Michael S. Curtis

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.

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.

Breast cancer recurrence following postmastectomy reconstruction compared to mastectomy with no reconstruction.

Background:Continuing advances in breast reconstruction have provided surgeons with a multitude of reconstructive options. Concerns remain, however, about the effects of the various reconstructive methods on ultimate oncologic outcome. This study compares incidence, detection, and management of recurrent breast cancer in a large series of patients treated with mastectomy alone or with mastectomy and various forms of reconstruction. Methods:A retrospective analysis was performed on all patients who underwent mastectomy and/or immediate reconstruction for breast cancer at our institution between January 1999 and December 2006. The 921 patients were divided into 2 groups: mastectomy and reconstruction (n = 494) and mastectomy alone (n = 427). All modern reconstructive methods were included. Patients were followed for a mean of 4.5 years. Results:The total incidence of recurrence—locoregional and/or distant—was 5.9% in patients who had mastectomy with reconstruction and 11.5% in patients who had mastectomy alone (P < 0.0023). The incidence of locoregional recurrence only was 2.2% in patients who had mastectomy with reconstruction and 4.0% in patients who had mastectomy alone (P = 0.1220). Of the 11 reconstructed patients with a locoregional recurrence, all recurrences were detected by self or clinical examination. Median time to detection was the same in both groups: 1.6 years (P = 0.5471). Conclusions:Reconstruction with a variety of methods does not adversely affect the incidence or time to detection of recurrent breast cancer. Further, our data point to an important role for physical examination in tumor surveillance after mastectomy and reconstruction.

Postmastectomy breast reconstruction after previous lumpectomy and radiation therapy: analysis of complications and satisfaction.

Background:Lumpectomy and radiation therapy (breast conservation therapy [BCT]) are common treatments for early-stage breast cancer. However, many of these patients will require a subsequent salvage mastectomy and reconstruction after a locoregional recurrence. This study examines whether prior BCT leads to higher rates of complications and dissatisfaction with subsequent mastectomy and breast reconstruction. Methods:All women undergoing initial breast reconstruction at an academic institution were identified (1999–2006). Women who had undergone prior BCT were compared with women without prior BCT. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered. Rates of complications, as well as general and aesthetic satisfaction, were compared between the 2 groups. Multiple logistic regression was used to analyze the effects of prior BCT, age, comorbidities, reconstruction type, and time between radiation and reconstruction. Results:Overall, 532 women underwent 802 reconstructions, of whom 113 women (137 reconstructions) had prior BCT. Prior BCT did not correlate with higher complication rates (odds ratio [OR] = 1.09, P = 0.690), or lower general or aesthetic satisfaction (OR = 0.84, P = 0.559; OR = 0.91, P = 0.723, respectively); however, there was an increased rate of mastectomy skin flap loss (12.4% vs. 6.8%, P = 0.024). Increasing age was the most significant risk factor for complications and dissatisfaction. Conclusion:Radiation in the setting of BCT did not increase overall rates of complications or dissatisfaction with subsequent breast reconstruction in our patient population. These patients, however, had a higher incidence of mastectomy skin flap loss. These findings are important for preoperative counseling and intraoperative planning in patients with prior lumpectomy and radiation.

An analysis of delayed breast reconstruction outcomes as recorded in the American College of Surgeons National Surgical Quality Improvement Program

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a prospective, multi-institutional clinical registry established as an auditing instrument to monitor and improve patient care in surgery. To date no publication has queried the NSQIP dataset from a plastic surgery perspective. A retrospective analysis was carried out of all delayed breast reconstruction cases recorded by the NSQIP from 2005 to 2008 (n=645). The 30-day morbidity was 5.7%, with wound infections being the most common complication. Logistic regression analysis identified BMI >25 and preoperative radiotherapy as independent risk factors for overall morbidity and wound infection. The NSQIP does not allow for capture of procedure-specific outcomes and this results in underreporting of overall morbidity compared to the literature; this may limit the capability to assess risk factors for complications. As breast reconstruction modules for NSQIP are currently under development, modifications to capture procedure-specific outcomes are recommended.

