The purpose of this study was to identify important sociodemographic factors affecting the utilization of immediate and early delayed postmastectomy breast reconstruction in the United States. Using the Surveillance, Epidemiology, and End Results (SEER) program, all cases of mastectomy-treated breast cancer that were reported to a SEER registry in 1998 were identified. Data were limited to reconstructions within the first 4 months postmastectomy, and logistic regression was used to analyze the effects of sociodemographic variables on reconstruction rates. Of the 10,406 mastectomy-treated breast cancer patients, 1607 (15 percent) underwent reconstruction within the first 4 months postmastectomy. Compared with women 45 to 54 years old, those 35 to 44 years old were significantly more likely to have breast reconstruction (OR = 1.52, p < 0.001), but women 55 to 64, 65 to 74, and 75 years and older were significantly less likely to have reconstruction (OR = 0.42, p < 0.001; OR = 0.16, p< 0.001; OR = 0.04, p< 0.001, respectively). Compared with Caucasian women, African American, Hispanic, and Asian women were significantly less likely to have reconstruction (OR = 0.48, p < 0.001; OR = 0.45, p< 0.001; OR = 0.29, p< 0.001, respectively). In addition, a four-fold difference in reconstruction rates existed in high-use versus low-use regions. With regard to the type of reconstruction, patients younger than 35 and 65 to 74 years old were significantly less likely to receive autogenous tissue reconstruction compared with women 45 to 54 years old (OR = 0.47, p = 0.047; OR = 0.61, p = 0.031, respectively). However, African Americans were significantly more likely to receive autogenous tissue reconstructions compared with Caucasians (OR = 2.03, p = 0.021). According to these data, the utilization of immediate and early delayed breast reconstruction in the United States is low and is significantly influenced by patients' age, race, and geographic location. Further research is needed to evaluate the impact of provider bias, patient preference, and barriers to care on the utilization of breast reconstruction in the United States. (Plast. Reconstr. Surg. 111: 695, 2003.)
Breast reconstruction following mastectomy is an important aspect of cancer care. Surgical outcomes data help patients navigate the complex decision-making process of choosing an implant or an autogenous tissue reconstructive technique. In general, complications rates are similar across procedure types. However, both pedicle and free transverse rectus abdominis musculocutaneous (TRAM) procedures are associated with an 11-18% decrease in flexion peak torque. However, no significant difference in flexion peak torque has been found between patients with pedicle and free TRAM reconstructions. In addition, patients with TRAM compared with expander/implant procedures appear to be more aesthetically satisfied and have greater gains in body image. In summary, with a variety of reconstructive procedures available, choosing the 'right' operation can be a daunting task. Outcomes data can provide patients with objective, reliable information to assist in surgical decision making.
PURPOSE: Breast cancer is the most common cause of malignancy-related mortality worldwide. Stark disparities in survival in sub-Saharan Africa (SSA) have been attributed to presentation delays. Fears of mastectomy are a prominent reason. This study assesses quality of life and mental health implications of mastectomy in African women. METHODS: Women in Ghana and Ethiopia, with breast cancer undergoing mastectomy were followed prospectively. Demographics, clinical and treatment variables were collected. Breast related quality of life and mental health measures were evaluated preoperatively and six months postoperatively, using BREAST-Q, PHQ-9, and GAD-7. Univariate tests and logistic regression analyses evaluated changes in these measures and assessed regional differences. RESULTS: 125 women were recruited, 50 from Ghana and 75 from Ethiopia. Over 50% were diagnosed with stage III or IV disease. Radiation was more common in Ghana (p <0.001). At six months, the entire cohort of women reported decreased scores for breast satisfaction (mean difference, -6.0) and sexual well-being (mean difference, -8.7). Ghanaian women reported decreased BREAST-Q scores for all measured satisfaction and quality of life domains and Ethiopian women reported increased scores across the same domains. Women in both countries reported similar significant improvements in anxiety and depression postoperatively. CONCLUSION: This study demonstrates previously undescribed quality of life experiences, with interesting regional variations, amongst women in Ghana and Ethiopia undergoing mastectomy and provides evidence of mental health benefits of mastectomy. This is vital information as we seek to understand reasons for women's fears and work to improve on breast cancer care in SSA.
Purpose: The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions. Methods: In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed. Results: We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012). Conclusion: Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.
AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK
Expander/implant and autogenous tissue breast reconstructions have different aging processes, and the time when these processes stabilize is unclear. The authors' goal was to evaluate long-term patient-reported aesthetic satisfaction with expander/implant and autogenous breast reconstruction.The authors surveyed a cross-section of University of Michigan women who underwent postmastectomy breast reconstruction (response rate, 73 percent) between 1988 and 2006 [110 expander/implant and 109 transverse rectus abdominis myocutaneous (TRAM) reconstructions]. Each group was stratified into three postreconstructive periods: short term (8 years). Validated satisfaction items were scored on a 5-point Likert scale; scores were dichotomized into positive and negative responses. Logistic regression assessed satisfaction by procedure, while controlling for sociodemographic and clinical variables.Mean follow-up time after reconstruction was 6.5 years (range, 1 to 18 years). Procedure type had no effect on short-term aesthetic satisfaction. However, in the long term, reconstruction type considerably affected satisfaction. Although satisfaction with TRAM reconstruction remained relatively constant, satisfaction with expander/implants was significantly less among those patients in the long term. Patients who had undergone implant reconstruction more than 8 years earlier, compared with those who undergone implant reconstruction less than 5 years earlier, were significantly less satisfied with breast appearance (odds ratio, 0.10; 95% CI, 0.02 to 0.48), softness (odds ratio, 0.14; 95% CI, 0.03 to 0.64), and size (odds ratio, 0.13; 95% CI, 0.03 to 0.62).In the long term, TRAM patients, compared with expander/implant patients, appear to have significantly greater aesthetic satisfaction. These long-term data have important implications for women's health in the survivorship period and will help women navigate the complex decision-making process of breast reconstruction.
