Reconstructive Burnout after Mastectomy: Implications for Patient Selection : Plastic and Reconstructive Surgery

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Breast: Original Articles

Reconstructive Burnout after Mastectomy: Implications for Patient Selection

Halani, Sameer H. MD, MSc1; Jones, Kaitlin BS1; Liu, Yulun PhD2; Teotia, Sumeet S. MD1; Haddock, Nicholas T. MD1

Author Information
Plastic and Reconstructive Surgery 151(1):p 13e-19e, January 2023. | DOI: 10.1097/PRS.0000000000009776
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Abstract

The reconstructive journey after mastectomy can be a long, challenging road for patients, with varying hurdles and complications encountered along the way. The development of genetic testing and breast imaging, and increased awareness of surgical options have led to an increase in both mastectomy rates and breast reconstruction rates.1,2 Breast reconstruction improves patient satisfaction with their breasts, their psychosocial well-being, and their sexual well-being.3 This journey, however, is not to be taken lightly. The emotional burden of breast cancer can result in depression at a rate of three to four times that seen in the general population.4,5 In addition, if patients ultimately undergo mastectomy and breast reconstruction, whether immediate, delayed, implant-based, or autologous, the emotional burden of surgery must be considered. Operative complications, revisions to optimize breast aesthetics, chemotherapy, hormonal therapy, and radiation therapy are also critical factors in a patient’s treatment course.

Although the psychological benefits from breast reconstruction have been shown in multiple studies,1,3,6 there are a subset of patients who begin the reconstructive journey but do not complete it—a term we introduce as reconstructive burnout. These are patients who begin the reconstructive process but do not complete it for some reason. We hypothesize that patients with a higher number of comorbidities and more postoperative complications are more likely to experience reconstructive burnout. In this study, we define reconstructive burnout and aim to identify predictors of burnout in patients undergoing breast reconstruction after mastectomy, including patient comorbidities, reconstructive modality selected, and postoperative complications. With this information, we hope to guide conversations between surgeons and patients to select the best reconstructive modality for them and allow for a shared decision-making process to optimize patient outcomes and satisfaction.

PATIENTS AND METHODS

Study Design and Patient Selection

After obtaining approval from the University of Texas Southwestern Medical Center Institutional Review Board (STU 052015-021), we performed a retrospective review of patients undergoing breast reconstruction after mastectomy from 2014 to 2017 performed by one of two senior surgeons (N.T.H. and S.S.T.) at a single institution who share standardized surgical and perioperative strategies.7 Patients underwent either immediate or delayed-immediate reconstruction with tissue expanders, implant-based reconstruction, or autologous reconstruction (including deep inferior epigastric artery perforator, lumbar artery perforator, profunda artery perforator flaps, or a combination of the above). All tissue expander–based reconstructions included coverage with acellular dermal matrices.

Data collection was performed with a Research Electronic Data Capture database,8 and analysis included patient demographics, age, medical history, smoking status, indication for mastectomy (prophylactic versus oncologic), adjuvant or neoadjuvant chemotherapy or radiation therapy, unilateral or bilateral reconstruction, timing and type of reconstruction (implant-based or autologous), and postoperative complications. Complications included hematoma (requiring operative intervention), seroma (requiring formal drainage), wound dehiscence, infection requiring oral or intravenous antibiotics, explantation of tissue expander or implant, and flap-related complications (including partial/complete flap failure and donor-site complications). Patients were excluded if they lacked postoperative follow-up data; underwent lumpectomy, nipple-sparing mastectomy, or partial mastectomy; or decided preoperatively to have no reconstruction following mastectomy.

Endpoints of Reconstruction

Included patients were evaluated to determine whether they completed reconstruction. Based on our algorithm at our institution, patients underwent either tissue expander placement followed by implant or flap reconstruction, immediate implant reconstruction, immediate flap reconstruction, or true delayed flap reconstruction. Reconstruction completion was defined as formation of a breast mound with completion of all major revisions (where either the surgeon or patient felt satisfied with reconstruction) and/or nipple reconstruction/areola tattoo. In an effort to maintain a homogenous cohort, patients who underwent nipple-sparing mastectomy were excluded from this cohort, as nipple-areola reconstruction/tattooing could not be considered as an endpoint of reconstruction. Patients who experienced reconstructive burnout were defined as those who had no breast mound created, elected to have their expanders removed without complication, lost their initial reconstruction entirely and aborted reconstruction, or had completion of the breast mound without completion of all major revisions, including those lost to follow-up (Fig. 1). Patients who underwent any reconstruction with only one postoperative follow-up visit with our team were also considered to have experienced reconstructive burnout.

