Breast Reconstruction Effects on Post Mastectomy Pain Syndrome: A Meta-Analysis

Purpose: Post Mastectomy Pain Syndrome (PMPS) is characterized by neuropathic pain from direct nerve injury during oncologic breast surgery that can result in chronic opioid dependence and long term disability¹. Reports on prevalence vary greatly, but the negative effects of PMPS on Quality of Life (QOL) and Patient reported outcomes (PROs) are well established². To our knowledge, this study represents the first meta-analysis that defines the incidence of PMPS in patients undergoing mastectomy, with and without subsequent breast reconstruction.

Methods: The Cochrane and PubMed databases were queried using specific key terms related to breast surgery and PMPS. A total of 166 citations from 1991 to 2017 were then reviewed to identify 21 unique manuscripts. Inclusion criteria included study size greater than 30, minimum 2-month follow-up after surgery, and explicit documentation of whether patients pursued post-mastectomy reconstruction. Studies which reported only arm or abdominal pain were excluded. Studied which did not distinguish between post-lumpectomy and post-mastectomy pain were excluded.  Comprehensive Meta- Analysis Software and Microsoft Excel was used for statistical calculations. An unweighted single-factor ANOVA was performed to evaluate whether undergoing breast reconstruction significantly effects the incidence of PMPS.

Results: Sixteen manuscripts described the prevalence of post-mastectomy pain and 10 described the prevalence of post-reconstruction pain (5 had data for both). Of the 21 included studies, 16 were retrospective cohort/ cross-sectional studies and 5 were prospective studies. Study population size ranged from 32 to 1165 patients. All studies were of level 2 or level 3 evidence. Pain was assessed using either a variety of patient surveys or the need for a pain specialist referral. Prevalence of post-mastectomy pain ranged from 17% to 64%. The mean prevalence of pain after mastectomy alone using a random- effects model is 35.6% (30.3%-41.3%). Prevalence of post- mastectomy reconstruction pain varied from 19% to 49%. Mean prevalence of pain after mastectomy with reconstruction using the random- effects model is 38.8% (32.0% - 46.0%). Our ANOVA analysis of all included manuscripts showed no significant difference between mean prevalence of chronic pain after mastectomy alone versus mastectomy and reconstruction (p= 0.54). 

Conclusion: Our meta-analysis establishes that post-mastectomy reconstruction does not significantly increase PMPS incidence. However, because this neuropathic pain often persists after reconstructive surgery, it is incumbent on the plastic surgeon to counsel patients on PMPS. Moving forward, prospective studies on the effects of reconstruction type are warranted. Additionally, adjunct procedures at the time of reconstruction, such as intercostal neurectomies and fat grafting, should be investigated for efficacy in treating PMPS and improving post- mastectomy reconstruction outcomes. 

1. Vilholm, O. J., Cold, S., Rasmussen, L., & Sindrup, S. H. (2008). The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer. British Journal of Cancer, 99(4), 604-610

2. Roth, R. S., Lowery, J. C., Davis, J., & Wilkins, E. G. (2007). Persistent Pain Following Postmastectomy Breast Reconstruction. Annals of Plastic Surgery, 58(4), 371-376. doi:10.1097/01.sap.0000239810.38137.84