1. Breast Reconstruction: Outcomes Analysis Michael J Bass, MD, JD www.drmichaeljbass.com Michael J Bass Plastic Surgery, PLLC

2. Disclosures None Still need some

3. Analysis Factors What affects outcome – Neoadjuvant chemotherapy (Malata) – Radiation (Cordeiro) Overall Satisfaction – Unilateral versus bilateral reconstruction (Craft)

4. Neoadjuvant Chemotherapy and Immediate Breast Reconstruction 171 patients (198 breasts) by one surgeon – 64 free flaps, 74 pedicled flaps, 60 implant based 53 neoadjuvant, 118 controls Neoadjuvant phase III randomized trial Malata, et al, Plastic and Reconstructive Surgery July 2010;126(1):1-11

5. Neoadjuvant Chemo (cont.) Malata, et al, Plastic and Reconstructive Surgery July 2010;126(1):1-11

6. Neoadjuvant Chemo (cont.) Minor complications: – 6 (10%) neoadjuvant, 9 (6%) controls (p=.380) Major complications: – 1 (2%) neoadjuvant; 3 (2%) controls (p=1.0) No effect of neoadjuvant chemotherapy on risk of complications nor delay in adjuvant radiation Paper did not evaluate patient or surgeon satisfaction of reconstruction Malata, et al, Plastic and Reconstructive Surgery July 2010;126(1):1-11

7. Radiation and Implant Based Reconstruction 143 patients with 1 year of follow up receiving immediate tissue expander reconstruction (1995-2001); no autologous reconstruction patients 68 patients with chest wall radiation (CWR) four weeks after placement of permanent prosthesis 75 control patients during same period Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

8. Radiation and Implants (cont.) Patients received 50 Gray in 25-28 fractions 6 MV to reconstructed breast, axillary apex, and supraclavicular region 68% of irradiated patients had grade II-IV capsular contracture; 40% control group (p=.006) Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

9. Radiation and Implants (cont.) Doctors: 80% of irradiated patients marked good- excellent; 88% for non- irradiated patients Patient satisfaction based upon self assessment questionnaire 67% irradiated, 88% non- irradiated patients satisfied (p=.004) Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

10. Radiation and Implants (cont.) No discussion on tumor grade or disease stage 72% of irradiated patients and 85% of non- irradiated patients would have again elected for tissue expander based reconstruction Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

11. Unilateral Versus Bilateral Reconstruction and Satisfaction 702 women (910 reconstructions) identified between 1999-2006 494 unilateral reconstructions, 416 bilateral reconstructions Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

12. Unilateral Versus Bilateral (cont.) Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

13. Unilateral Versus Bilateral (cont.) Patient surveys mailed Minimum post reconstruction time 13 months, average of 56 months for unilateral and 49 months for bilateral patients Survey response: 75% unilateral, 79% bilateral Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

14. Unilateral Versus Bilateral (cont.) Reconstruction (cont.) Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

15. Barriers To Reconstruction Doctor recommendation to seek counseling with a plastic surgeon – 7/10 women eligible for reconstruction after a mastectomy are not informed that the option exists (ASPS poll, 2009) Logistical problem of coordinating consultations and immediate reconstruction Immediate reconstruction: 23.4% for invasive breast cancer, 36.4% for DCIS Medicaid kerfuffle quadrification in Kentucky Age >50, rural living, black least likely to get reconstruction

16. Thank You For Coming Your participation in this lecture creates new opportunities for newly diagnosed women Breast cancer is far away from being treated with a pill