F1
Fig. 1.:
Flowchart demonstrating endpoints of completion for breast reconstruction. Groups I and II are considered to have completed reconstruction, whereas groups III and IV are those that experienced reconstructive burnout.

Statistical Analysis

Comparisons of proportions between groups were performed using chi-square or Fisher exact test. Differences between continuous variables were assessed using the t test or Wilcoxon ranked sum test. Univariable and multivariable logistic regression was performed using logistic regression to estimate odds ratios of predictive factors for completing reconstruction using 95% confidence intervals. A criterion of P < 0.10 was used to determine inclusion of predictors in the multivariable regression model, and a backward selection model was used for the final model. Significance was determined at the P < 0.05 level. Data analysis was performed using R (v4.0.3; R Foundation for Statistical Computing, Vienna, Austria) and Stata (v12.0; StataCorp, College Station, TX).

RESULTS

Demographics

A total of 530 patients were included in our study and were subsequently separated into four subgroups (Fig. 1) based on their reconstructive endpoints as follows: group I consisted of patients who completed breast mound creation with nipple reconstruction [n = 259 (48.9%)]; group II consisted of patients with completion of the breast mound and completion of all major revisions [n = 146 (27.7%)]; group III consisted of patients who had breast mounds created without completion of major revisions [n = 86 (16.2%)]; and group IV consisted of patients who had no breast mound creation [n = 38 (7.2%)]. Overall, 406 patients (76.6%) completed reconstruction (groups I and II combined). The overall burnout rate in our cohort was 23.4% (n = 124) (groups III and IV combined).

The large majority of patients underwent therapeutic mastectomies [n = 496 (93.6%)], most of which were bilateral [n = 409 (77.2%)]. A total of 217 patients (40.9%) received radiotherapy, whereas 159 patients (30%) received adjuvant chemotherapy.

There was a significant positive correlation between reconstructive burnout and both diabetes (P = 0.008) and active smoking (P = 0.032). There was no significant correlation seen between burnout and race, any chemotherapy, or radiation therapy. The summary demographics of the cohort are listed in Table 1.

Table 1. - Patient Demographics of Those Who Underwent Breast Reconstruction and Either Completed Reconstruction or Had Reconstructive Burnout
Characteristic Complete Reconstruction (%) Burnout (%) P
No. 406 124
Mean age ± SD, yr 53.5 ± 10.3 55.7 ± 10.7 0.42
Mean BMI ± SD, kg/m2 28.8 ± 5.6 30.9 ± 6.7 0.0006 a
Race
 White 277 (68.2) 77 (62.1) 0.598
 Black 59 (14.5) 23 (18.5)
 Hispanic 52 (12.8) 17 (13.7)
 Other 18 (4.4) 7 (5.6)
HTN 125 (30.8) 45 (36.3) 0.251
Diabetes 30 (7.4) 19 (15.3) 0.008 a
Autoimmune 25 (6.2) 12 (9.7) 0.178
Smoking status
 Current smoker 9 (2.2) 8 (6.5) 0.032 a
 Former smoker 98 (24.1) 35 (28.2)
Neoadjuvant chemotherapy 130 (32.0) 35 (28.2) 0.415
Adjuvant chemotherapy 115 (28.3) 44 (35.5) 0.132
Radiotherapy 157 (38.7) 60 (48.4) 0.057
Prophylactic SSM 27 (6.7) 7 (5.6) 0.689
Laterality 0.511
 Unilateral 90 (22.2) 31 (25.0)
 Bilateral 316 (77.8) 93 (75.0)
BMI, body mass index; HTN, hypertension; SSM, skin-sparing mastectomy.
aStatistically significant.

