Janet H. Yueh

Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, andImplant Techniques

Background: Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction. Methods: All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. Results: Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198). Conclusions: Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Impact of Complications on Patient Satisfaction in Breast Reconstruction

Background: The development of a complication after surgery can be difficult for both patient and surgeon. With a growing body of literature evaluating patient satisfaction after breast reconstruction, few studies directly focus on the impact of surgical complications on satisfaction. This study analyzed the effect of complications on general and aesthetic satisfaction after breast reconstruction. Methods: All women at an academic institution undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and history of complications were collected. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered examining general and aesthetic satisfaction. Patients with complications were compared with patients with no complications. Results: Overall, 716 women underwent 932 reconstructions; 233 patients had a complication. Patient demographics and response rate were similar between the two groups (overall response rate 75.4 percent). Development of a complication correlated with increased odds of aesthetic dissatisfaction (odds ratio = 1.61, p = 0.047). Other predictors of dissatisfaction were older age, reconstruction with an implant, and a longer time interval between reconstruction and survey, while autologous reconstruction was a predictor of satisfaction. Among patients with a complication, implant reconstruction and mastectomy for prophylaxis were significant predictors of dissatisfaction. Conclusions: Aesthetic satisfaction after breast reconstruction is lower in patients developing a complication, older patients, and those receiving an implant reconstruction. Furthermore, patients with a prophylactic mastectomy are more likely than those with a therapeutic mastectomy to be dissatisfied when complications arise. These relationships are important, as measures to improve quality and decrease complications can directly improve patient satisfaction.

Postmastectomy radiation therapy and breast reconstruction: an analysis of complications and patient satisfaction.

The indications for postmastectomy radiotherapy (PMRT) have expanded over the past decade. This study examines PMRT and reconstruction compared with a control group without radiotherapy. There were 919 reconstructed breasts identified (1999–2006) and separated into 3 groups: mastectomy with PMRT before reconstruction (n = 57), immediate reconstruction then PMRT (n = 59), and reconstruction without PMRT (n = 665). A validated questionnaire assessed patient satisfaction (response rate 73.7%). Overall complication rates for patients undergoing PMRT (before and after reconstruction) were higher than that of the controls (39.66% vs. 23.16%, P < 0.001). Immediate reconstruction before PMRT had increased overall and late (>90 days) complication rates, compared with controls (47.46% vs. 23.16%, P < 0.001; 33.90% vs. 15.59%, P < 0.001, respectively); however general and aesthetic satisfaction was similar. In contrast, PMRT before reconstruction has similar complication rates and general satisfaction with controls, but decreased aesthetic satisfaction (50% vs. 66.88%, P < 0.035).

Patient satisfaction in unilateral and bilateral breast reconstruction [outcomes article].

Background: The goal of reconstruction after mastectomy is to provide a long-term and symmetric reconstruction. Providing symmetry entails different decision making when faced with a unilateral or bilateral reconstruction. In unilateral reconstruction, the goal is to match the contralateral breast; however, in bilateral reconstruction, symmetry between the reconstructed breasts is more important. The purpose of this study was to examine patient satisfaction between unilateral and bilateral reconstruction. Methods: All women at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected. A survey was administered examining general and aesthetic satisfaction. Patients with unilateral reconstruction were identified and compared with patients with bilateral reconstruction. Additional analysis was performed based on the type of reconstruction, including autologous, autologous with implant, and tissue expander/implant-based reconstruction. Results: Overall, 702 women underwent 910 breast reconstructions (494 unilateral, 416 bilateral). Patients in the bilateral reconstruction group were more likely to have prophylactic mastectomy and immediate reconstruction. Complication rates were similar between unilateral and bilateral reconstruction. Patient satisfaction was highest in unilateral patients with autologous compared with implant reconstruction (general satisfaction, 73.9 versus 40.9 percent, p < 0.0001; aesthetic satisfaction, 72.3 versus 43.2 percent, p < 0.0001). Bilateral reconstruction had similar general and aesthetic satisfaction scores across autologous, autologous with implant, and implant-based reconstruction. Conclusions: Patients undergoing unilateral reconstruction have the highest satisfaction with autologous reconstruction. As symmetry between reconstructed breasts is essential for patient satisfaction in bilateral reconstruction, it is important to use the same type of reconstruction, whether autologous or implant-based.

Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation.

The purpose of this study is to describe our experience with nipple-sparing mastectomy and immediate reconstruction, with particular attention to patient satisfaction, aesthetic results, and nipple sensation. Immediate reconstruction was performed on 17 breasts in 10 patients, using either implants or autologous tissue flaps. Assessment of outcomes was performed through patient interviews, a self-reported patient satisfaction survey and review of postoperative photographs. Short-term complications included partial loss of the nipple-areolar complex requiring debridement (n = 3) and removal of the nipple-areolar complex (n = 2) for occult ductal carcinoma in situ. While all patients with completed breast reconstructions were satisfied with their general reconstructive experience, 6 of 9 patients were aesthetically satisfied with their breast reconstruction. Postoperative nipple sensation was reported in 75% of patients, although sensation was low (mean of 2.8 of 10). As nipple-sparing mastectomy is becoming an increasing patient preference, preoperative discussion needs to address expectations, aesthetic satisfaction, and long-term cancer control.

Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction.

Background: The potential for donor-site morbidity associated with bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has led to the popularization of deep inferior epigastric artery perforator (DIEP) flap reconstruction. This study compares postoperative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction. Methods: One hundred five women with bilateral pedicled TRAM flaps were compared with 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Postoperative follow-up data were obtained through Short Form-36, Functional Assessment of Cancer Therapy-Breast, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys. Results: The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data were otherwise similar. Abdominal hernias occurred in three TRAM patients (2.9 percent) and in no DIEP patients, whereas abdominal bulges occurred in three TRAM patients (2.9 percent) and four DIEP patients (6.9 percent); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Postoperative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the Medical Outcome Study Short Form-36 subjective energy category (p = 0.01) and mean Functional Assessment of Cancer Therapy-Breast score (p = 0.01). Conclusions: This study suggests no significant differences in donor-site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction.

Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction.

AbstractThe purpose of this study was to evaluate complications and patient satisfaction after pedicled transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap reconstruction at a single institution. There were 346 patients identified from 1999 to 2006 who underwent 197 pedicled TRAM and 217 DIEP flap reconstructions. Flap complication rates were similar between groups, whereas pedicled TRAM reconstructions had higher rates of abdominal bulge (9.5% vs. 2.3%, P = 0.0071) and hernias (3.9% vs. 0%, P = 0.0052). DIEP flap patients had significantly higher general satisfaction (81.7% vs. 70.2%, P = 0.0395), whereas aesthetic satisfaction was similar between groups. Furthermore, DIEP flap patients, particularly those undergoing bilateral reconstructions, were more likely to choose the same type of reconstruction compared with pedicled TRAM patients (92.5% vs. 80.7%, P = 0.0113). Understanding the differences in complications and satisfaction will help physicians and patients make informed decisions about abdominal-based autologous breast reconstruction.

Design and Impact of an Intraoperative Pathway: A New Operating Room Model for Team-Based Practice

