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Breast Reconstruction After Mastectomy: A Systematic Review and Meta-Analysis

Systematic Review Draft

Open for comment through Apr 21, 2021

This draft report is available in electronic format only (Draft Report, [PDF, 2.6 MB]; Draft Appendixes [PDF, 4.6 MB]). For additional assistance, please contact us.

Main Points

  • Implant-based Reconstruction (IBR) Versus Autologous Reconstruction (AR)
    • Compared with IBR, AR is probably associated with clinically better sexual well-being and patient satisfaction with breast aesthetics (Moderate strength of evidence [SoE], both outcomes) and maybe surgical outcome (Low SoE), but comparable general quality of life (Low SoE) and psychosocial well-being (Moderate SoE).
    • Compared with IBR, AR probably poses a greater risk of pulmonary embolism (Moderate SoE), but comparable risk of unplanned repeat hospitalization (Moderate SoE). AR may lead to worse chronic abdominal pain (Low SoE), but comparable chronic breast pain (Low SoE).
    • Compared with AR, IBR may pose a greater risk of breast seroma (Low SoE).
  • Timing of IBR and AR in Relation to Chemotherapy and Radiation Therapy
    • We found no evidence comparing timing of IBR or AR before or after chemotherapy or timing of AR before or after radiation therapy.
    • Whether IBR is conducted before or after radiation therapy may result in comparable risk of implant failure/loss or need for explant surgery (Low SoE). There is insufficient evidence addressing patient-reported clinical outcomes.
  • Comparisons of Implant Materials for IBR
    • Silicone and saline implants may result in clinically comparable patient satisfaction with breast aesthetics (Low SoE).
    • There is insufficient evidence to make conclusions about surgical complications when comparing silicone and saline implants.
    • There is insufficient evidence regarding double lumen implants.
  • Comparisons of Anatomic Planes of Implant Placement During IBR
    • There is insufficient evidence for clinical outcomes and surgical complications comparing prepectoral and total submuscular planes.
    • We did not find eligible studies addressing partial submuscular placement.
  • Use Versus Nonuse of Acellular Dermal Matrices (ADMs) During IBR
    • The evidence is inconsistent regarding whether human ADM use during IBR impacts patient physical well-being, psychosocial well-being, or satisfaction with breast aesthetics.
    • ADM use probably increases the risk of implant failure/loss or need for explant surgery (Moderate SoE) and may increase the risk of infections not explicitly related to the implants or ADM (Low SoE). The odds of unplanned repeat surgeries for revision and seroma probably are comparable with or without ADM use (Moderate SoE); the odds of necrosis may be comparable (Low SoE).
  • Comparisons of Flap Types for AR
    • Although AR with transverse rectus abdominis (TRAM) and deep inferior epigastric perforator (DIEP) flaps may result in comparable patient satisfaction with breast aesthetics (Low SoE), TRAM flaps probably increase the risk of harms to the area of flap harvest (Moderate SoE).
    • AR with DIEP and latissimus dorsi (LD) flaps may result in comparable patient satisfaction with breast aesthetics (Low SoE), but we found no evidence comparing risk of surgical complications.
    • There is insufficient evidence regarding other flap types.

Structured Abstract

Objectives. This systematic review evaluates breast reconstruction options for women after mastectomy for breast cancer (or breast cancer prophylaxis). We addressed six Key Questions (KQs): (1) implant-based reconstruction (IBR) versus autologous reconstruction (AR), (2) timing of IBR and AR in relation to chemotherapy and radiation therapy, (3) comparisons of implant materials, (4) comparisons of anatomic planes for IBR, (5) use versus nonuse of human acellular dermal matrices (ADMs) during IBR, and (6) comparisons of AR flap types.

Data Sources and Review Methods. We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov from inception to February 14, 2020 to identify comparative and single group studies. We extracted study data into the Systematic Review Data Repository Plus (SRDR+). We assessed the risk of bias and evaluated the strength of evidence (SoE) using standard methods. The PROSPERO protocol registration number is CRD42020193183.

Results. We found four randomized controlled trials, 66 nonrandomized comparative studies, and 59 single group studies. Risk of bias was moderate to high for most studies. KQ 1: Compared with IBR, AR is probably associated with clinically better patient satisfaction with breast aesthetics (Moderate SoE) and sexual well-being (Moderate SoE) but comparable psychosocial well-being (Moderate SoE). Compared with IBR, AR may be associated with greater satisfaction with surgical outcome (Low SoE) but comparable general quality of life (Low SoE). AR probably poses a greater risk of pulmonary embolism (Moderate SoE) and abdominal flaps may lead to worse abdominal pain than IBR (Low SoE), but IBR may pose a greater risk of breast seroma than AR (Low SoE). KQ 2: Whether IBR is conducted before or after radiation therapy may result in comparable risks of implant failure/loss or need for explant surgery (Low SoE); there is insufficient evidence addressing patient-reported clinical outcomes. We found no evidence addressing timing of IBR or AR in relation to chemotherapy or timing of AR in relation to radiation therapy. KQ 3: Silicone and saline implants may result in clinically comparable patient satisfaction with breast aesthetics (Low SoE). There is insufficient evidence regarding double lumen implants. KQ 4: There is insufficient evidence addressing the comparison between prepectoral and total submuscular placement of implants and no evidence addressing partial submuscular placement. KQ 5: The evidence is inconsistent regarding whether human ADM use during IBR impacts physical well-being, psychosocial well-being, or satisfaction with breast aesthetics. However, ADM use probably increases the risk of implant failure/loss or need for explant surgery (Moderate SoE) and may increase the risk of infections not explicitly implant-related (Low SoE). Whether ADM is used or not is probably associated with comparable risks of unplanned repeat surgeries for revision and seroma (Moderate SoE for both) and maybe necrosis (Low SoE). KQ 6: Although AR with transverse rectus abdominis (TRAM) and deep inferior epigastric perforator (DIEP) flaps may result in comparable patient satisfaction with breast aesthetics (Low SoE), TRAM flaps probably increase the risk of harms to the area of flap harvest (Moderate SoE). AR with DIEP and latissimus dorsi (LD) flaps may result in comparable patient satisfaction with breast aesthetics (Low SoE), but we found no evidence regarding surgical complications.

Conclusion. Evidence regarding surgical breast reconstruction options is largely insufficient or of low SoE, with few moderate SoE conclusions possible. New high-quality research is needed, especially for timing of IBR and AR in relation to chemotherapy and radiation therapy, for comparisons of implant materials, and for comparisons of anatomic planes of implant placement.