Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multi-Center Comparison of Four Abdominally-Based Autologous Reconstruction Methods

Background: Of women who elect to undergo breast reconstruction following mastectomy approximately 20% choose autologous reconstruction with the most common donor site being the abdomen. An increasing proportion of women are seeking muscle-sparing procedures but the benefit remains controversial. It is therefore important that the potential benefits of these procedures be quantified; if patients that undergo these procedures have better outcomes the longer operative times and increased health care costs may be justified.

Methods: This is a multi-center, cross-sectional survey design. Patients were deemed eligible if they had completed abdominally-based breast reconstruction using the deep inferior epigastric artery perforator flap (DIEP), muscle-sparing free transverse abdominis myocutaneous flap (msf-TRAM), free transverse abdominis myocutaneous flap (f-TRAM), or the pedicled transverse abdominis myocutaneous flap (p-TRAM) and were at least one year post-procedure. Patients were contacted by mail: the BREAST-Q^© questionnaire, a contact letter, and an incentive gift-card were included. Demographics and complication profiles were collected by chart review for both responders and non-responders. BREAST-Q© scores were compared between responder groups.

Results: 1790 charts were analyzed representing 670 DIEP, 293 msf-TRAM, 683 p-TRAM, and 144 f-TRAM patients. Average follow up time for the cohort was 5.5 years. The rate of flap loss was low and did not differ by flap type. Partial flap loss and fat necrosis differed by flap type and were highest in the pTRAM group (8.9%; p=0.002 and 25%;p<0.001 respectively). Rates of hernia/bulge and hernia/bulge requiring surgery were significantly different between groups with p-TRAM displaying the highest rates (16.6%;p<0.001 and 10%;p<0.001 respectively). 943 patients responded to the BREASTQ© for a response rate of 53% representing 387 DIEP, 359, 123 msf-TRAM, p-TRAM and 74 f-TRAM patients. Satisfaction with outcome and physical well-being (abdomen) BREASTQ scale scores differed significantly with the highest scores in the DIEP group. All significant results remained after controlling for age, time since surgery, BMI, laterality, and mesh placement.

Conclusions: We have shown that complication profiles and patient-reported outcomes differ by flap type when comparing the four most common abdominally-based breast reconstruction techniques. The results of this study favour the DIEP flap when choosing between the four studied techniques as it is associated with the highest patient-reported satisfaction with outcome and physical well-being (abdomen) as well as the lowest rate of abdominal wall morbidity.