procedure’ With Potential Short- and Long-Term Complications


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Deanna J. Attai, MD

Deanna J. Attai, MD

The complication rate among women who underwent postmastectomy breast reconstruction was 32.9% at 2 years postoperatively, and women undergoing autologous reconstruction “had significantly higher odds of developing any complication compared with those undergoing expander-implant reconstruction,” according to a recent study in JAMA Surgery.1 Another study in the same issue, also based on data from the Mastectomy Reconstruction Outcomes Consortium, found, “At 2 years after reconstruction, patients who underwent autologous construction reported significantly greater satisfaction and breast-related quality of life compared with patients who underwent implant-based techniques.”2

The findings of the two studies suggest that reconstruction is a “process not a procedure, with the potential for short and long-term complications,” Deanna J. Attai, MD, wrote in her blog after the studies were published and reiterated in an interview with The ASCO Post. Dr. Attai is Assistant Clinical Professor of Surgery at the David Geffen School of Medicine at the University of California, Los Angeles, and Past President of the American Society of Breast Surgeons.

Complication Rates

A prospective multicenter trial, the Mastectomy Reconstruction Outcomes Consortium was funded by the National Cancer Institute to compare long-term outcomes among common techniques of breast reconstruction. Eligible patients included all women 18 years and older presenting for first-time breast reconstruction after mastectomy for cancer treatment or prophylaxis at 1 of the 11 participating institutions across the United States and Canada.1 The patients were recruited between February 1, 2012, and July 31, 2015.

A total of 2,343 patients underwent breast reconstruction: 1,525 (65.1%) patients had expander-implant reconstruction and 112 (4.8%) received direct-to-implant reconstruction. Among those receiving autologous procedures, 390 patients (16.6%) had deep inferior epigastric perforator flaps, 95 (4.1%) had free transverse rectus abdominis myocutaneous flaps, 85 (3.6%) had pedicled transverse rectus abdominis myocutaneous flaps, 71 (3.0%) had latissimus dorsi flaps, and 65 (2.8%) had superficial inferior epigastric artery flaps.

In patients who want reconstruction, I would definitely recommend it be performed at the time of mastectomy.
— Deanna J. Attai, MD

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“Overall, complications were noted in 771 (32.9%), with reoperative complications in 453 (19.3%) and wound infections in 230 (9.8%). Two years postoperatively, patients undergoing any autologous reconstruction type had significantly higher odds of developing any complication compared with those undergoing expander-implant reconstruction,” the study authors reported.

“The 2-year complication rates in our study were impressively high,” the authors added in the discussion section of the study report. “Overall rates ranged from 26.6% for expander-implant reconstruction to 73.9% for superficial inferior epigastric artery flaps.

All flap procedures, except latissimus dorsi flap reconstructions, “were associated with higher odds of reoperative complications,” the authors reported. Only patients undergoing deep inferior epigastric perforator flaps had “significantly lower odds of infection compared with those undergoing expander-implant procedures,” but “direct-to-implant and expander-implant procedures had higher failure rates.”

More Complications: Not Surprising

Dr. Attai said the overall complication rate of 32.9% and the higher odds of complications for patients undergoing reconstruction should not be a surprise. “The more surgery we do, the higher the potential complication rate,” she added.

Previously reported studies found complication rates “anywhere from 20% to 40%,” Dr. Attai pointed out. “That includes everything from a skin infection that can be treated with antibiotics and is of minimal consequence, all the way to multiple repeat surgeries and loss of the reconstruction.”

“Interestingly, the procedure types with the highest complication rates also had the lowest likelihood of failure,” the authors noted. “Although a postoperative wound infection in an implant-based reconstruction often necessitates explantation, an infection in an autologous reconstruction rarely requires debridement or flap removal.”

For women who have undergone autologous reconstruction, “a standard soft-tissue infection is more likely to respond to antibiotics without a repeat operation. If you have an implant of a foreign body, you are more likely to have to remove that implant to clear the infection,” Dr. Attai explained.

