Abstract
Background:
Immediate breast reconstruction following mastectomy has many proven advantages. Although more than half of the patients with breast cancer in the United States are older than 65 years of age, breast reconstruction rates in this age group are low. The goal of this study was to evaluate safety and patient satisfaction of direct-to-implant (DTI) prepectoral breast reconstruction in women older than 65 years of age.
Methods:
This was a retrospective, single-center study of 56 women (56 breasts) undergoing DTI prepectoral breast reconstruction. Twenty-eight patients were older than the age of 65 years and 28 were younger. Groups were matched for surgical procedure, smoking status, body mass index, and history of radiation therapy. Outcomes were compared between groups, and possible correlations were studied.
Results:
Twelve patients older than 65 years of age had hypertension (P = 0.007). Perioperative pain management, major complications, total number of surgical complications, reconstruction failure, and duration of hospitalization were similar in both groups. More advanced age was correlated with higher psychosocial well-being, sexual well-being and satisfaction with breasts on the BREAST-Q scale. Median follow-up was 11.5 months (older) and 23 months (younger).
Conclusions:
Prepectoral DTI breast reconstruction in women older than 65 years of age is safe, reproducible, has high patient satisfaction, and may be performed in this patient cohort.
Takeaways
Question: Is prepectoral immediate implant-based breast reconstruction safe in women older than 65 years of age?
Findings: Prepectoral direct-to-implant (DTI) breast reconstruction has many advantages that are particularly beneficial in older patients. We found prepectoral DTI breast reconstruction in women older than 65 years of age to be safe and reproducible with high patient satisfaction.
Meaning: Prepectoral DTI breast reconstruction may be offered and performed in women undergoing mastectomy regardless of chronological age.
INTRODUCTION
Breast cancer is the most common cancer diagnosed in female patients worldwide, affecting 1 of 8 during a woman’s lifetime1; a third of the pool of patients is older than the age of 70 years.2 As survival rates for breast cancer are improving, the importance of successful surgical outcomes is rising.3–5 Mastectomy is required in about 40% of patients and can have damaging physical and emotional consequences. Many women are offered immediate breast reconstruction to mitigate these effects, resulting in improvements in aesthetic result, self-image, quality of life, and overall well-being.6 Still, a standardized approach to breast reconstruction is lacking and may vary between centers, depending upon medical history, cancer stage, adjuvant therapies, and patient and surgeons’ preferences.
Although women older than 65 years represent half the patients treated with mastectomy for breast cancer,7 reconstruction rates are substantially lower as compared with younger patients.3,7–11 Some patients are not offered reconstruction due to medical comorbidities and a higher surgical risk, which may deter patients and physicians from prolonging surgical procedures and potentially facing reconstruction-related complications. Others may regard their physical appearance without clothes less important than younger patients and are more concerned with health issues and physical well-being.7,9–11 Furthermore, breast cancer–specific survival in patients older than 70 years of age who undergo lumpectomy, with or without adjuvant radiation, is higher than in patients treated by mastectomy, hence limiting the number of mastectomies and reconstructions in this age group.10
Studies regarding breast reconstruction safety in older patients are controversial.5,9,11,12 Oh et al9 published a systematic review of patterns and outcomes of breast reconstruction in older women. They reported that patients 60 years of age and older have lower breast reconstruction rates and tend to undergo more implant-based than autologous reconstructions, but have similar rates of complications and equivalent or higher quality of life and should be offered breast reconstruction after mastectomy.9
Data from the Canadian National Surgical Quality Improvement Program show that only 6.5% of 28,850 immediate implant-based and 5.7% of 9123 autologous breast reconstructions between 2005 and 2016 were done in patients older than 70 years. Breast reconstruction in this patient cohort proved safe without a difference in reconstruction failure but had higher rates of postoperative complications following implant-based reconstruction.13
Despite the rise in the number of patients undergoing breast reconstruction,2 data regarding prepectoral breast reconstruction in older women are lacking. This study aimed to assess safety and patient satisfaction of DTI prepectoral reconstruction in women older than 65 years of age compared with a matched younger cohort.
