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Breast Reconstruction After Mastectomy

Systematic Review

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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 breasts, but comparable general quality of life and psychosocial well-being (Moderate strength of evidence [SoE], all outcomes).
    • Compared with IBR, AR probably poses a greater risk of deep vein thrombosis or pulmonary embolism but comparable risk of unplanned repeat hospitalization (both Moderate SoE).
    • Compared with AR, although results in the short term (1 to 1.3 months) are inconsistent, IBR probably poses greater risk of reconstructive failure in the long term (1.5 to 4 years) (Moderate SoE). IBR may also pose a greater risk of breast seroma (Low SoE).
  • Timing of IBR and AR in Relation to Chemotherapy and Radiation Therapy
    • Conducting IBR either before or after radiation therapy may result in comparable physical well-being, psychosocial well-being, sexual well-being, and patient satisfaction with breasts (Low SoE for all).
    • Conducting IBR either before or after radiation therapy probably results in comparable risk of implant failure/loss or need for explant surgery (Moderate SoE).
    • We found no evidence comparing timing of IBR or AR before or after chemotherapy or timing of AR before or after radiation therapy.
  • Comparisons of Implant Materials for IBR
    • Silicone or saline implants may result in clinically comparable patient satisfaction with breasts (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
    • Whether the implant is placed in the prepectoral or total submuscular plane may not impact the risk of infections that are not explicitly implant-related (Low SoE).
    • There is insufficient evidence for all outcomes comparing prepectoral versus partial submuscular planes and partial versus total submuscular planes.
  • 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 breasts.
    • 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 risks of seroma or of unplanned repeat surgery for revision probably are comparable with or without ADM use (Moderate SoE); the risk of necrosis may be comparable (Low SoE).
  • Comparisons of Flap Types for AR
    • AR with either transverse rectus abdominis (TRAM) or deep inferior epigastric perforator (DIEP) flaps may result in comparable patient satisfaction with breasts (Low SoE); however, TRAM flaps probably increase the risk of harms to the area of flap harvest (Moderate SoE).
    • AR with either DIEP or latissimus dorsi (LD) flaps may result in comparable patient satisfaction with breasts (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 March 23, 2021, 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 protocol was registered in PROSPERO (registration number CRD42020193183).

Results. We found 8 randomized controlled trials, 83 nonrandomized comparative studies, and 69 single group studies. Risk of bias was moderate to high for most studies. KQ1: Compared with IBR, AR is probably associated with clinically better patient satisfaction with breasts and sexual well-being but comparable general quality of life and psychosocial well-being (moderate SoE, all outcomes). AR probably poses a greater risk of deep vein thrombosis or pulmonary embolism (moderate SoE), but IBR probably poses a greater risk of reconstructive failure in the long term (1.5 to 4 years) (moderate SoE) and may pose a greater risk of breast seroma (low SoE). KQ 2: Conducting IBR either before or after radiation therapy may result in comparable physical well-being, psychosocial well-being, sexual well-being, and patient satisfaction with breasts (all low SoE), and probably results in comparable risks of implant failure/loss or need for explant surgery (moderate SoE). 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 breasts (low SoE). There is insufficient evidence regarding double lumen implants. KQ 4: Whether the implant is placed in the prepectoral or total submuscular plane may not be associated with risk of infections that are not explicitly implant related (low SoE). There is insufficient evidence addressing the comparisons between prepectoral and partial submuscular and between partial and total submuscular planes. KQ 5: The evidence is inconsistent regarding whether human ADM use during IBR impacts physical well-being, psychosocial well-being, or satisfaction with breasts. 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 or not ADM is used probably is associated with comparable risks of seroma and unplanned repeat surgeries for revision (moderate SoE for both), and possibly necrosis (low SoE). KQ 6: AR with either transverse rectus abdominis (TRAM) or deep inferior epigastric perforator (DIEP) flaps may result in comparable patient satisfaction with breasts (low SoE), but TRAM flaps probably increase the risk of harms to the area of flap harvest (moderate SoE). AR with either DIEP or latissimus dorsi flaps may result in comparable patient satisfaction with breasts (low SoE), but there is insufficient evidence regarding thromboembolic events and no evidence regarding other surgical complications.

Conclusion. Evidence regarding surgical breast reconstruction options is largely insufficient or of only low or moderate SoE. 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.

Citation

Saldanha IJ, Cao W, Broyles JM, Adam GP, Bhuma MR, Mehta S, Dominici LS, Pusic AL, Balk EM. Breast Reconstruction After Mastectomy: A Systematic Review and Meta-Analysis. Comparative Effectiveness Review No. 245. (Prepared by the Brown Evidence-based Practice Center under Contract No. 75Q80120D00001.) AHRQ Publication No. 21-EHC027. Rockville, MD: Agency for Healthcare Research and Quality; July 2021. DOI: 10.23970/AHRQEPCCER245. Posted final reports are located on the Effective Health Care Program search page.