BREAST Evolution of Bilateral Free Flap Breast Reconstruction over 10 Years: Optimizing Outcomes and Comparison to Unilateral Reconstruction Edward I. Chang, M.D. Eric I. Chang, M.D. Miguel A. Soto-Miranda, M.D. Hong Zhang, Ph.D. Naveed Nosrati, M.D. Shadi Ghali, M.D. David W. Chang, M.D. Houston, Texas
Background: There is an increasing trend for contralateral prophylactic mastectomy, but studies focusing on bilateral free flap breast reconstruction are lacking. Methods: A retrospective review was performed of all bilateral free flap breast reconstructions performed from 2000 to 2010. Results: Overall, 488 patients underwent bilateral breast reconstruction (bilateral immediate, n = 283; bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which more than doubled from the years 2000–2005 to 2006–2010 [147 versus 341 (232.0 percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a similar increase over the decade [139 versus 282 (203.9 percent)]. There was an increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17 percent)] between the first and second halves of the decade. Patients undergoing a bilateral immediate/ delayed reconstruction were significantly more likely to undergo a revision (p = 0.05), particularly on the immediate reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity were significantly associated with postoperative complications. Obesity, smoking, and radiation therapy significantly increased fat necrosis rates, 2.77 (p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In comparison to unilateral reconstruction, bilateral reconstruction had significantly higher flap loss rates (p = 0.004), comparable donor-site complications, and equivalent rates of revisions. Conclusions: There has been an increase in bilateral free flap breast reconstruction. Bilateral immediate/delayed reconstruction had higher revision rates of the prophylactic breast to achieve symmetry. Obesity, smoking, and radiation therapy were associated with increased complications, including fat necrosis, but successful reconstruction can be achieved with acceptable risks. (Plast. Reconstr. Surg. 135: 946e, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
O
ptimization of breast reconstruction is dependent not only on restoring the volume and shape of the breast following a mastectomy but also on restoring symmetry with the contralateral breast. A contralateral balancing From the Department of Plastic and Reconstructive Surgery, University of Texas M. D. Anderson Cancer Center. Received for publication August 27, 2014; accepted December 5, 2014. Presented at the 2014 Annual Meeting of the American Society of Reconstructive Microsurgery, in Kauai, Hawaii, January 8 through 14, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001233
946e
procedure has become the standard of care in the United States following passage of the Women’s Health Care and Rights Act. However, a number of studies have also demonstrated an increasing trend in contralateral prophylactic mastectomies.1,2 Although there is debate over the precise indications and impetus for proceeding with a contralateral prophylactic mastectomy, reconstructive surgeons are expected to perform an Disclosure: The authors have no financial disclosures or conflicts of interest relevant to the material presented in this article.
www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Bilateral Free Flap Breast Reconstruction increasing number of bilateral breast reconstructions. To date, there are few studies directly examining the unique nuances of bilateral autologous breast reconstruction and optimizing the final outcomes.3–5 Furthermore, for patients who decide to proceed with bilateral mastectomies and autologous tissue reconstruction, the index breast and prophylactic breast are not necessarily equivalent, and to our knowledge, no large studies currently exist with which to counsel patients on expectations and outcomes. Factors such as radiation therapy and neoadjuvant chemotherapy have been shown to have an impact on the success of microvascular breast reconstruction.6–8 A number of studies have also examined patient satisfaction with bilateral versus unilateral breast reconstruction, but optimizing outcomes in bilateral free flap breast reconstruction is poorly described.9–12 We hypothesize that there has been an increase in bilateral autologous free flap breast reconstruction over the decade and therefore more data are needed to counsel patients, improve outcomes, and reduce complications in bilateral free flap breast reconstruction. The aim of the present study was (1) to examine the evolution of bilateral free flap breast reconstruction over a 10-year period and (2) to assess optimization of the reconstruction for these patients while minimizing complications in bilateral free flap breast reconstruction as plastic and reconstructive microsurgeons are predicted to treat an increasing number of patients seeking bilateral breast reconstruction.