PATIENTS AND METHODS
Study Design
This is a single-center, institutional review board–approved, retrospective study of patients undergoing mastectomy and DTI prepectoral reconstruction between January 2017 and December 2023. Patients were divided into 2 groups: all consecutive women older than 65 years and a matched control group of women younger than 65 years (Figs. 1, 2). Patients were matched for type of surgery and risk factors for reconstruction failure: body mass index, smoking, and history of radiation.
Fig. 1.
67-year-old woman, 18 months after left nipple spearing mastectomy and immediate prepectoral reconstruction with Polytech MesmoHS 395 cc anatomic implant without any surgical procedure on the contralateral side. A–C, Before. D–F, After.
Fig. 2.
55-year-old woman, 6 months following left nipple spearing mastectomy and immediate prepectoral reconstruction with Mentor M + 325 cc smooth round implant. Notice good symmetry to contralateral ptotic LT breast and lack of upper pole fullness. A–C, Before. D–F, After.
Subjects
In both cohorts, patients were older than 18 years and were diagnosed with breast cancer. Following the mastectomy, DTI AlloDerm (LifeCell, Branchburg, NJ)–assisted prepectoral breast reconstruction was performed. Our preoperative antibiotic protocol was intravenous 2 g cefazolin administered 1 hour before incision to all patients, and we continued antibiotic treatment (Oral Keflex 1 g 3 times a day) until drain removal (12 d in average). Patients with known allergy to cephalosporin received clindamycin instead.
All women with clinically good nontraumatized skin flaps (regular, viable color, and with absence of bare dermis on the undersurface) were considered for prepectoral reconstruction. Patients shown by clinical assessment to possess poorly vascularized or traumatized flaps underwent subpectoral reconstruction with a tissue expander and were excluded from the study. Patients were also excluded from this study if they were oncologically and/or medically unfit or unwilling to undergo immediate breast reconstruction in general, or, specifically, by an implant-based procedure.
Assessments
Patient demographics were collected at the initial consultation (Table 1). Key procedural data, postoperative course, and complications were assessed in both cohorts (Tables 2, 3).
Table 1.
Patient Demographics
| Variable | Age < 65 y, N = 28 | Age > 65 y, N = 28 | P |
|---|---|---|---|
| Age. y, mean ± SD | 46.25 ± 6.69 | 68.71 ± 3.03 | <0.001 |
| BMI, kg/m2, mean ± SD | 27.85 ± 4.82 | 27.37 ± 4.53 | 0.70 |
| Diabetes, n (%) | 3 (10.7) | 3 (10.7) | 1 |
| Hypertension, n (%) | 3 (10.7) | 12 (42.9) | 0.007 |
| Smoking, n (%) | 5 (17.9) | 5 (17.9) | 1 |
| Tumor grade | 3 (2–3) | 2 (2–2.25) | 0.08 |
| Adjuvant or neoadjuvant chemotherapy, n (%) | 13 (46.4) | 8 (29.6) | 0.20 |
| Postsurgical radiation, n (%) | 10 (35.7) | 10 (37.0) | 0.92 |
Table 2.
Reconstructive Procedure and Postoperative Course
| Variable | Age < 65 y, N = 28 | Age > 65 y, N = 28 | P |
|---|---|---|---|
| Prepectoral, n (%) | 28 (100) | 28 (100) | 1 |
| Skin-sparing mastectomy, n (%) | 21 (75.0) | 22 (81.5) | 0.56 |
| Nipple-sparing mastectomy, n (%) | 7 (25.0) | 5 (18.5) | |
| ALND, n (%) | 7 (25.0) | 6 (22.2) | 0.34 |
| Amputated breast weight, g, mean ± SD | 524.8 ± 233.4 | 580.0 ± 299.50 | 0.47 |
| Implant weight, g, mean ± SD | 426.61 ± 136.99 | 415.36 ± 144.76 | 0.77 |
| Implant shape, round, n (%) | 9 (32.1) | 10 (37.0) | 0.70 |
| Peripheral nerve blocks, n (%) | 23 (82.1) | 19 (67.9) | 0.21 |
| Opioids used, n (%) | 21 (91.3) | 17 (81.0) | 0.40 |
| Duration of opioids usage, d | 6 (2–13.5) | 3 (0.25–5) | 0.03 |
| NSAIDS used, n (%) | 13 (65.0) | 6 (30.0) | 0.03 |
| Hospitalization, d | 14 (9.5–17.5) | 13.0 (6–15.0) | 0.32 |
| Drain time, d | 13.0 (11.0–18.0) | 12.0 (5.0–15.0) | 0.18 |
| Follow-up, mo | 23 (8.25–29.75) | 11.5 (4–26.75) | 0.05 |
NSAIDS, nonsteroidal anti-inflammatory drugs.
