Plastic Surgery Research Council

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Patient Reported Satisfaction and Quality of Life in Post-Mastectomy Radiated Patients: A Comparison between Delayed and Delayed Immediate Autologous Breast Reconstruction in a Predominantly Minority Patient Population
George Kamel, MD, David Nash, MD, Robin Berk, BA, Amanda Rizzo, BA, Teresa Benacquista, MD, Evan Garfein, MD, Katie Weichman, MD.
Montefiore Medical Center, Bronx, NY, USA.

Background: Delayed immediate autologous breast reconstruction consists of immediate post mastectomy tissue expander placement, followed by radiation therapy and subsequent autologous reconstruction. The decision between delayed versus delayed immediate autologous breast reconstruction in patients anticipating post mastectomy radiotherapy is challenging and remains to be elucidated. The purpose of this investigation was to evaluate the effects of delayed versus delayed immediate autologous breast reconstruction in patients undergoing post mastectomy radiotherapy on patient reported outcomes and quality of life in predominantly minority patients.
Methods:  After IRB approval was obtained, a retrospective review of all patients who underwent autologous based breast reconstruction at Montefiore Medical Center from January of 2009 to December of 2016 was conducted. Patients who underwent post mastectomy radiotherapy were included for analysis.  Patients were divided into two cohorts: those undergoing delayed and delayed immediate autologous breast reconstruction. Patients were mailed a BREAST-Q survey. Demographic information, complications, and need for revisionary procedures were analyzed in comparison.  BREAST Q satisfaction was then analyzed using Q-Score software.
Results: 56 patients met the inclusion criteria: 37.5 percent (n=21) of patients underwent delayed autologous breast reconstruction and 62.5 percent (n=35) underwent delayed immediate autologous breast reconstruction. 87.5 percent (n=49) of the patients were identified as minority. Patients in each cohort were similar in BMI, mean mastectomy specimen weight, indication for surgery and smoking status. All patients received post mastectomy radiotherapy. However, patients undergoing delayed immediate autologous breast reconstruction were more likely to have bilateral reconstruction (34.3 percent (n=12) versus 9.5 percent (n=2), p=0.04), and were more likely to have major mastectomy flap necrosis (17.0 percent (n=8) versus 0.0 percent (n=0), p= 0.02). Furthermore, 14.9 percent (n=7) of patients undergoing delayed immediate autologous breast reconstruction required removal of their tissue expanders. Of those patients undergoing delayed autologous breast reconstruction, 28.6% (n=6) responded to the BREAST-Q survey, whereas 40.0% (n=14) of patients with delayed immediate autologous breast reconstruction were responders. BREAST-Q responses showed similar satisfaction with their breasts, overall outcome, chest wall physical well-being, sexual well-being, and psychosocial well-being in both groups.
Conclusion: Delayed autologous breast reconstruction yields similar satisfaction with breasts, overall outcome, chest wall physical well-being, sexual well-being, and psychosocial well-being as compared to delayed immediate autologous based reconstruction. However, patients who undergo delayed immediate autologous breast reconstruction have higher rates of major mastectomy necrosis and subsequent removal of their tissue expanders. This information will be important in preoperative patient discussions and counseling.
Delayed versus Delayed Immediate (DI) Outcomes Data Sheet

Delayed (n=27)DI (n= 52)Testp-value
Patients2752n/an/a

Breasts2976n/an/a
Laterality
Unilateral
Bilateral
25 (92.6)
2 (7.4)
28 (53.8)
24 (46.2)
Chi Squared0.0005
Age51 (10.3)47 (9.5)T-test0.09
BMI (kg/m2)30.4 (4.7)31.2 (3.8)T-test0.4
Average mastectomy weight (grams)1049 (800)877 (365)T-test0.19
Average Flap weight (grams)930 (210)897 (233)T-test0.54
Adjuvant radiation27 (100)52 (100)Fishers Exact1.0
Neoadjuvant radiation0 (0)0 (0)Fishers Exact1.0
Neoadjuvant chemotherapy20 (74.1)44 (84.6)Fishers Exact0.36
Adjuvant chemotherapy1 (3.7)1 (1.9)Fishers Exact1.0
Indications
Prophylactic
Therapeutic
2 (6.9)
27 (93.1)
12 (15.8)
64 (84.2)
Chi Squared0.23
Smoking Status
Current smoker
Former Smoker
Non-Smoker
1 (3.7)
6 (22.2)
20 (74.1)
1 (1.9)
14 (25.9)
39 (72.2)
Chi Squared0.36
Flap Type
DIEP
MS0 TRAM
MS1 TRAM
16 (55.2)
12 (41,4)
1 (3.4)
35 (46.0)
37 (48.7)
4 (5.3)
Chi Squared0.74
Race
White
Hispanic
Black
Multiracial
2 (7.4)
6 (22.2)
7 (26.0)
12 (44.4)
5 (9.6)
18 (34.6)
22 (42.3)
7 (13.5)
Chi Squared0.02
Hematoma1 (3.4)2 (2.6)Fishers Exact1.0
Seroma1 (3.4)2 (2.6)Fishers Exact1.0
Donor Site Wound Infection3 (11.1)9 (17.3)Fishers Exact0.53
Reconstructive Failure0 (0.0)2 (2.6)Fishers Exact1.0
Vessel Thrombosis
Arterial
Venous
0 (0.0)
1(3.4)
3 (3.9)
1 (1.3)
Fishers Exact1.0

Mastectomy Skin flap necrosis
Minor
Major
3 (10.3)
0 (0.0)
5 (6.6)
17 (22.4)
Fishers Exact0.68
0.002
Fat Necrosis0 (0.0)5 (6.6)Fishers Exact0.32
TE Explantn/a9 (11.8) or (17.3% of patients)
Total Complications955


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