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Comparison of Clinical Outcomes and Patient Satisfaction in Immediate Single-Stage versus Two-Stage Implant-Based Breast Reconstruction
Seenu Susarla, M.D., D.M.D.1, Ingrid Ganske, M.D.2, Lydia Helliwell, M.D.2, Elof Eriksson, M.D., Ph.D.1, Donald Morris, M.D.3, Yoon S. Chun, M.D.1.
1Brigham and Women's Hospital, Boston, MA, USA, 2Harvard Plastic Surgery Residency Program, Boston, MA, USA, 3Longwood Plastic Surgery, Brookline, MA, USA.

PURPOSE: Implant-based breast reconstruction is the most commonly utilized method of breast reconstruction and generally involves a two-stage approach: placement of a tissue expander (TE) at the time of mastectomy and subsequent expansion, followed by exchange to an implant. More recently, with the availability of acellular dermal matrix, immediate single-stage implant breast reconstruction has become popularized. While the single-stage approach may obviate the need for expansion and reduce the number of surgical procedures, it has potential disadvantages, such as potential increased risk of skin necrosis and limitations in reconstruction size. This study compares the clinical outcomes and patient satisfaction between immediate single-stage versus two-stage implant-based breast reconstructions.
METHODS: The authors performed a retrospective analysis of consecutive immediate breast reconstructions over an eight-year period. A total of 512 breast reconstructions in 346 patients were divided into either single-stage or two-stage implant-based reconstructions. Demographic information, co-morbidities, oncologic data, and post-operative complications were collected for comparison. Patient satisfaction across multiple domains was assessed by the Breast-Q survey instrument.1 Descriptive, bivariate and multiple regression statistics were computed.
RESULTS: Among 512 total breast reconstructions, 100 reconstructions were performed as single-stage implant-based reconstruction and 412 were performed as two-stage TE/implant-based reconstruction. Upon comparing the single- and two-stage groups, there were no significant differences in the rate of post-operative complications including minor infections (0% versus 1.0%, p = 0.23), major infections (7.0% versus 4.0%, p = 0.18), hematoma (0% versus 2.0%, p = 0.14), seroma (6.0% versus 6.0%, p = 0.87), and major skin necrosis (15.0% versus 13.0%, p = 0.53). There was a trend towards lower rate of minor skin necrosis in the single-stage group (1.0% versus 6.0%, p = 0.052). Forty-six percent of the single-stage reconstructions underwent operative revision. Analysis of the Breast-Q survey data from 238 breast reconstructions (37 single-stage reconstructions; 201 two-stage reconstructions) showed patients undergoing two-stage reconstructions had higher scores for satisfaction with breasts, satisfaction with information, and satisfaction with medical and office staff (p < 0.03).
CONCLUSION: There were no significant differences in surgical complication rates between immediate single-stage versus two-stage implant-based breast reconstructions. However, almost half of single-stage breast reconstructions underwent operative revisions. Patients undergoing two-stage reconstructions were more satisfied with their breasts, the quality of information regarding the reconstruction, and the medical and office staff. These differences may be related to the significant need for revisions in the single-stage group and the increased number of office visits inherent in the expansion process in the two-stage reconstructions.
References:
1. Pusic AL, Klassen AF, Cano SJ. Use of the BREAST-Q in clinical outcomes research. Plast Reconstr Surg. 2012 Jan;129(1):166e-167e.


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