Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study.

Abstract

Sir: We read with great interest the article published in the Journal in November of 2017 by Srinivasa et al.,1 and we would like to add our experience in the analysis of patient satisfaction following breast reconstruction. We use the BREAST-Q in our clinical practice for each breast operation.2–5 In this case, we designed a retrospective cohort study of patients. The subjects of our study population were further divided into two groups: patients exposed to mastectomy alone (group 1) and patients exposed to mastectomy with tissue expander and definitive breast reconstruction (group 2). All patients were treated at our hospital between 2005 and 2016 and were asked to complete the postoperative BREAST-Q reconstruction questionnaire, independently from the group to which they had been assigned. Furthermore, in group 2, each patient was asked to complete the BREAST-Q questionnaire twice, after the first breast reconstruction with a tissue expander and after the second breast reconstruction with definite implants. The patient selection procedure is shown in Figure 1. Twenty-six women underwent prophylactic mastectomy and reconstruction. Four women underwent prophylactic mastectomy alone. All patients in the group with mastectomy alone underwent simple mastectomy: 58 with lymphadenectomy, six with biopsy of sentinel lymph nodes, 55 with invasive ductal carcinoma, six with infiltrating lobular carcinoma, and three with ductal carcinoma in situ. In the group that underwent breast reconstruction, the following procedures were performed: nipple-sparing mastectomy (n = 27), skin-sparing mastectomy (n = 57), skin-reducing mastectomy (n = 6), simplex mastectomy (n = 54), mastectomy with lymphadenectomy (n = 53), mastectomy with resection of sentinel lymph node (n = 90), invasive ductal carcinoma (n = 67), infiltrating lobular carcinoma (n = 12), and ductal carcinoma in situ (n = 55). As shown in Table 1, pairwise comparisons between the two groups yielded significant results regarding the feedback of the postoperative BREAST-Q reconstruction questionnaire. Patients who had been exposed to a second breast reconstruction with definite implants were significantly more satisfied with the appearance of their breasts, also showing improved psychosocial, sexual, and physical well-being compared with patients who had undergone their first breast reconstruction with a tissue expander or mastectomy alone. However, as expected, additional complications were identified directly as a result of breast reconstruction, which were comparable between the two groups (first versus second breast reconstruction). The most notable complications were related to anastomosis, partial or total flap necrosis, and loss of prosthesis. The goal of breast reconstruction surgery should be the attainment of patient satisfaction with breast appearance and normal body image, without the perception of body demolition. By using a validated survey tool (i.e., BREAST-Q), in this study, we show that patients with breast reconstruction (even only with tissue expander) were significantly more satisfied with the appearance of their breast and showed improved psychosocial, sexual, and physical well-being compared with patients exposed to mastectomy alone. To the best of our knowledge, our study is novel, compared with previous research, for two reasons: (1) our study evaluates the satisfaction of patients not only by comparing patients following mastectomy alone versus breast reconstruction but by further dividing patients exposed to reconstruction between first (tissue expander) and second (definite implants) breast reconstructions; and (2) our study represents the largest number of patients who completed the BREAST-Q questionnaire following mastectomy with a control group.Table 1.: BREAST-Q Postoperative Module in 208 Patients following Mastectomy with or without Reconstruction*Fig. 1.: Flow diagram of selection of patients.DISCLOSURE The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication. No intramural or extramural funding supported any aspect of this work. Mauro Barone, M.D.Annalisa Cogliandro, M.D., Ph.D.Plastic and Reconstructive Surgery Unit Antonella Grasso, M.D.Vittorio Altomare, M.D., Ph.D.Plastic and Reconstructive Surgery UnitDepartment of Senology Paolo Persichetti, M.D., Ph.D.Plastic and Reconstructive Surgery UnitCampus Bio-Medico University of RomeRome, Italy