Initial Reconstruction with Tissue Expanders

A total of 439 patients (82.8%) underwent reconstruction with tissue expanders. The complication rate within the burnout group was significantly higher than in the completed group (48.1% versus 36.3%, respectively; P = 0.03). Among these complications, those requiring operative interventions were significantly higher in the burnout group (35.8% versus 17.4%, respectively; P < 0.001), including a significantly higher explantation rate (22.6% versus 5.1%, respectively; P < 0.001) (Table 2).

Table 2. - Operative Complication Data of Patients Who Underwent Reconstruction with Tissue Expanders (N = 439)
Characteristic Complete (%) Burnout (%) P
No. 333 106
Any TE complications 121 (36.3) 51 (48.1) 0.031 a
Hematoma 8 (2.4) 2 (1.9) 1.000
Seroma 23 (6.9) 5 (4.7) 0.422
Wound dehiscence 76 (22.8) 39 (36.7) 0.004 a
TE breast infection 32 (9.6) 18 (16.9) 0.037 a
Complication requiring operative intervention 58 (17.4) 38 (35.8) <0.001 a
TE explantation 17 (5.1) 24 (22.6) <0.001 a
TE, tissue expander.
aStatistically significant.

Implant-Based Reconstruction

Implant-based reconstruction was performed in 187 patients (35.3%), with a minority of these being immediate reconstructions [n = 4 (2.1%)]. The overall burnout rate was 17.1% (n = 32). The overall complication rate in this subgroup was 2.7%, with no significant difference in rates in either the burnout or the complete group. The average number of operative revisions after implant placement was 0.76 ± 0.9.

Autologous Reconstruction

The majority of patients in this cohort [n = 320 (60.4%)] underwent autologous reconstruction, with an overall burnout rate of 19.1% (n = 61). Although there was no significant difference in overall complication rates, flap failure rates, or donor-site complications between the two groups, burnout patients had a higher average number of complications compared to those who completed reconstruction (mean, 1.2 ± 0.2 complications per patient versus 0.8 ± 0.07 complications per patient, respectively). The total number of revisions required in the autologous group was 1.44 ± 1.1, which was significantly higher than in the implant-based group (P < 0.0001) (Table 3). When compared to implant-based reconstruction, autologous reconstruction burnout rates were comparable (17.1% versus 19.1%, respectively; P = 0.58).

Table 3. - Operative Complication Data of Patients Who Underwent Autologous Reconstruction (N = 320)
Characteristic Complete (%) Burnout (%) P
No. 259 61
Any complications? 141 (54.4) 42 (68.9) 0.041
Flap-specific complication? 92 (35.5) 28 (45.9) 0.132
Donor-site–specific complication? 87 (33.6) 28 (45.9) 0.057
Mean no. of complications ± SD 0.8 ± 0.07 1.2 ± 0.2 0.011 a
aStatistically significant.

Predictors of Burnout

Univariable logistic regression models were run to identify predictors of burnout (Table 4) and revealed older age (OR, 0.98; 95% CI, 0.96 to 0.999), higher body mass index (OR, 0.94; 95% CI, 0.913 to 0.976), diabetes (OR, 0.44; 95% CI, 0.24 to 0.83; P = 0.009), any tissue expander complication (OR, 0.62; 95% CI, 0.41 to 0.94; P < 0.001), and tissue expander explantation (OR, 0.18; 95% CI, 0.09 to 0.35; P < 0.001) to be the strongest predictors of burnout. Placement of a tissue expander was not a predictor of burnout (OR, 0.78; 95% CI, 0.43 to 1.33; P = 0.37). On multivariable models, radiation therapy, higher body mass index, and tissue expander explantation were found to be strong predictors of burnout. Notably, delayed autologous reconstruction was the strongest individual predictor of completion of reconstruction on univariable models (OR, 2.8; 95% CI, 1.2 to 8.1; P = 0.037), and approached significance on multivariable models. Autologous reconstruction held its significance as a positive predictor of completion of reconstruction on multivariable models (OR, 2.1; 95% CI, 1.28 to 3.4; P = 0.003).