PATIENTS AND METHODS We performed a retrospective review of the records of all patients who underwent breast reconstruction after mastectomy using autologous free tissue transfer at a single cancer hospital from January of 2000 to December of 2010. Subgroup analysis was performed analyzing patients undergoing bilateral reconstruction and compared to patients undergoing unilateral reconstruction. Patients’ medical records and operative notes were reviewed, and the following data was recorded: patient demographics, comorbidities, timing of reconstruction, preoperative chemotherapy and radiation therapy, type of flap, and secondary revisions. Postoperative outcomes and follow-up data were also recorded. Nipple-areola reconstructions are routinely performed as office procedures using local anesthesia and were not included in this study.
Institutional review board approval was obtained before this study was performed. Statistical Analysis Categorical patient characteristics were tabulated and chi-square tests of independence or Fisher’s exact tests were used to examine differences in categorical patient characteristics between groups (bilateral immediate, bilateral delayed, and unilateral immediate/delayed groups). Continuous patient characteristics were summarized using means and standard deviations, and analysis of variance or a nonparametric test (KruskalWallis test) was used to examine differences between groups. We performed univariate logistic regression modeling to examine the associations between these outcomes and the patient characteristics in which p values were less than or equal to 0.05 in the chi-square test of independence. The analyses were performed by a senior statistical analyst (H.Z.) using SAS 9.2 software (SAS Institute, Inc., Cary, N.C.).
RESULTS Our cohort included 488 patients (mean age, 47.9 years; range, 23 to 73 years) who underwent bilateral reconstruction (average body mass index, 28.6 kg/m2; range, 19 to 49 kg/m2). One hundred ninety patients (38.9 percent) received radiation therapy and 264 patients (54.1 percent) received adjuvant chemotherapy. Bra sizes were documented in 442 patients (size A, n = 26; size B, n = 118; size C, n = 158; size D, n = 81; size DD, n = 47; size DDD, n = 10; and size F, n = 2). Overall, 147 patients (30.1 percent) had a history of smoking. Fifty-six patients (11.5 percent) underwent contralateral prophylactic mastectomy for a documented BRCA mutation, and five patients (1.0 percent) with a deleterious BRCA mutation underwent bilateral prophylactic mastectomies. Sixty-six patients (13.5 percent) had bilateral breast cancer. Analysis of timing of reconstruction demonstrated 283 bilateral immediate reconstructions (58.0 percent), 93 bilateral delayed reconstructions (19.1 percent), and 112 patients (22.9 percent) who underwent a delayed reconstruction on one side and an immediate reconstruction on the other. The remaining patient demographics are listed in Table 1. Trends in Bilateral Free Flap Breast Reconstruction Over the 10-year period, there was an increase in the number of patients undergoing bilateral
947e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015 Table 1. Patient Demographics Timing Characteristic
Total (%)
Bilateral Immediate (%)
Bilateral Delayed (%)
Bilateral Immediate/ Delayed (%)
No. Age, yr BMI, kg/m2 Smoke No Yes Preoperative radiation therapy No Yes Preoperative chemotherapy No Yes Length of follow-up, mo
488 47.9 ± 9.1 28.6 ± 5.3
283 48.3 ± 8.9 28.3 ± 5.4
93 47.4 ± 9.2 29.2 ± 5.0
112 47.1 ± 9.7 28.7 ± 5.0
341 (69.9) 147 (30.1)
202 (71.4) 81 (28.6)
60 (64.5) 33 (35.5)
79 (70.5) 33 (29.5)
296 (60.7) 190 (38.9)
231 (81.6) 50 (17.7)
37 (39.8) 56 (60.2)
28 (25.0) 84 (75.0)
222 (45.5) 264 (54.1) 50.0 ± 33.2
192 (67.8) 89 (31.4) 54.3 ± 34.2
15 (16.1) 78 (83.9) 39.0 ± 30.6
15 (13.4) 97 (86.6) 48.1 ± 30.8
p 0.43 0.38 0.45
