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Procedures and elective revisions to achieve a stable breast reconstruction: an examination of the Mastectomy Reconstruction Outcomes Consortium (MROC) study
Jonas A. Nelson, MD1, Sophocles H. Voineskos, MD, MSc1, Qi Ji, MS2, Jennifer B. Hamill, MPH2, Edwin G. Wilkins, MD, MS2, Andrea L. Pusic, MD, MHS1.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2University of Michigan, Ann Arbor, MI, USA.

Purpose: To determine the total number of procedures required to achieve a stable breast reconstruction and to determine the frequency of elective revision surgery among this cohort of patients.
Methods: Women enrolled at one of 11 MROC centers who underwent first-time breast reconstruction were considered eligible for inclusion. Reconstructive modalities included direct-to-implant (DTI), tissue-expander/implant (TEI), latissimus dorsi (LD), pedicle TRAM (PTRAM), free TRAM (FTRAM), DIEP and SIEA reconstructions. Clinical and demographic information were prospectively collected with two year follow up. Patients who experienced a failure in their initial reconstructive modality were excluded from the final analysis. We analyzed two main cohorts of patients: 1) patients without complications and 2) patients with complications. Mixed-effects regression modelling identified factors associated with elective revisions.
Results: In total, 2113 MROC patients were identified, with 1996 (94.5%) achieving a stable reconstruction at 2 years for analysis. Of these patients, 1534 (76.9%) had a complication free postoperative course. Within this cohort of patients without complications, 40.2% underwent elective revisions, with significant differences noted by reconstructive modality (p<0.001) (min. DTI 25%, max. LD 59%). The average number of elective revisions also differed by modality (p<0.001)(min. TE 0.7 (SD 1.3), max. fTRAM/DIEP/SIEA 1.3 (SD1.5)). Average total number of procedures in patients without complications at two years was 2.9 (SD 1.6), ranging from 1.7 for PTRAM to 3.3 for TEI (p<0.001). Reconstructive complications occurred in 462 (23.1%) patients achieving a stable reconstruction at 2 years. Within this cohort, 67.1% underwent elective revision procedures and differences were noted by reconstructive modality (p=0.041)(min DTI 56%, max LD 80%). The mean number of procedures to achieve reconstruction in patients with complications was 3.6 (SD2.0), and also differed by reconstructive modality ranging from 2.5 in DTI to 4.2 in TEI (p<0.001). Controlling for clinical and demographic characteristics, patients undergoing DIEP, FTRAM, and LD were more likely to undergo elective revisions (p<0.05) compared to TEI patients; OR 2.66 (CI 1.83, 3.86), OR 2.26 (CI 1.35, 3.78), and OR 1.98 (CI 1.07, 3.64) respectively. While patients undergoing DTI reconstruction (p=0.035) or requiring post-operative radiation (p=0.012) were less likely. Having a postoperative complication further increased the odds of undergoing elective revision procedures (p<0.001) OR 3.21 (CI 2.52, 4.10).
Conclusions: Breast reconstruction involves multiple procedures to achieve a final satisfactory result, with the average number of revisions differing by reconstructive modality and when complications are encountered. Patients experiencing complications undergo more elective revision procedures in comparison to patients without complications, with differences noted across reconstructive modalities in terms of total procedures performed. Patients should be counselled that the average patient without a complication undergoes nearly 3 procedures to achieve a satisfactory reconstruction. Whereas if a complication occurs, the number of procedures increases.


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