Table 4. - Univariable and Multivariable Regression Models for Reconstructive Burnout as the Primary Outcomea
Covariate Univariable Regression Multivariable Regression b
OR (95% CI) P OR (95% CI P
Age 0.980 (0.961–0.999) 0.042 c 0.981 (0.961–1.001) 0.064 c
BMI 0.944 (0.913–0.976) 0.001 c 0.935 (0.900–0.970) <0.001 c
Neoadjuvant chemotherapy 1.202 (0.777–1.890) 0.416
Adjuvant chemotherapy 0.721 (0.472–1.110) 0.133
Radiation therapy (any history) 0.675 (0.450–1.013) 0.057 0.541 (0.345–0.845) 0.007 c
Diabetes 0.441 (0.240–0.826) 0.009 c
Smoking status
 Never smoked Ref
 Former smoker 0.759 (0.483–1.208) 0.236
 Current smoker 0.305 (0.113–0.835) 0.018 c
TE 0.775 (0.431–1.330) 0.372
Any TE complications? 0.615 (0.406–0.935) 0.022 c
TE explantation 0.182 (0.093–0.350) <0.001 c 0.202 (0.097–0.410) <0.001 c
Implant 1.685 (1.080–2.685) 0.024 c
Flap 1.820 (1.212–2.735) 0.004 c 2.068 (1.282–3.360) 0.002 c
Delayed reconstruction 2.746 (1.162–8.085) 0.037 c 2.522 (0.999–7.805) 0.072
BMI, body mass index; TE, tissue expander; Ref, reference.
aReference values for each of the covariates was “no.” For the univariate logistic regression analysis, those factors with values of P < 0.1 were included in the initial multiple logistic regression analysis. The final model was chosen based on the backward selection criterion.
bAkaike information criterion = 544.06.
cStatistically significant.

DISCUSSION

Breast reconstruction after mastectomy has significant benefits for the overall well-being of patients, but it is a process that can be an emotional and psychological burden on patients. Reconstructive burnout must be considered by both patient and surgeon in preparation for reconstruction to highlight the risks ahead, as the weight associated with operative complications and preexisting disease burden can hinder completion of reconstruction. In this study, we have highlighted key demographic, clinical, and surgical predictors of reconstructive burnout. We found radiotherapy and high body mass index to be strong predictors of burnout. From an operative standpoint, complications associated with tissue expanders—namely, those involving explantation—were the strongest surgical predictors of burnout. In addition, both implant-based and autologous reconstruction had comparable rates of burnout.

Although the diagnosis of breast cancer is an emotional burden for patients, comorbidities on their own can make patients feel like the deck is stacked against them. Our study found diabetes to be an independent predictor of reconstructive burnout on univariable models (OR, 0.44; P = 0.009) and high body mass index to be predictive on both univariable (OR, 0.98; P = 0.001) and multivariable models (OR, 0.94; P < 0.001). Management of diabetes and obesity has advanced; however, it has been shown that breast cancer–specific mortality remains higher among obese women and those with diabetes.9 Although this is likely multifactorial, there are certain prevailing theories that suggest oncogenesis of breast cancer and obesity/diabetes may be intertwined, thereby further contributing to the load this subset of patients bear.10,11 Furthermore, patients with diabetes are already managing a medical problem and thus may have a lower threshold for being overwhelmed by disease burden. In addition, these patients are more susceptible to complications related to oncologic therapy and thus may be more likely to experience reconstructive burnout.

Similarly, radiation therapy was found to be a predictor of reconstructive burnout on multivariable models (OR, 0.58; P = 0.015). Radiotherapy alone has been described in the literature to have profoundly devastating effects on patients. This includes increased overall complication rates in both autologous and implant-based reconstruction, with preoperative radiation leading to an average 14% incidence of failure of implant-based reconstruction.12–15 Given its adverse effect on skin and tissue quality, and subsequently the variable role these play in contributing to increased operative complication rates,16 it is no surprise that radiation therapy is associated with increased rates of burnout. It may be prudent, therefore, to spend more time focused on managing expectations of patients who are highly likely to undergo radiation therapy, to facilitate handling complications that may be more likely to arise in this subset of patients.