Delayed Reconstruction

“Patients undergoing delayed reconstruction were significantly less likely to develop any complication compared with women receiving immediate reconstruction (overall response, 0.55),” the authors noted. However, Dr. Attai said there are good reasons to recommend immediate reconstruction.

“In patients who want reconstruction, I definitely recommend it be performed at the time of mastectomy. The reason I do—and this is part of the discussion we have with patients—is that in many cases, we have better options,” Dr. Attai explained. “If a patient wants reconstruction, I encourage her to do it at the time of mastectomy. There are fewer surgeries, and we have the option of nipple preservation, of skin sparing. For patients who either don’t want reconstruction or are not sure, or for those with inflammatory breast cancer, we will perform a more traditional mastectomy with radiation if indicated but let the patients know that delayed reconstruction certainly can be an option.”

Variation in Practice

Radiotherapy during or after reconstruction was also associated with significantly higher rates of complications (overall response, 1.99). “Sometimes, we just don’t know whether the patient is going to need radiation. Sometimes, we are surprised by the extent of the disease. Sometimes, we find positive nodes where we didn’t expect them. I think we are getting better at predicting who will need postoperative radiation,” Dr. Attai said. However, there are still times when that need is not clear until after reconstruction.

If the implants are fine, we usually don’t recommend that they be removed. Some women may get many, many years out of them and never have a revision.
— Deanna J. Attai, MD

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“In cases where we know upfront that patients are going to get reconstruction, we are more likely to put a tissue expander in, do the radiation, and then complete whatever reconstruction afterward,” Dr. Attai said. That could be autologous or with an implant, although “after radiation, sometimes surgeons won’t put an implant it. There is a tremendous amount of variation in practice. It is definitely not a universal protocol by any stretch,” she noted. “Doing the autologous reconstruction after radiation minimizes the likelihood of flap problems due to the radiation.”

Bilateral reconstruction was also associated with higher odds of complications (overall response, 1.50). Asked whether this finding might have an impact on women who elect to have bilateral mastectomy when cancer is detected in one breast, Dr. Attai replied: “It is way too early to tell. Studies like these bring more awareness both to physicians and patients and maybe change the way physicians counsel patients who are considering prophylactic mastectomy: Double the surgery, double the potential complication rate.”

Satisfaction Survey

Up to 90 days before surgery, and at 1, 2, 3, and 4 years after surgery, patients participating in the Mastectomy Reconstruction Outcomes Consortium study were asked to complete the BREAST-Q survey. In a JAMA Surgery article about satisfaction with and quality of life after breast reconstruction, the authors described BREAST-Q as “a validated, breast-specific, patient-reported outcome instrument calibrated to detect differences between specific procedure groups and patients over time.”2

The article primarily reported the results of BREAST-Q surveys completed by 1,217 patients 2 years after reconstruction, although some patient-reported outcomes for patients at 3 and 4 years after reconstruction were also included. “After controlling for baseline patient characteristics, patients who underwent autologous reconstruction had greater satisfaction with their breasts (difference, 7.94; 95% confidence interval [CI]: 5.68–10.20; P < .001), psychosocial well-being (difference, 3.27; 95% CI: 1.25–5.29; P = .002), and sexual well-being (difference, 5.53; 95% CI: 2.95–8.11; P < .001) at 2 years compared with patients who underwent implant reconstruction,” the authors reported.

Donor-Site Morbidity

The benefits in satisfaction and quality of life “may come with a price in abdominal donor-site morbidity,” the authors added. “Abdominal well-being among patients who underwent autologous reconstruction not only worsened from baseline in the acute 1-year postoperative period but did not return to baseline even at 2 years after surgery. The magnitude of the difference was clinically meaningful; patients who underwent autologous reconstruction reported a mean decrease of 13 points in physical well-being of abdomen scores at 2 years compared with baseline.”