Table 3.
Complications
| Age < 65 y, N = 28 | Age > 65 y, N = 28 | P | |
|---|---|---|---|
| Infection, n (%) | 1 (3.6) | 4 (14.3) | 0.35 |
| Necrosis, n (%) | 2 (7.1) | 2 (7.1) | 1 |
| Seroma, n (%) | 0 (0.0) | 0 (0.0) | 1 |
| Hematoma, n (%) | 0 (0.0) | 1 (3.6) | 1 |
| Major complication, n (%) | 1 (3.6) | 2 (7.1) | 1 |
| Reconstruction failure, n (%) | 0 (0.0) | 0 (0.0) | 1 |
| Any complication, n (%) | 3 (10.7) | 7 (25.0) | 0.16 |
Patients filled out a translated, validated BREAST-Q questionnaire (BREAST-Q version 2.0 Reconstruction Module Pre- and Postoperative Scales Hebrew [IL] Version, Memorial Sloan Kettering Cancer Center, The University of British Columbia)—Breast Cancer Core Scale (Postoperative): Psychosocial Well-Being, Sexual Well-Being, Satisfaction with Breasts and Physical Well-Being: Chest (scores from 0 [worst] to 100 [best]; higher scores reflect a better outcome).12 Outcomes were compared between groups, and possible correlations were studied.
Statistical Analysis
Patient demographics, surgery, and outcomes were compared using chi-square or Fisher exact tests for categorical variables and t test for continuous variables. Nonnormally distributed variables are presented as medians with interquartile range and compared with the Mann-Whitney test using the log-rank test. The Pearson correlation was used for correlation between variables. Analyses were performed using SPSS version 25 for Mac (IBM, Armonk, NY) with a P value of 0.05 indicating statistical significance.
RESULTS
Baseline Characteristics
A total of 56 women and 56 breasts were included in the study. The mean age was 68.7 years (SD ± 3) in the study and 46.2 (SD ± 6.6) in the control group. Patients older than 65 years of age had higher incidence of hypertension (42.9% versus 10.7%, P = 0.007), with similar rates of diabetes mellitus (10.7% versus 10.7%, P = 1), body mass index (27.37 versus 27.85, P = 0.7) and neoadjuvant or adjuvant chemotherapy (29.6% versus 46.4%, P = 0.2). All patients had a therapeutic mastectomy with comparable tumor grades (P = 0.08). Among the 56 breasts operated on, 20 (37% versus 35.7%, P = 0.9) had adjuvant radiation therapy (Table 1).
Reconstructive Procedure and Postsurgical Course
All patients had a unilateral mastectomy and DTI acellular dermal matrix prepectoral breast reconstruction. Mastectomy type (skin spearing, reducing, or nipple spearing), amputated breast weight (524.8 ± 233.4 versus 580.0 ± 299.50, P = 0.47), axillary surgery (25% versus 22%, P = 0.34), implant volume (426.61 ± 136.99 versus 415.36 ± 144.76, P = 0.77), and implant shape were comparable between groups. Analgesia, number of peripheral nerve blocks performed (82.1% versus 67.9%, P = 0.21), number of patients who used opioid painkillers (21 versus 17, P = 0.4), number of hospitalization days (14 versus 13, P = 0.32), and duration of surgical draining (13 versus 12, P = 0.18) were also similar in both cohorts. However, younger patients used more nonsteroidal pain medication (13 versus 6, P = 0.03) and opioids for more days (6 versus 3, P = 0.03). The mean follow-up was 11.5 months in the study group and 23 months in the control (P = 0.05) (Table 2).