Tissue expanders play a major role in both breast reconstruction and subsequently in reconstructive burnout. The rates of tissue expander complications are no surprise and have been described in the literature to range as high as 45%.17 Complications in this subset of patients is not limited to staged implant-based reconstruction. Those undergoing autologous reconstruction with tissue expander placement at the time of mastectomy have 7.5 times higher risk of intraoperative complications during autologous flap reconstruction, a higher incidence of venous thrombosis, and an overall tissue expander loss rate of 18.6%.18 Our study identified any tissue expander complication to be a strong predictor of burnout, with tissue expander explantation being the single strongest predictor on both univariable and multivariable models. There are options after tissue expander failure, including a second attempt at tissue expansion, which has been shown to have high long-term success rates.19 In theory, this is an option; however, the emotional and psychological toll of additional tissue expander complications and potential hospitalizations must be considered by both the patient and the surgeon before going down this road. An alternative option is conversion to autologous tissue.

The central question of autologous versus implant-based reconstruction is an essential point to discuss, as each has its benefits and drawbacks. Implant-based reconstruction has the obvious benefits of an easier, shorter surgery, no additional donor-site morbidity, and a lower observed complication rate in the literature. Autologous reconstruction has the benefit of replacing “like with like,” with the tradeoff of a larger operation and an additional donor site, among other factors. The overall complication rate in our implant-based cohort was 2.7%, with each patient averaging less than one operative revision. In contrast, our autologous cohort revision rate averaged 1.44 ± 1.1 per patient. The literature has demonstrated multiples times over the benefits of autologous reconstruction with patient-reported outcome measures (i.e., BREAST-Q) in both short-term and long-term studies. The Mastectomy Reconstruction Outcomes Consortium has shown that, at 2 years, patients who underwent autologous reconstruction were more satisfied with their breasts, psychosocial well-being, and sexual well-being than those that underwent implant reconstruction, with other systematic reviews and meta-analyses showing similar trends.1,3,20 Our finding of comparable rates of burnout between the two groups (implant-based, 17.1%; autologous, 19.1%; P = 0.58) suggest that autologous reconstruction may be superior to implant-based reconstruction from a patient-reported outcome measure standpoint but requires a more complicated operation. Despite the inherently more complicated procedure, patients undergoing autologous reconstruction are twice as likely to complete reconstruction based on multivariable logistic regression models (OR, 2.1; P = 0.003). Moreover, those patients who underwent delayed autologous reconstruction and circumvented tissue expansion had the highest probability of completing reconstruction. The aesthetic outcome of autologous reconstruction incentivizes patients to complete reconstruction and, based on the literature findings, have improved quality of life. Given our findings, it is our recommendation that obese patients who previously received radiation therapy would be best advised to avoid tissue expansion and undergo delayed autologous reconstruction to optimize their postoperative risk profile, minimize complications, and have the best chance at completing reconstruction.

This study is not without limitations. First, it is retrospective by design and inherently fraught with the limitations that come with this study type. Second, our definition of reconstructive burnout includes patients who may have been lost to follow-up, and there is no way to track whether or not these patients completed reconstruction elsewhere. As a corollary, the clinical judgment of what qualifies as a “major revision” and thus a patient being considered to have “completed reconstruction” was based on the two senior surgeon’s clinical judgment and may be open to debate. Subsequently, this may skew the burnout rate reported here to be higher than is actually observed in practice. Another consideration in our study that skews the burnout rate toward a higher value is our classification of any patient who had one postoperative visit after the first stage of reconstruction who was then lost to follow-up as experiencing burnout. Finally, our study lacks patient-reported outcome measures as to why patients decided to stop reconstruction prematurely, and these would be a major benefit in further addressing reconstructive burnout in the future.

CONCLUSIONS

During the course of breast reconstruction after mastectomy, patients can be overwhelmed either emotionally, mentally, and/or physically and prematurely stop reconstruction because of reconstructive burnout. The major predictors of burnout in these patients include preexisting comorbidities such as diabetes, radiation therapy, and operative complications associated with tissue expanders. Rates of burnout are comparable in both implant-based and autologous reconstruction groups, with autologous reconstruction prevailing as the strongest predictor of completion of reconstruction and supporting the established findings in the literature of providing the best recovery in patient-reported outcomes. These findings will help guide preoperative and prereconstructive conversations with patients to manage expectations for patients who may be highly susceptible to burnout.

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