Actopaxin is phosphorylated during mitosis and is a substrate for cyclin B1/cdc2 kinase.

Prior to cell division, normal adherent cells adopt a round morphology that is associated with a loss of actin stress fibres and disassembly of focal adhesions. In this study, we investigate the mitotic phosphorylation of the recently described paxillin and actin-binding focal-adhesion protein actopaxin [Nikolopoulos and Turner (2000) J. Cell Biol. 151, 1435-1448]. Actopaxin is comprised of an N-terminus containing six putative cdc2 phosphorylation sites and a C-terminus consisting of tandem calponin homology domains. Here we show that the N-terminus of actopaxin is phosphorylated by cyclin B1/cdc2 kinase in vitro and that this region of actopaxin precipitates cdc2 kinase activity from mitotic lysates. Actopaxin exhibits reduced electrophoretic mobility during mitosis that is dependent on phosphorylation within the first two consensus cdc2 phosphorylation sites. Finally, as cells progress from mitosis to G(1) there is an adhesion-independent dephosphorylation of actopaxin, suggesting that actopaxin dephosphorylation precedes cell spreading and the reformation of focal adhesions. Taken together, these results suggest a role for cyclin B1/cdc2-dependent phosphorylation of actopaxin in regulating actin cytoskeleton reorganization during cell division.

Early results using ultrasound-assisted liposuction as a treatment for fat necrosis in breast reconstruction.

Background: Fat necrosis is a common complication from autologous breast reconstruction that can compromise the aesthetic outcome and can be confused with recurrent breast cancer. Removal of fat necrosis through direct excision can be difficult with lesions in the periphery and may result in contour deformities. The article describes a case series of patients with fat necrosis treated with ultrasound-assisted liposuction. Methods: A retrospective database was created consisting of consecutive patients treated with ultrasound-assisted liposuction at a single academic institution. Patient demographics and complications were identified, including initial size of fat necrosis, number of ultrasound-assisted liposuction treatments, and final size of fat necrosis. Surgical technique was standardized over the entire series. Results: There were 54 breast reconstructions with fat necrosis treated with ultrasound-assisted liposuction. The average initial size of fat necrosis was 2.72 cm. Twenty-seven lesions (50.0 percent) were treated once, 20 (37.0 percent) were treated twice, and seven (13.0 percent) were treated three times. The final size of fat necrosis was 0.44 cm (p < 0.0001), with an average time to follow-up of 17.8 months. Complete resolution (<0.5 cm) was seen in 44 lesions (81.5 percent). Only one complication, a thermal burn, was seen from ultrasound-assisted liposuction, and this resolved with conservative management. Conclusions: This case series describes the successful use of ultrasound-assisted liposuction for treatment of fat necrosis after autologous breast reconstruction. The authors find this technique to be safe, effective, and reproducible, as the majority of fat necrosis areas resolved with one or two treatments.

The forked liposuction cannula: a novel approach to the correction of cicatricial contracture deformities in breast reconstruction.

AbstractCicatricial contracture deformities in breast reconstruction can result from delayed wound healing, fat necrosis, or chest wall radiation. Secondary revision can be difficult as these contour deformities compromise the final result. The authors describe correction of these scar deformities with a forked liposuction cannula in 38 breast reconstructions (32 patients). Mean follow-up time was 6 months, and no complications resulted from the use of the forked cannula. In 33 reconstructions (86.8%), autologous fat grafting was performed simultaneously. Multiple revisions were required in 8 reconstructions (23.7%). Three patients had a residual contracture after treatment; all 3 had a history of radiation therapy. This early experience demonstrates that use of a forked liposuction cannula for cicatricial breast deformities is both easy and safe. This technique can be a useful adjunct, especially in patients undergoing autologous fat grafting; however, residual contracture may be observed in patients with a history of radiation therapy.