Impact of Unilateral versus Bilateral Breast Reconstruction on Procedure Choices and Outcomes.

BACKGROUND: In choosing between implant-based and autologous breast reconstruction, surgeons and patients must weigh relative risks and benefits. However, differences in outcomes across procedure types may vary between unilateral versus bilateral reconstructions. Procedure-related differences in complications and patient-reported outcomes were evaluated for unilateral and bilateral reconstruction. METHODS: Complications and patient-reported outcomes (BREAST-Q and Patient-Reported Outcomes measurement Information System surveys) were assessed at 2 years for patients undergoing autologous or implant-based reconstructions. Stratified regression models compared outcomes between autologous and implant-based reconstructions, separately for unilateral and bilateral cohorts. RESULTS: Among 2125 patients, 917 underwent unilateral (600 implant and 317 autologous) and 1208 underwent bilateral (994 implant and 214 autologous) reconstructions. Complication rates were significantly higher in the autologous versus implant-based group for both unilateral (overall: OR, 2.50, p < 0.001; major: OR, 2.19, p = 0.001) and bilateral (overall: OR, 2.13, p < 0.001; major: OR, 1.69, p = 0.014) cohorts. In unilateral reconstruction, the autologous group demonstrated significantly better patient-reported outcomes versus implant-based group in satisfaction with breast (mean difference, 9.85; p < 0.001), psychosocial well-being (mean difference, 4.84; p = 0.006), and sexual well-being (mean difference, 11.42; p < 0.001). In bilateral reconstruction, the autologous group demonstrated significantly higher patient-reported outcomes only for satisfaction with breast (mean difference, 5.13; p = 0.001). CONCLUSIONS: Although autologous reconstruction is associated with significantly better patient-reported outcomes compared to implant-based techniques in unilateral reconstruction, procedure choice has far less impact in bilateral reconstruction. Autologous procedures have higher complications rates in both unilateral and bilateral settings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study.

BACKGROUND: Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. METHODS: Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes. RESULTS: Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction. CONCLUSIONS: Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.