Peter A. Lennox

Patient satisfaction with postmastectomy breast reconstruction: a comparison of saline and silicone implants.

At a time when the safety and effectiveness of breast implants remains under close scrutiny, it is important to provide reliable and valid evidence regarding patient outcomes. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life may be the most significant outcome variables when evaluating surgical success. The objective of the current study was to identify predictors of patient satisfaction with breast appearance, including implant type, in a large sample of women who underwent breast reconstruction surgery using implants.

Patient satisfaction and health-related quality of life following breast reconstruction: patient-reported outcomes among saline and silicone implant recipients.

Background: In recent years, there has been a growing acceptance of the value of breast reconstruction. The majority of women who choose to proceed will undergo alloplastic reconstruction. The primary objective of this study was to determine whether the type of implant used in alloplastic breast reconstruction has an impact on patient-reported satisfaction and quality of life. Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least 1 year before study initiation. Patients were contacted by mail: two questionnaires [the BREAST-Q and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (Br23) (EORTC QLQC30 (Br23))], a contact letter, and an incentive gift card were included. Scores were compared between silicone and saline implant recipients. Results: Seventy-five silicone implant recipients and 68 saline implant recipients responded, for a response rate of 58 percent. BREAST-Q responses showed silicone implant recipients to have higher scores on all nine subscales. This difference reached statistical significance on four of nine subscales: overall satisfaction (p = 0.008), psychological well-being (p = 0.032), sexual well-being (p = 0.05), and satisfaction with surgeon (p = 0.019). Regression analysis adjusted for follow-up time, timing of surgery, unilateral versus bilateral surgery, radiation, and age. Results from the EORTC QLQC30 (Br23) showed a statistically significant difference on two of 22 subscales: silicone recipients had higher overall physical function, and saline recipients had higher systemic side effects. Conclusions: This study has shown higher satisfaction with breast reconstruction in silicone gel implant recipients compared with saline recipients using the BREAST-Q. There was no difference in overall global health status between the two patient groups as measured by the EORTC-QLQC30 (Br23).

Nontuberculous mycobacterial breast implant infections.

Background: For reasons that are unclear, the incidence of nontuberculous mycobacterial disease is increasing worldwide. Periprosthetic nontuberculous mycobacterial infections following augmentation mammaplasty and breast reconstruction have been reported previously in the form of case reports. Methods: This retrospective case series examines periprosthetic nontuberculous mycobacterial infections in two western Canadian cities (Edmonton, Alberta, and Vancouver, British Columbia) over a 10-year time period. Results: Ten patients were identified, four of whom had bilateral infections. The most common isolate was Mycobacterium fortuitum. Clinical features were similar to nonmycobacterial periprosthetic infections. The median time to onset of symptoms was 4.5 weeks and the median time to culture an organism was 5.4 weeks. The median duration of antibiotic therapy was 22 weeks. Patients required a mean of three additional operations after diagnosis. Nine patients underwent explantation of the involved implant(s). Reimplantation was performed in six patients a median of 11.5 months after explantation. All cases of reimplantation were successful. Conclusions: Experience with this postoperative complication is limited, as nontuberculous mycobacteria represent a minority of the pathogens responsible for periprosthetic infections. In the absence of specific features with which to identify patients at risk, the surgeon must be aware of the possibility of this infection. To achieve earlier diagnosis, the clinician should have a high index of suspicion in a patient with delayed onset of symptoms, negative preliminary cultures, and a periprosthetic infection that fails to resolve following a course of conventional antimicrobial treatment. With appropriate treatment, nontuberculous mycobacterial periprosthetic infections can be managed successfully.

The magnitude of effect of cosmetic breast augmentation on patient satisfaction and health-related quality of life.

Background: The objective of this study was to gain a better understanding of the magnitude of clinical change in health-related quality of life and patient satisfaction brought about by cosmetic breast augmentation. Methods: A prospective, longitudinal study was performed. Women undergoing cosmetic breast augmentation were asked to complete the BREAST-Q Augmentation module both before and after augmentation. Before and after group-level comparisons included paired t tests and effect size statistics. The responsiveness of the BREAST-Q scales was also compared at the individual person level by computing, for each and every person, the significance of her own change in measurement. Results: A total of 41 patients completed the BREAST-Q before and after augmentation. Patients reported that “satisfaction with breasts,” “psychosocial well-being,” and “sexual well-being” were significantly higher following augmentation compared with preoperative levels (p = 0.00, p = 0.00, and p = 0.00, respectively). These statistically significant change scores were associated with large effect sizes (d = 2.4, 1.7, and 1.9, respectively). Significant improvements in satisfaction with breasts, psychosocial well-being, and sexual functioning were seen in 38 (83 percent), 36 (88 percent), and 33 (81 percent) of individuals, respectively. Conclusions: These findings suggest that the BREAST-Q Augmentation module detected significant benefits of breast augmentation surgery, as assessed by both group-level and individual-level responsiveness indices. Importantly, this finding strongly supports the hypothesis that cosmetic breast augmentation can have a significant and profound positive impact on a womans satisfaction with her breasts and her psychosocial and sexual well-being. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of abdominal quilting sutures for seroma prevention in TRAM flap reconstruction : A prospective, controlled trial

This study is designed to evaluate the effect of abdominal quilting sutures on the incidence of abdominal seroma formation in patients undergoing pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. It is theorized that the use of such sutures during closure of abdominal flaps will collapse dead space, thus preventing abdominal seroma formation. A total of 71 consecutive patients undergoing pedicled TRAM flap breast reconstruction were randomly assigned to receive abdominal quilting sutures or to undergo a standard abdominal closure. Primary outcome measures included: daily drain output for the first 3 postoperative days, time to drain removal, and seroma formation. Drain output per day decreased with the use of abdominal quilting sutures; however, the time to drain removal was not significantly affected. Most importantly, there was no significant decrease in the incidence of seroma formation with the use of abdominal quilting sutures in this series.

