ASPS 2008: Perforator Flap is Patients' Preferred Method of Breast Reconstruction

November 06, 2008

November 6, 2008 (Chicago, Illinois) — Women who underwent postmastectomy breast reconstruction had higher satisfaction rates with the deep inferior epigastric perforator (DIEP) flap than other types of reconstruction, results of a large new study found.

Performed at a single academic medical center, the study compared patients' general satisfaction and aesthetic satisfaction with 4 reconstructive methods: breast implant, the pedicled or free transverse rectus abdominis myocutaneous (TRAM) flap, the latissimus dorsi flap, and the DIEP flap.

"There is no consensus on the best method of breast reconstruction," said Janet H. Yueh, the study's lead author and a medical student at Harvard Medical School in Boston, Massachusetts. "We need satisfaction outcomes data to help patients make educated decisions about reconstruction."

She presented the findings here at Plastic Surgery 2008, the American Society of Plastic Surgeons Annual Meeting.

The researchers performed a retrospective chart review of all women who had breast reconstruction at Beth Israel Deaconess Medical Center in Boston between 1999 and 2006, and identified 615 patients. Those patients were mailed a questionnaire that consisted partly of a survey tool previously validated by the Michigan Breast Reconstruction Outcome Study, and the investigators received 462 completed questionnaires (75% response rate). The questionnaire also included questions on demographic information and health-related quality of life.

Patients who did not respond to a second mailing received a follow-up phone call, Ms. Yueh said in response to a question from the audience about the high response rate.

Survey results showed that, of the 462 respondents, 143 patients had undergone a TRAM flap; 117, a DIEP flap; 115, a latissimus dorsi flap; and 87, a tissue expander and implant. About 75% of the TRAM flaps were pedicled, and none involved the muscle-sparing free TRAM flap, Ms. Yueh told Medscape Dermatology. The 4 groups reportedly did not have a statistically significant difference in quality of life.

Autologous Reconstruction Reported to Have Better Aesthetics

Using logistic regression analysis, the authors showed that autologous reconstruction produced significantly higher satisfaction rates than implants for both general satisfaction (P = .026) and aesthetic satisfaction (P < .001). Aesthetic satisfaction reported with implants was only 48%, compared with 60% to 71% for the other options, according to the abstract. Reconstruction using an abdominal donor site had significantly better general and aesthetic satisfaction rates than latissimus flap reconstruction (P = .002 and P = .033, respectively).

Patients who had the DIEP flap, when compared with all 4 procedures combined, were significantly more satisfied with its aesthetic appearance (71% vs. 64%, respectively; P = .001) and more satisfied overall (80% vs. 66%, respectively; P < .001). The DIEP flap was also associated with higher general satisfaction than with the TRAM flap alone (80% vs 69%, respectively; P = .031), but both groups reported similar aesthetic satisfaction (71%).

The 29% who did not express aesthetic satisfaction with either technique represented "unsatisfied" or neutral feelings, based on the 5-point scale used, coauthor Bernard T. Lee, MD, said in an interview. Dr. Lee is a plastic surgeon at Beth Israel Deaconess Medical Center.

The new findings both confirm and augment previously reported data of patient satisfaction with breast reconstruction, Dr. Lee told Medscape Dermatology.

Pros and Cons of Study

"The size of our sample was a lot larger" than previously reported studies, he said. "Previous reports did not evaluate the DIEP flap, and many did not have information on the latissimus flap."

Although the results are from only 1 medical center and about 90% of respondents were white, Dr. Lee said the data are relevant to other centers, especially the finding that autologous reconstruction gives higher satisfaction rates than implants.

Andrea Pusic, MD, a plastic surgeon at Memorial Sloan-Kettering Cancer Center in New York City, who was not involved with the study, called the research "good work." However, she told Medscape Dermatology that it only begins to answer the question of which reconstructive technique is best. A limitation of the study was its use of a questionnaire developed for the Michigan Breast Reconstruction Outcome Study, she said.

"It has few questions on effects on the abdomen and has no patient input," Dr. Pusic said. "We have a better measure of patient satisfaction now: the BREAST-Q."

Dr. Pusic led the development of the BREAST-Q, a new patient-reported questionnaire for measuring satisfaction and quality of life after breast surgery, and reported on at the meeting.

"The BREAST-Q has scales that examine abdominal morbidity, and things like tightening and bloating," she said.

The BREAST-Q is owned jointly by Memoral Sloan-Kettering Cancer Center and the University of British Columbia. Ms. Yueh, Dr. Lee, and Dr. Pusic have disclosed no relevant financial relationships.

Plastic Surgery 2008: American Society of Plastic Surgeons (ASPS) Annual Meeting:Abstract 69. Presented November 4, 2008.

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