The decision-making process for women considering breast reconstruction following mastectomy is complex. Research suggests that fewer than half of women undergoing mastectomy have adequate knowledge and make treatment decisions that are concordant with their underlying values. This systematic review assesses the feasibility and efficacy of preoperative decision aids (DAs) to improve the patient decision-making process for breast reconstruction.A systematic review was performed using PubMed, Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Databases published prior to January 4, 2018. Studies that assessed the impact of a DA on patient decision making for breast reconstruction were identified. The effect of preoperative DAs on decisional conflict in randomized controlled trials (RCTs) was measured with inverse variance-weighted mean differences (mean difference [MD] ± 95% confidence interval [CI]).Among 1299 unique articles identified, 1197 were excluded after reviewing titles and abstracts against selection criteria. Among the 17 studies included in this review, 11 assessed the efficacy of DAs for breast reconstruction and 6 additional studies described the development and usability of these DAs. Studies suggest that DAs reduce patient-reported decisional conflict (MD, -4.55 [95% CI, -8.65 to -0.45], P = 0.03 in the fixed-effects model and MD, -4.70 [95% CI, -10.75 to 1.34], P = 0.13 in the random-effects model). Preoperative DAs also improved patient satisfaction with information and perceived involvement in the decision-making process.The existing literature suggests that DAs reduce decisional conflict, improve self-reported satisfaction with information, and improve perceived involvement in the decision-making process for women considering breast reconstruction.
Surgical-site infection causes devastating reconstructive failure in implant-based breast reconstructions. Large national database studies offer insights into complication rates, but only capture outcomes within 30 days postoperatively. This study evaluates both early and late surgical-site infection in immediate implant-based reconstruction and identifies predictors.As part of the Mastectomy Reconstruction Outcomes Consortium Study, 1662 implant-based breast reconstructions in 1024 patients were evaluated for early versus late surgical-site infection. Early surgical-site infection was defined as infection occurring within 30 days postoperatively; late surgical-site infection was defined as infection occurring 31 days to 1 year postoperatively. Minor infection required oral antibiotics only, and major infection required hospitalization and/or surgical treatment. Direct-to-implant patients had 1-year follow-up, and tissue expander patients had 1-year post-exchange follow-up.Among 1491 tissue expander and 171 direct-to-implant reconstructions, overall surgical-site infection rate for tissue expander was 5.7 percent (85 of 1491) after first-stage, 2.5 percent (31 of 1266) after second-stage, and 9.9 percent (17 of 171) for direct-to-implant reconstruction. Over 47 to 71 percent of surgical-site infection complications were late surgical-site infection. Multivariate analysis identified radiotherapy and increasing body mass index as significant predictors of late surgical-site infection. No significant difference between the direct-to-implant and tissue expander groups in the occurrence of early, late, or overall surgical-site infection was found.The majority of surgical-site infection complications in immediate implant-based breast reconstructions occur more than 30 days after both first-stage and second-stage procedures. Radiotherapy and obesity are significantly associated with late-onset surgical-site infection. Current studies limited to early complications do not present a complete assessment of infection associated with implant-based breast reconstructions or their long-term clinical outcomes.Risk, II.
Background: Specific International Classification of Diseases, Ninth Revision codes for different methods of autologous breast reconstruction have been introduced recently, prompting investigators to use discharge databases to evaluate outcomes of autologous breast reconstruction. The accuracy and validity of these data sources have not been evaluated. Methods: All patients who underwent autologous breast reconstruction in a single center from October of 2008 to April of 2013 were retrospectively included. Patient medical records were used as the criterion standard to identify specific autologous procedure performed and any perioperative reoperations. These findings were compared against procedure codes documented in the coded discharge data obtained from hospital billing. Results: A total of 163 autologous procedures were performed in 115 patients, including 40 pedicled and 37 free transverse rectus abdominis musculocutaneous, 74 deep inferior epigastric perforator, five superficial inferior epigastric artery, four transverse upper gracilis, and three superior gluteal artery perforator flaps. Only 126 of 163 flaps (77 percent) were coded correctly. Twenty-two of 48 bilateral procedures had coding for only one flap. An additional 16 cases were either incorrectly coded as another type of reconstruction or not coded at all. Only 19 of 21 reoperations (90 percent) could be captured by review of the coding alone. Conclusions: Using International Classification of Diseases, Ninth Revision, codes alone to evaluate autologous breast reconstructions could result in an incomplete and inaccurate data set, with exclusion of many bilateral flaps. Reoperations during the same hospital stay may also be missed if identified only by a discharge code, thus limiting the evaluation of acute complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.