Most of the patients had autologous breast reconstruction with muscle-sparing techniques thought to lessen donor-site morbidity. “Our findings suggest otherwise,” the authors observed. “Studies to determine why physical well-being is compromised after abdominal muscle-sparing techniques are needed.”

The study authors “emphasized the importance of educating patients about the trade-offs inherent in choosing a reconstructive option.” When first learning about autologous breast reconstruction using abdominal tissue, some women may think of it as a “tummy tuck,” with a side benefit of a flatter stomach. But the scar left after the removal of tissue for autologous breast reconstruction “is a large scar,” Dr. Attai pointed out. “It goes all the way across the lower abdomen. It is much larger than with a traditional tummy tuck, which is done only for cosmetic reasons. For some women, that scar is just a constant reminder.”

In addition, “anytime we do surgery, there can be numbness of the skin. If the abdominal wall is persistently numb, that can be bothersome to patients,” Dr. Attai said.

Sustained Results Suggested

“Unadjusted mean patient-reported outcome scores at 3 and 4 years suggest a sustained positive association of autologous reconstruction on patient satisfaction and sexual well-being but also highlight that physical well-being of the abdomen does not return to baseline scores, even at 4 years after reconstruction,” the authors wrote.

One of the challenges of longer-term studies using self-reported outcomes, Dr. Attai noted, is that the numbers and percentages of survey responders drop off considerably. In this study, 60.5% of patients completed the survey at 2 years after breast reconstruction, but that number decreased to 21% at 3 years and 10.2% at 4 years. Such drop-offs can introduce selection bias, Dr. Attai said, “because if you are doing fine and are 4 years out, you might be less inclined to fill out a lengthy, several-page survey compared to someone who is still having a lot of problems.”3

In general, as the time from surgery lengthens, “patients want to move on,” she said. “Many patients are back to their normal activity, their normal life. The last thing they want to do is go through another multipage questionnaire about their breast cancer surgery.”

Not ‘One and Done’

An accompanying commentary on the two studies in JAMA Surgery describes autologous reconstruction as “‘doing all the work upfront.’ With capsular contracture and a limited lifetime of implants, a return to the operating room more than 10 years later is inevitably necessary after prosthetic-based reconstruction is completed. Much evidence of superior long-term satisfaction and improved quality of life after autologous breast reconstruction exists, which translates to long-term cost-effectiveness to society.”4

With autologous breast reconstruction, “once you get past a couple of years, it is not likely you will need revisions,” Dr. Attai acknowledged. She said that she took issue, however, with the statement about the inevitability of replacement of implants. “If the implants are fine, we usually don’t recommend that they be removed,” she said. “Some women may get many, many years out of them and never have a revision.”

Patients need to understand, however, that implants are synthetic objects. “They have a defined lifespan, and that lifespan is different for everyone. So, it is possible that this is not just a ‘one and done’ type of procedure, nor is autologous reconstruction. Some patients wind up needing revisions later down the line. They gain or lose weight. They need fat grafting. They decide they want a lift. Fat necrosis might develop and they need a second surgery,” she explained.

“It is not as simple as get the procedure and then you heal,” she explained. “This is not having your appendix out.” ■

DISCLOSURE: Dr. Attai reported no conflicts of interest.

REFERENCES

1. Bennett KG, Qi J, Kim HM, et al: Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg. June 20, 2018 (early release online).

2. Santosa KB, Qi J, Kim HM, et al: Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. June 20, 2018 (early release online).

3. Attai DJ: Patient reported outcomes and complication rates from post-mastectomy reconstruction. Blog, June 24, 2018. Available at http://drattai.com/patient-reported-outcomes-and-complication-rates-from-post-mastectomy-reconstruction/. Accessed July 27, 2018.

4. Fan KL, Song DH: Autologous vs prosthetic breast reconstruction: Where do we stand? JAMA Surg. June 20, 2018 (early release online).


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