Breast Reconstruction Completion in the Obese: Does Reconstruction Technique Make a Difference in Its Achievement?

Background Deep inferior epigastric perforator (DIEP) reconstruction can be performed in an immediate (at time of mastectomy), delayed–immediate (immediate tissue expander followed by staged DIEP), or delayed timing following mastectomy. Avoiding flap radiation is a known benefit of the delayed–immediate approach. The purpose of this study is to evaluate patients who chose DIEP flap as the reconstructive method during initial consultation and compared characteristics of surgery in relation to their final reconstructive choice. Methods Consecutive patients having breast reconstruction from 2017 to 2019 were divided into three groups: immediate DIEP after mastectomy (Group I); delayed–immediate DIEP with tissue expander first followed by DIEP (Group II); and patients who initially chose delayed–immediate DIEP but later decided on implants for the second stage of reconstruction (Group III). Exclusion criteria were patients that had delayed DIEP (no immediate reconstruction) or had initially chose implant-based reconstruction. Results The study included 59 patients. Unilateral free flaps in Group II had shorter operative times (318 minutes) compared with Group I unilateral free flaps (488 minutes) (p = 0.024). Eleven patients (30.6%) had prophylactic mastectomies in Group I compared with none in Group II (p = 0.004). Patients who had immediate tissue expansion frequently changed their mind from DIEP to implant for second stage reconstruction frequently (52.2%). Conclusion Delayed–immediate DIEP reconstruction has several advantages over immediate DIEP flap including shorter free flap operative times. Patients commonly alter their preference for second stage reconstruction. A patient-centered advantage of delayed–immediate reconstruction is prolonging the time for patients to make their choice for the final reconstruction.

Section: Discussionmentioning

confidence: 99%

“…30.5%, 11/36) group compared with no patients receiving tissue expanders first (0%) (p ¼ 0.004).The operative time for the DIEP flap was significantly greater in Group I (537 AE 111 minutes) compared with Group II (411 AE 144 minutes) (p ¼ 0.004) (►Table 2).…”

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confidence: 97%

Advantages of the Delayed–Immediate Microsurgical Breast Reconstruction: Extending the Choice

Pittelkow

DeBrock

Christopher

et al. 2022

“…Future prospective studies examining the influence of these characteristics on patient-reported outcomes among those with previously failed implant reconstruction are needed. 26 Finally, the small sample size of patients who required conversion to a free-flap reconstruction limits the statistical power and described associations, as well as generalizability to other institutions.…”

Section: Limitationsmentioning

confidence: 99%

Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction

Shammas

Sergesketter

Taskindoust

et al. 2021

Background Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction. Methods All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction. Results Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91). Conclusion A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

“…10 11 12 Previously, Velazquez et al demonstrated a higher rate of breast reconstruction completion in an obese population using abdominal-based free autologous breast reconstruction (ABFABR) compared with IBR. 13…”

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confidence: 99%

Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction

Maus,

Pestana

2023

Self Cite

Background: Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes in breast reconstruction has been poorly characterized. Methods: A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction (ABFABR) was conducted over fifteen years. Patient and operative characteristics were recorded and outcomes analyzed. Patient-reported outcomes (PRO) were assessed using the BREAST-Q™ abdominal survey. Results: 75 women (108 flaps) with mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (DIEP; 24%), muscle-sparing (MS-TRAM; 43%) and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in seven percent; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p<0.05). Bulge formation occurred more often in f-TRAM donor sites (p=0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. Survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with post-op bulge reported higher abdominal physical well-being scores, regardless of flap type (p<0.01). Bulge was correlated with lower satisfaction (p<0.05). Conclusion: The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was a primarily cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.