Women Happier With Autologous Breast Reconstruction

Megan Brooks

June 20, 2018

Women who undergo autologous postmastectomy breast reconstruction are more likely to develop complications but are more apt to be satisfied 2 years later with their breasts and feel better about themselves than women who opt for reconstruction with implants, according to two studies published online June 20 in JAMA Surgery.

"These studies are vital in shared decision making, assuming that patients are candidates for both autologous and prosthetic breast reconstruction," write Kenneth Fan, MD, and David Song, MD, from MedStar Georgetown University Hospital, Washington, DC, in an invited commentary.

In the first study, Edwin Wilkins, MD, from the University of Michigan, Ann Arbor, and colleagues compared 2-year complication rates associated with common techniques for postmastectomy breast reconstruction among 2343 women from 11 sites participating in the Mastectomy Reconstruction Outcomes Consortium.

Of these patients, 1525 women (65.1%) underwent expander-implant (EI) reconstruction; 112 (4.8%) underwent direct-to-implant (DTI) reconstruction; 85 (3.6%) were treated with pedicled transverse rectus abdominis myocutaneous (pTRAM) flaps; 95 (4.1%) were treated with free transverse rectus abdominis myocutaneous (fTRAM) flaps; 390 (16.6%), deep inferior epigastric perforator (DIEP) flaps; 71 (3.0%), latissimus dorsi (LD) flaps; and 65 (2.8%), superficial inferior epigastric artery (SIEA) flaps.

The overall complication rate was 32.9%. Reoperative complications occurred in 19.3% of patients, and wound infections occurred in 9.8%. At 2 years, women who had undergone any type of autologous reconstruction were significantly more likely to develop any complication and reoperative complications compared with women who opted for prosthetic EI techniques.

Overall complication rates ranged from 26.6% for EI reconstruction to 73.9% for SIEA flaps. Reoperative complication rates ranged from 15.5% for EI procedures to 30.8% for SIEA reconstructions.

The rates of reoperative complications are "startling," the editorialists say, and are similar to those reported in a study published more than 15 years ago.

Overall, reconstruction failure occurred in only 5.4% of women. Failure rates were higher with EI and DTI reconstruction (7.1% each) than with all other procedures, which ranged from 1.2% for pTRAM flap to 2.8% for LD flap. The overall rate of wound infection was 9.8% and ranged from 5.3% for fTRAM flap to 15.2% for DTI reconstruction.

Summing up, the researchers say the "significant differences" across reconstructive procedure types for overall and reoperative complications is "critically important information for women and surgeons making breast reconstruction decisions."

Women More Satisfied With Autologous Reconstruction

In the second study, Andrea Pusic, MD, Brigham Health in Boston, Massachusetts, and colleagues used the BREAST-Q survey to examine satisfaction and breast-related quality of life 2 years after breast reconstruction using implant or autologous techniques in 2013 women.

They found that women who underwent autologous reconstruction were significantly more satisfied with their breasts (BREAST-Q score difference, 7.94; P < .001) and had greater psychosocial well-being (difference, 3.27; P = .002) and sexual well-being (difference, 5.52; P < .001) than their peers who underwent implant reconstruction.

"These findings can inform patients and their clinicians about expected satisfaction and quality of life outcomes of autologous vs implant-based procedures and further support the adoption of shared decision making in clinical practice," Pusic and colleagues conclude.

This study adds to a body of literature demonstrating better long-term satisfaction and improved quality of life after autologous breast reconstruction, "which translates to long-term cost-effectiveness to society," Fan and Song write.

"However, rates of autologous breast reconstruction have remained stagnant, while, since 2002, prosthetic-based techniques have become the most common method of breast reconstruction," they point out. This trend correlates with reimbursement rates, which have dropped for autologous breast reconstruction but have held steady for implant-based reconstruction, they note.

We have found after autologous breast reconstruction, rates of immediate revision are higher, but delayed revision is rare. Dr Kenneth Fan and Dr David Song

The editorialists say both study teams should be "commended" for conducting one of the largest prospective multicenter patient-focused outcome series on breast reconstruction. "However, further analyses of long-term (>10 years) longitudinal and cost-effectiveness outcomes in a similar cohort are necessary to give us a clearer picture. The time frame for reoperation is inevitable with implant-based breast reconstruction, whereas we have found after autologous breast reconstruction, rates of immediate revision are higher, but delayed revision is rare," they conclude.

Funding for this research was provided by the National Cancer Institute. Dr Wilkins has disclosed no relevant financial relationships. Dr Pusic is a codeveloper of the BREAST-Q survey and receives royalties from its use. Dr Fan and Dr Song have disclosed no relevant financial relationships.

JAMA Surg. Published online June 20, 2018. Wilkins et al, Abstract; Pusic et al, Full text

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