Background: There is an increasing trend for contralateral prophylactic mastectomy, but studies focusing on bilateral free flap breast reconstruction are lacking. Methods: A retrospective review was performed of all bilateral free flap breast reconstructions performed from 2000 to 2010. Results: Overall, 488 patients underwent bilateral breast reconstruction (bilateral immediate, n = 283; bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which more than doubled from the years 2000–2005 to 2006–2010 [147 versus 341 (232.0 percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a similar increase over the decade [139 versus 282 (203.9 percent)]. There was an increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17 percent)] between the first and second halves of the decade. Patients undergoing a bilateral immediate/ delayed reconstruction were significantly more likely to undergo a revision (p = 0.05), particularly on the immediate reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity were significantly associated with postoperative complications. Obesity, smoking, and radiation therapy significantly increased fat necrosis rates, 2.77 (p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In comparison to unilateral reconstruction, bilateral reconstruction had significantly higher flap loss rates (p = 0.004), comparable donor-site complications, and equivalent rates of revisions. Conclusions: There has been an increase in bilateral free flap breast reconstruction. Bilateral immediate/delayed reconstruction had higher revision rates of the prophylactic breast to achieve symmetry. Obesity, smoking, and radiation therapy were associated with increased complications, including fat necrosis, but successful reconstruction can be achieved with acceptable risks. (Plast. Reconstr. Surg. 135: 946e, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
O
ptimization of breast reconstruction is dependent not only on restoring the volume and shape of the breast following a mastectomy but also on restoring symmetry with the contralateral breast. A contralateral balancing From the Department of Plastic and Reconstructive Surgery, University of Texas M. D. Anderson Cancer Center. Received for publication August 27, 2014; accepted December 5, 2014. Presented at the 2014 Annual Meeting of the American Society of Reconstructive Microsurgery, in Kauai, Hawaii, January 8 through 14, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001233
946e
procedure has become the standard of care in the United States following passage of the Women’s Health Care and Rights Act. However, a number of studies have also demonstrated an increasing trend in contralateral prophylactic mastectomies.1,2 Although there is debate over the precise indications and impetus for proceeding with a contralateral prophylactic mastectomy, reconstructive surgeons are expected to perform an Disclosure: The authors have no financial disclosures or conflicts of interest relevant to the material presented in this article.
www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Bilateral Free Flap Breast Reconstruction increasing number of bilateral breast reconstructions. To date, there are few studies directly examining the unique nuances of bilateral autologous breast reconstruction and optimizing the final outcomes.3–5 Furthermore, for patients who decide to proceed with bilateral mastectomies and autologous tissue reconstruction, the index breast and prophylactic breast are not necessarily equivalent, and to our knowledge, no large studies currently exist with which to counsel patients on expectations and outcomes. Factors such as radiation therapy and neoadjuvant chemotherapy have been shown to have an impact on the success of microvascular breast reconstruction.6–8 A number of studies have also examined patient satisfaction with bilateral versus unilateral breast reconstruction, but optimizing outcomes in bilateral free flap breast reconstruction is poorly described.9–12 We hypothesize that there has been an increase in bilateral autologous free flap breast reconstruction over the decade and therefore more data are needed to counsel patients, improve outcomes, and reduce complications in bilateral free flap breast reconstruction. The aim of the present study was (1) to examine the evolution of bilateral free flap breast reconstruction over a 10-year period and (2) to assess optimization of the reconstruction for these patients while minimizing complications in bilateral free flap breast reconstruction as plastic and reconstructive microsurgeons are predicted to treat an increasing number of patients seeking bilateral breast reconstruction.