Complications
Overall, 7 (25%) patients in the study group and 3 (10%) in the control had a postoperative complication (P = 0.16). The incidence of major complications (ie, complications requiring operative management) was comparable between the groups (1 versus 2, P = 1). There were no reconstruction failures or seromas. Infection (1 case in the control group versus 4 cases in the study, P = 0.35) and skin necrosis (2 cases in each, P = 1) were the most common complications in both cohorts (Table 3).
Patient-reported Outcomes
Psychosocial well-being, sexual well-being, and satisfaction with breasts BREAST-Q scores were significantly higher (77.0 [67.75–85.5] versus 50.0 [42.75–71.0], P = 0.002, 59.0 [47.25–63.0] versus 46.0 [32.5–54.5], P = 0.03 and 59.0 [55.0–65.5] versus 47.0 [37.5–59.5], P = 0.03, respectively), and physical was well-being lower (28.0 [8.0–45.0] versus 45.0 [32.0–62.0], P = 0.05) in the study group. Overall, older age was correlated with higher mean BREAST-Q score (58.0 [50.37–60.62] versus 50.0 [42.25–56.0], P = 0.03) (Table 4).
Table 4.
Patient-reported Outcomes
| Age < 65 y, N = 18 | Age > 65 y, N = 14 | P | |
|---|---|---|---|
| Psychosocial well-being, median (IQR) | 50.0 (42.75–71.0) | 77.0 (67.75–85.5) | 0.002 |
| Sexual well-being, median (IQR) | 46.0 (32.5–54.5) | 59.0 (47.25–63.0) | 0.03 |
| Satisfaction with breasts, median (IQR) | 47.0 (37.5–59.5) | 59.0 (55.0–65.5) | 0.03 |
| Physical well-being, median (IQR) | 45.0 (32.0–62.0) | 28.0 (8.0–45.0) | 0.05 |
| BREAST-Q, median (IQR) | 50.0 (42.25–56.0) | 58.0 (50.37–60.62) | 0.03 |
IQR, interquartile range.
DISCUSSION
Breast reconstruction is constantly evolving. Advances in surgical technique such as prepectoral implant placement, usage of large acellular dermal matrix sheets, immediate fat grafting, and others have made postmastectomy breast reconstruction simpler to perform for surgeons and less invasive with easier postoperative recovery for patients, producing superior aesthetic outcomes.14–17 Developments in breast reconstruction surgery are especially advantageous for older patients who are not always favorable candidates for reconstruction due to higher rates of medical comorbidities and lower agility.2
In this retrospective single-center study, we matched 28 patients older than the age of 65 years with 28 younger patients who had the same surgical intervention and similar risk factors for postoperative complications. By matching the cohorts, we attempted to minimize confounders that may impact the surgical outcome and our study hypothesis. Other than age, the only statistically significant difference between cohorts was essential hypertension (P = 0.04), which, although more common in older patients,2 did not impact complication rates in multivariate analysis.
The advantages of placing the implant above the pectoralis major muscle, the anatomic location of the breast, are numerous.18,19 Prepectoral implant placement negates the dissection of the pectoralis major muscle, facilitating a shorter, less painful, and easier recovery,18,19 especially important for older patients. Aesthetically, prepectoral implant placement is advantageous, as it produces a more natural looking result, particularly important in implant-based unilateral reconstructions and reconstructions of ptotic breasts.20 The reconstructed breast must match the natural contralateral breast, a hard task to achieve in implant-based reconstruction. Placing the implant in a prepectoral pocket facilitates the decent of the implant onto the chest wall, creating a more natural breast shape with ptosis and lower pole fullness.20 Older patients typically have aging breasts; therefore, if they undergo unilateral mastectomy2 followed by implant-based reconstruction,16,21 the prepectoral reconstruction approach may be especially warranted.
