Does procedure type influence complication rates after breast reconstruction?

Nearly one-third of women undergoing postmastectomy breast reconstruction suffer complications, and patients having autologous reconstruction are more likely to develop complications than those who have expander-implant procedures, according to a study recently published in JAMA Surgery.

Researchers from the Mastectomy Reconstruction Outcomes Consortium (MROC) study followed 2,343 women (mean age: 49.5 years; mean body mass index: 26.6) undergoing breast reconstructive surgery at 11 participating centers. They tracked complication rates and patient-reported outcomes for 2 or more years after surgery.

“Imagine you’re a woman facing a mastectomy,” said senior author Edwin Wilkins, MD, professor and researcher, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI. “Then a plastic surgeon walks in the door and says you can have breast reconstruction, and there are six or seven different options. How do you know what to choose?”

The goal of the study was to compare the most commonly used breast reconstruction techniques, with outcome measures such as patient satisfaction, quality of life, body image, social functioning, physical well-being, and pain.

“We were particularly focused on assessing the risks and benefits from a patient’s eye view. Our ultimate goal is to empower consumers with information to work with their doctors to make decisions tailored to patients’ values and preferences,” said Dr. Wilkins.

In all, 65.1% of patients underwent expander-implant (EI) reconstruction, 4.8% direct-to-implant (DTI) reconstruction, 3.6% pedicled transverse rectus abdominis myocutaneous (pTRAM) flaps, 4.1% free transverse rectus abdominis myocutaneous (fTRAM) flaps, 16.6% deep inferior epigastric perforator (DIEP) flaps, 3.0% latissimus dorsi (LD) flaps, and 2.8% superficial inferior epigastric artery (SIEA) flaps.

Postsurgical complications occurred in 32.9% of patients, including 19.3% with reoperative complications and 9.8% with wound infections. Reconstructive failure occurred in 5%.

Across the different types of reconstructive procedures, researchers found significant differences in several outcome measures. For example, patients undergoing flap reconstruction had a higher risk of complications, but a much lower risk of failure compared with those having breast implants.

Patients who had any autologous reconstruction demonstrated significantly higher risks of developing a complication compared with those undergoing EI reconstruction:

• pTRAM flap: OR: 1.91; 95% CI: 1.10-3.31; P=0.02;
• fTRAM flap: OR: 2.05; 95% CI: 1.24-3.40; P=0.005;
• DIEP flap: OR: 1.97; 95% CI: 1.41-2.76; P < 0.001;
• LD flaps: OR: 1.87; 95% CI: 1.03-3.40; P=0.04; and
• SIEA flap: OR: 4.71; 95% CI: 2.32-9.54; P < 0.001

Compared with EI techniques, all flap procedures ex cept LD flap reconstructions were associated with higher odds of reoperative complications:

• pTRAM flap: OR: 2.48; 95% CI: 1.33-4.64; P=0.005;
• fTRAM flap: OR: 3.02; 95% CI: 1.73-5.29; P < 0.001;
• DIEP flap: OR: 2.76; 95% CI: 1.87-4.07; P < 0.001; and
• SIEA flap: OR: 2.62; 95% CI: 1.24-5.53; P=0.01

Among patients undergoing autologous reconstructions, only those with DIEP flaps had significantly lower odds of infection compared with EI procedures (OR: 0.45; 95% CI: 0.25-0.29; P=0.006).

Both DTI and EI procedures had higher failure rates, with EI and DTI techniques at 7.1%, pTRAM flap at 1.2%, fTRAM flaps at 2.1%, DIEP flaps at 1.3%, LD flap at 2.8%; and SIEA flaps at 0% (P < 0.001).

“The message here is that these operations are not without risk,” said Dr. Wilkins. “Complications are fairly common, but thankfully failure is uncommon. Based on these results, what I now tell new patients is that even with the bumps in the road, we usually get where we’re going with reconstruction.”

Dr. Wilkins and colleagues also found that patients undergoing flap reconstruction were significantly more satisfied with their breasts and breast-related quality of life ≥ 2 years postsurgery than those who had implants. Satisfaction levels of these women were even higher than their presurgery baselines.

Yet in some women, tightness and pain in the abdominal wall were present for years.

“The key takeaway from this research is that these are complicated decisions,” said Dr. Wilkins. “As with all health-care decisions, patients need up-to-date information that empowers them to actively work with their doctors to choose what’s best for them.”

Dr. Wilkins and colleagues are currently using MROC study data to build a web-based decision-making platform for which patients can enter variables such as height, weight, age, smoking status, and radiation therapy status, and then receive individualized information to guide them through their decision-making process and the operation and recovery.

This study was supported by grant R01CA152192 from the National Institutes of Health National Cancer Institute.