PATIENTS AND METHODS We performed a retrospective review of the records of all patients who underwent breast reconstruction after mastectomy using autologous free tissue transfer at a single cancer hospital from January of 2000 to December of 2010. Subgroup analysis was performed analyzing patients undergoing bilateral reconstruction and compared to patients undergoing unilateral reconstruction. Patients’ medical records and operative notes were reviewed, and the following data was recorded: patient demographics, comorbidities, timing of reconstruction, preoperative chemotherapy and radiation therapy, type of flap, and secondary revisions. Postoperative outcomes and follow-up data were also recorded. Nipple-areola reconstructions are routinely performed as office procedures using local anesthesia and were not included in this study.
Institutional review board approval was obtained before this study was performed. Statistical Analysis Categorical patient characteristics were tabulated and chi-square tests of independence or Fisher’s exact tests were used to examine differences in categorical patient characteristics between groups (bilateral immediate, bilateral delayed, and unilateral immediate/delayed groups). Continuous patient characteristics were summarized using means and standard deviations, and analysis of variance or a nonparametric test (KruskalWallis test) was used to examine differences between groups. We performed univariate logistic regression modeling to examine the associations between these outcomes and the patient characteristics in which p values were less than or equal to 0.05 in the chi-square test of independence. The analyses were performed by a senior statistical analyst (H.Z.) using SAS 9.2 software (SAS Institute, Inc., Cary, N.C.).
RESULTS Our cohort included 488 patients (mean age, 47.9 years; range, 23 to 73 years) who underwent bilateral reconstruction (average body mass index, 28.6 kg/m2; range, 19 to 49 kg/m2). One hundred ninety patients (38.9 percent) received radiation therapy and 264 patients (54.1 percent) received adjuvant chemotherapy. Bra sizes were documented in 442 patients (size A, n = 26; size B, n = 118; size C, n = 158; size D, n = 81; size DD, n = 47; size DDD, n = 10; and size F, n = 2). Overall, 147 patients (30.1 percent) had a history of smoking. Fifty-six patients (11.5 percent) underwent contralateral prophylactic mastectomy for a documented BRCA mutation, and five patients (1.0 percent) with a deleterious BRCA mutation underwent bilateral prophylactic mastectomies. Sixty-six patients (13.5 percent) had bilateral breast cancer. Analysis of timing of reconstruction demonstrated 283 bilateral immediate reconstructions (58.0 percent), 93 bilateral delayed reconstructions (19.1 percent), and 112 patients (22.9 percent) who underwent a delayed reconstruction on one side and an immediate reconstruction on the other. The remaining patient demographics are listed in Table 1. Trends in Bilateral Free Flap Breast Reconstruction Over the 10-year period, there was an increase in the number of patients undergoing bilateral
947e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015 Table 1. Patient Demographics Timing Characteristic
Total (%)
Bilateral Immediate (%)
Bilateral Delayed (%)
Bilateral Immediate/ Delayed (%)
No. Age, yr BMI, kg/m2 Smoke No Yes Preoperative radiation therapy No Yes Preoperative chemotherapy No Yes Length of follow-up, mo
488 47.9 ± 9.1 28.6 ± 5.3
283 48.3 ± 8.9 28.3 ± 5.4
93 47.4 ± 9.2 29.2 ± 5.0
112 47.1 ± 9.7 28.7 ± 5.0
341 (69.9) 147 (30.1)
202 (71.4) 81 (28.6)
60 (64.5) 33 (35.5)
79 (70.5) 33 (29.5)
296 (60.7) 190 (38.9)
231 (81.6) 50 (17.7)
37 (39.8) 56 (60.2)
28 (25.0) 84 (75.0)
222 (45.5) 264 (54.1) 50.0 ± 33.2
192 (67.8) 89 (31.4) 54.3 ± 34.2
15 (16.1) 78 (83.9) 39.0 ± 30.6
15 (13.4) 97 (86.6) 48.1 ± 30.8
p 0.43 0.38 0.45