BACKGROUND The concept of a team-based model for delivery of care has been critical at our institution for improving efficiency and safety. Despite these measures, difficulties continue to occur during lengthy operating room procedures. Using a novel team-based practice model, a multidisciplinary team was organized to improve efficiency in microsurgical breast reconstruction. We describe development of an intraoperative pathway for deep inferior epigastric perforator (DIEP) flap breast reconstruction and its impact on various outcomes. STUDY DESIGN We evaluated 150 patients who underwent DIEP flap breast reconstruction at Beth Israel Deaconess Medical Center from 2005 to 2008. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures before the intraoperative pathway and 25 unilateral and 25 bilateral procedures after. Outcomes measured included operative time, complications, operating room and hospital costs, proper administration of prophylactic antibiotics and heparin, and staff satisfaction surveys. RESULTS Mean operative times decreased after pathway implementation in both unilateral (8.2 hours to 6.9 hours; p < 0.001) and bilateral groups (12.8 hours to 10.6 hours; p < 0.001) and complication rates were unchanged. Mean operating room costs decreased in the unilateral group by 10.2% (p = 0.018). Prophylactic heparin administration showed substantial improvements, although antibiotic administration and redosing of antibiotics trended upward. Staff surveys showed improved interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization. CONCLUSIONS Implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. Refinement of the pathway with team resolution of variances might continue to improve outcomes. Complex, multi-team procedures can derive benefits from standardization and intraoperative pathway development.

Incidence of Hematoma Complication with Heparin Venous Thrombosis Prophylaxis after Tram Flap Breast Reconstruction

Background: Randomized controlled studies provide ample evidence that heparin is effective in reducing the risk of thromboembolic complications. Nevertheless, plastic surgeons are often reluctant to use heparin chemoprophylaxis for fear of postoperative bleeding. The authors investigated whether heparin chemoprophylaxis was associated with postoperative hematoma that required evacuation in patients who underwent transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Methods: A multicenter retrospective review of consecutive TRAM flap cases identified 679 patients, 392 in the heparin-treated group and 287 in the control group. The post hoc sample sizes were adequate to detect a 5 percent difference in hematoma rate with 89 percent power at an alpha level of 5 percent (p < 0.05). Outcome measures of reoperative hematoma, deep vein thrombosis, and pulmonary embolism were recorded. Results: Reoperative hematoma occurred in 0.5 percent of patients in the heparin-treated group and 1.0 percent of patients in the control group; this difference was not statistically significant (p = 0.66). Thromboembolic events were detected at a low rate (0.8 percent in the heparin-treated group versus 1.4 percent in the untreated group; p = 0.46). Conclusions: The use of heparin for venous thrombotic prophylaxis did not increase the risk of reoperative hematoma after breast reconstruction with abdominal tissue. The authors propose a risk assessment that balances a statistical hematoma rate of 0.5 to 5 percent (clinically observed rate, 0.5 percent) with use of heparin prophylaxis against a rare (clinically observed rate, 1.4 percent) but morbid occurrence of thromboembolic complications when chemoprophylaxis is omitted.

The impact of nipple reconstruction on patient satisfaction in breast reconstruction.

BackgroundNipple reconstruction is an integral part of the breast reconstruction process, as patients associate this stage with closure while providing a sense of completeness. This study evaluates the effect of nipple reconstruction on patient satisfaction with breast reconstruction. MethodsAll patients at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected retrospectively while aesthetic and general satisfaction was evaluated by an administered survey. Patients with nipple reconstruction at the time of survey were compared to patients without nipple reconstruction. ResultsNine hundred two breast reconstructions were performed in 696 patients; 490 patients underwent nipple reconstruction and 206 did not. Autologous reconstruction predominated in patients with and without nipple reconstruction (61.8% and 54.8%, respectively). There were no significant differences in individual and overall total complications between groups. Patients with nipple reconstruction had significantly higher general (72.2% vs 52.8%, P < 0.0001) and aesthetic (70.5% vs 46.5%, P < 0.0001) satisfaction scores compared to patients without nipple reconstruction. These results were seen in unilateral and bilateral breast reconstruction. Across reconstructive techniques, patients with nipple reconstruction had higher aesthetic satisfaction. Patient satisfaction scores in all individual survey questions were statistically higher in patients with nipple reconstruction. ConclusionsPatients with breast reconstruction who undergo nipple reconstruction have higher general and aesthetic satisfaction compared to breast reconstruction alone. These differences were observed in both unilateral and bilateral reconstruction. Patients should be fully counseled about potential benefits nipple reconstruction can provide to all forms of breast reconstruction.