title: Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients.
abstract: BACKGROUND
  Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions.
  
  
  METHODS
  A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs.
  
  
  RESULTS
  One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively).
  
  
  CONCLUSIONS
  The authors' analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.
  
  
  METHODS
  : Therapeutic, III.
authors: Philadelphia, Pa. From the Divisions of Plastic Surgery and Finance, Hospital of the University of Pennsylvania.
authors: John P
authors: JP
authors: Fischer
authors: Jonas A
authors: JA
authors: Nelson
authors: Emily
authors: E
authors: Cleveland
authors: Brady
authors: B
authors: Sieber
authors: Jeff I
authors: JI
authors: Rohrbach
authors: Joseph M
authors: JM
authors: Serletti
authors: Suhail
authors: S
authors: Kanchwala
mesh_terms: D000328:Adult; D018427:Breast Implants / Q000191:economics / Q000706:statistics & numerical data*; D001943:Breast Neoplasms / Q000191:economics / Q000453:epidemiology* / Q000601:surgery*; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D016208:Databases, Factual / Q000706:statistics & numerical data; D005260:Female; D058752:Free Tissue Flaps / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016014:Linear Models; D016462:Mammaplasty / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D015625:Tissue Expansion Devices / Q000191:economics / Q000706:statistics & numerical data*; D016896:Treatment Outcome
references: Andrade WN, Baxter N, Semple JL. Clinical determinants of patient satisfaction with breast reconstruction. Plast Reconstr Surg. 2001;107:46–54
references: Roberts C, Wells KE, Daniels S. Outcome study of the psychological changes after silicone breast implant removal. Plast Reconstr Surg. 1997;100:595–599
references: Guyomard V, Leinster S, Wilkinson M. Systematic review of studies of patients’ satisfaction with breast reconstruction after mastectomy. Breast. 2007;16:547–567
references: Didier F, Radice D, Gandini S, et al. Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality?. Breast Cancer Res Treat. 2009;118:623–633
references: Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. J Am Coll Surg. 2007;204:7–12
references: Vega S, Smartt JM Jr, Jiang S, et al. 500 Consecutive patients with free TRAM flap breast reconstruction: A single surgeon’s experience. Plast Reconstr Surg. 2008;122:329–339
references: Fogarty BJ, Brown AP, Miller R, Khan K. TRAM flap versus nonautologous breast reconstruction: What do patients really think?. Plast Reconstr Surg. 2004;113:1146–1152
references: Brockhurst AC, Alderman AK, Lowery JC, Davis JA, Wilkins EG. Survey assessment of physical function following postmastectomy breast reconstruction. Plast Reconstr Surg. 2008;121:1108–1115
references: Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: A comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125:1585–1595
references: Kalaaji A, Bruheim M. Quality of life after breast reconstruction: Comparison of three methods. Scand J Plast Reconstr Surg Hand Surg. 2010;44:140–145
references: Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769–776
references: Cederna PS, Yates WR, Chang P, Cram AE, Ricciardelli EJ. Postmastectomy reconstruction: Comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction. Ann Plast Surg. 1995;35:458–468
references: Kroll SS, Baldwin B. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg. 1992;90:455–462
references: Kroll SS, Evans GR, Reece GP, et al. Comparison of resource costs between implant-based and TRAM flap breast reconstruction. Plast Reconstr Surg. 1996;97:364–372
references: Alderman AK, Storey AF, Nair NS, Chung KC. Financial impact of breast reconstruction on an academic surgical practice. Plast Reconstr Surg. 2009;123:1408–1413
references: Damen TH, Wei W, Mureau MA, et al. Medium-term cost analysis of breast reconstructions in a single Dutch centre: A comparison of implants, implants preceded by tissue expansion, LD transpositions and DIEP flaps. J Plast Reconstr Aesthet Surg. 2011;64:1043–1053
references: Atherton DD, Hills AJ, Moradi P, Muirhead N, Wood SH. The economic viability of breast reconstruction in the UK: Comparison of a single surgeon’s experience of implant; LD; TRAM and DIEP based reconstructions in 274 patients. J Plast Reconstr Aesthet Surg. 2011;64:710–715
references: Disa JJ, Ad-El DD, Cohen SM, Cordeiro PG, Hidalgo DA. The premature removal of tissue expanders in breast reconstruction. Plast Reconstr Surg. 1999;104:1662–1665
references: Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: Part II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction. Plast Reconstr Surg. 2006;118:832–839
references: Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: Part I. A prospective analysis of early complications. Plast Reconstr Surg. 2006;118:825–831
references: Spear SL, Newman MK, Bedford MS, Schwartz KA, Cohen M, Schwartz JS. A retrospective analysis of outcomes using three common methods for immediate breast reconstruction. Plast Reconstr Surg. 2008;122:340–347
references: Serletti JM, Moran SL. The combined use of the TRAM and expanders/implants in breast reconstruction. Ann Plast Surg. 1998;40:510–514
references: Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol. 2010;17(Suppl 3):202–210
references: Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345–353