Patient-reported satisfaction and health-related quality of life following breast reconstruction: a comparison of shaped cohesive gel and round cohesive gel implant recipients.

Background: Decision-making in breast reconstruction is complicated as women are offered an increasingly large range of options. Alloplastic surgery continues to evolve with the introduction of new prostheses to the breast reconstruction market but with limited patient-reported outcomes data. Evaluating the outcomes of surgical interventions and their impact on patients is imperative to improve the patient decision-making process and to improve quality of care. The authors evaluated the effect of the two most commonly used silicone prostheses on patient-reported satisfaction and health-related quality of life following alloplastic breast reconstruction. Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least 1 year before study initiation. Patients were contacted by mail with the BREAST-Q questionnaire, a contact letter, and an incentive gift card. BREAST-Q scores were compared between shaped cohesive and round cohesive silicone gel implant recipients. Results: Sixty-five round, cohesive, non–form-stable and 63 shaped, cohesive, form-stable silicone gel implant recipients responded, for an overall response rate of 75 percent. BREAST-Q responses showed no difference on any scale, including overall satisfaction with breast and outcome. Item-wise analysis revealed that implant recipients find shaped cohesive form-stable implants to be significantly firmer than cohesive round implants. No difference was found in implant rippling. Conclusion: Although previous studies have shown silicone implant recipients to be more satisfied overall than saline implant recipients after alloplastic breast reconstruction, this study showed that patients do not differ in terms of satisfaction with outcome when compared regarding reconstruction using round versus shaped cohesive silicone gel implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast reconstruction in older women : Should age be an exclusion criterion?

Background: At present, breast reconstruction is undertaken by fewer than 10 percent of breast cancer patients undergoing mastectomy. Even though the benefits are numerous, this finding is even more notable among older women. Traditionally, women older than the age of 60 have been offered implant reconstruction or no reconstruction at all in hopes of minimizing potential morbidity. This practice may be due to a number of factors including a lack of patient education and information, as well as physician/surgeon bias regarding the safety or relevance of breast reconstruction in older women. Methods: The authors undertook a retrospective study in which they surveyed 75 women (age range, 60 to 77 years) from two surgeons’ practices who underwent various forms of breast reconstruction over the past 8 years. Type of reconstruction, recovery time, and complication rate were correlated with patient satisfaction, general health, and quality of life. Results: An 81 percent response rate was obtained, yielding an average age of 66.6 years over a 3.8-year period. The overall rate of complications requiring operative intervention was 20.5 percent. When asked whether age should be a determining factor for breast reconstruction, more than 90 percent felt that it should not be. Only 16.1 percent of patients who had a delayed reconstruction stated that the option of breast reconstruction was presented to them at the time of their diagnosis, although 100 percent felt that it should have been. A significantly poorer physical health score was found among patients who experienced a complication, and lower mental health scores correlated with women who were less satisfied with their outcome. Conclusions: The authors believe that all types of reconstruction should be an option for women older than 60 years of age and that age as an isolated factor should not deter physicians from offering these women the option of breast reconstruction.

Acellular dermal matrices: Use in reconstructive and aesthetic breast surgery.

Acellular dermal matrices (ADMs) were first described for use in breast surgery in 2001. Since this initial report, ADMs have become an increasingly common component of implant-based breast procedures. ADMs have shown promise for use in both aesthetic and reconstructive breast surgery; however, concerns about their use remain because of the significant costs associated with these products. The present article reviews the history of ADM use in breast surgery and the outcomes reported to date. Common techniques for placement of ADMs in aesthetic revisionary and breast reconstruction surgery are provided, and use in the setting of chest wall irradiation and capsular contracture is discussed. Finally, the authors comment on the cost implications of these products in the Canadian and American health care systems.

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective.

Background: An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant. Methods: Patients who had their tissue expander irradiated before implant exchange were identified. Complications, capsular contracture, revision surgery, and autologous salvage rates of irradiated patients were compared with a control group of nonirradiated patients. Results: Immediate two-stage tissue expander/implant reconstruction was initiated in 604 patients, with 113 irradiated breasts meeting inclusion criteria. Three hundred thirty-nine nonirradiated breasts constituted the control group. There was a 4.2 increased odds of major complications in the irradiated group, after adjusting for plastic surgeon, age, body mass index, smoking, chemotherapy, and cancerous breast (OR, 4.2; p = 0.001). The grade III and IV capsular contracture rate was significantly higher in the irradiated group compared with the control group (21.7 percent versus 10 percent; p < 0.008). The revision rate in the control group was higher compared with the irradiated group (30.2 percent versus 20.9 percent; p < 0.001). Conclusions: Postmastectomy irradiation to the tissue expander is associated with high complications; however, these patients have an acceptable capsular contracture rate that compares favorably with other implant-based radiotherapy algorithms. Revision rates were less than expected in irradiated breasts. This study suggests that immediate tissue expander/implant reconstruction is a reasonable surgical option in the setting of postmastectomy radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods

Background: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs. Methods: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected. Results: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders. Conclusions: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.