The overall complication rate in this study was 17%, comparable with the published literature.3,9,19,21–24 Although older women undergoing mastectomy and DTI prepectoral reconstruction had more complications compared with their younger matching controls, this did not reach statistical significance (P = 0.16), which supports the safety of DTI prepectoral reconstruction in this age group. Other studies comparing younger and older patients show similar rates of postoperative complications in immediate breast reconstruction2,24–26; however, none of these took place in the prepectoral setting. As our cohort is relatively small, interpretation of these results should be taken cautiously, and results of larger-scale studies are desired.
Knackstedt et al5 compared the safety profile of a single-stage procedure versus 2-stage tissue expander/implant reconstruction in patients older than 65 years of age. DTI breast reconstruction in older patients yielded similar complication and reconstruction failure rates as 2-stage reconstruction. Compared with 2-stage reconstruction, DTI was associated with reduced number of drain days, fewer readmissions, shorter hospital stays, and fewer postoperative visits.5 Reducing the burden of care, with the DTI approach necessitating only 1 operation and fewer follow-up visits for tissue expansion, is appealing for all patient groups but is particularly relevant for older patients.
A review by Oh et al of postmastectomy breast reconstruction outcomes in older patients has shown significantly better scores in breast-related body image and breast-related psychosocial health in patients who underwent breast reconstruction in comparison with patients of the same age-range who received mastectomy only.9,27 There were no differences in physical health, pain, or disability between the 2 groups, and no correlation between age and reported outcomes.3,9 Older patients also scored higher in questions related to mental health,3 were more satisfied with the aesthetic results, would be prepared to undergo the same treatment again, and believe that reconstruction should be offered to all patients regardless of age.27 These are sensible results, as older patients with breast cancer may experience fewer worries about their appearance and more concerns for health-related matters. In fact, previous studies report that older patients have better mental health than younger patients after mastectomy and reconstruction.28
Our results confirm these findings, thus demonstrating a significant correlation between age older than 65 years and higher psychosocial well-being (P = 0.002), sexual well-being (P = 0.03), satisfaction with breasts (P = 0.03), and mean BREAST-Q scores (P = 0.03). Also, we found that age was a significant predictor of lower physical well-being of the chest (P = 0.05), as older patients may have longer recovery time and experience more pain.28 In fact, age may not be the only factor to impact BREAST-Q scores. The timing of the questionnaire after surgery may impact scores, as it can be influenced by postoperative complications or recovery. Thus, scores vary between time points after surgery. Postoperative complications are also predictors of dissatisfaction with breasts.28 Overall, these results suggest that older age should not be a barrier for postmastectomy breast reconstruction, and the high scores of patient-reported outcomes in the study group further support the importance of offering DTI reconstruction for generally healthy patients regardless of age.
However, we acknowledge the limitations of the present work. It was a single-center retrospective analysis of a relatively small patient cohort. Also, there were higher rates of breast reconstruction after mastectomy in younger women, which may have led to a selection bias of our older cohort. The purpose of this study was to report safety and patient-reported outcomes of prepectoral DTI breast reconstruction in older patients. As this is a relatively new technique, we included our learning curve patients as we studied appropriate patient selection and surgical technique. Finally, we report a difference in average follow-up of a year in favor of our control group (11.5 versus 23 mo). This may impact results such as long-term complication rate or patient satisfaction. Despite this, we were able to demonstrate results that are comparable with a younger group with regard to complication rates and patient-reported outcomes. A prospective, multicenter trial of a larger patient cohort would be welcomed.
CONCLUSIONS
Prepectoral DTI breast reconstruction has many advantages that are particularly beneficial in older patients. In this study, we found that prepectoral DTI breast reconstruction in women older than 65 years of age is safe and reproducible, with high patient satisfaction. We concluded that this technique may well be offered and performed in women undergoing mastectomy regardless of chronological age.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
Footnotes
Disclosure statements are at the end of this article, following the correspondence information.
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