Sunday, October 10, 2004

Outcomes After Autologous Breast Reconstruction in Elderly Patients

Patrick B. Garvey, MD, Edward W. Buchel, MD, Barbara A. Pockaj, MD, Richard J. Gray, MD, Thomas D. Samson, MD, and Jenevieve H. Hughes, MD.

PURPOSE: Many consider increasing age to be a contraindication to post-mastectomy breast reconstruction with autologous tissue. We have evaluated our experience with pedicled TRAM flaps, free TRAM flaps, and free DIEP flaps to see if such concerns are valid.

METHODS AND MATERIALS: We retrospectively reviewed the computerized records of women undergoing autologous tissue breast reconstruction after mastectomy over a ten-year period at a single institution. Patients underwent either pedicled or free transverse rectus abdominis myocutaneous (PTRAM or FTRAM) or free deep inferior epigastric perforator (DIEP) flap reconstruction. Patients were divided into two groups according to age: less than 65 years old or 65 years old and older. Demographic information, preoperative co-morbid conditions, cancer information, and information pertaining to the procedure itself was collected and compared between the groups. Postoperative flap site and donor site complications were recorded. Fishers Exact test was used for statistical analysis in comparison of the groups’ rates.

EXPERIENCE: Two-hundred and six women underwent 227 autologous flap breast reconstructions. There were 192 reconstructions in 174 patients aged less than 65 years old, while 35 reconstructions were performed in 32 women aged 65 and older. Ninety-nine women had 115 DIEP flaps, 97 women had 99 pedicled TRAM flaps, and 11 women underwent 13 free TRAM flap reconstructions. Mean postoperative follow-up was 20.5 months for the under 65 group and 29.3 months for the 65 and older group.

SUMMARY OF RESULTS: When the patients’ preoperative conditions were compared, significantly more of the older patients had been smokers (&#61619;65 years old: 53.1% vs. <65 years old: 23.0%, p<.01), had undergone previous abdominal surgery (65.6% vs. 43.1%, p=0.03), and had more medical illnesses (50.0% vs. 25.3%, p<.01). Of the medical illnesses, there were significantly more elderly patients with hypertension (46.9% vs. 18.4%, p<.01). Both groups were similar in terms of reconstructive techniques, operative times, timing of reconstruction (immediate vs. delayed), and severity of cancer. Though not statistically significant, more of the younger patients underwent postoperative chemotherapy (&#61619;65 years old: 28.6% vs. <65 years old: 46.0%, p=0.07) and flap irradiation (8.6% vs. 18.3%, p=0.16). Return to the OR for reasons other than nipple reconstruction was similar between the two groups. More of the older patients suffered flap failure (11.4% vs. 5.2%, p=0.19), surgical site infections (17.1% vs. 9.9%, p=0.23), and abdominal wall hernias (12.5% vs. 8.0%, p=0.47), but the difference in the rates of these complications was not statistically significant. The older patients on average stayed significantly longer in the hospital (7.4 days) than the younger patients (4.6 days) (p<.01) after surgery.

CONCLUSIONS: Elderly patients were found to have absolute higher percentages of post-operative complications, but these were not significant when compared to their younger counterparts. The elderly patients did require a significantly longer post-operative hospital recovery. Ultimately, our experience shows that autologous breast reconstruction can be performed safely in elderly patients, and that age alone should not represent a contraindication to autologous breast reconstruction.