The role of regional referral centers in breast reconstruction: The New England perforator flap experience
Janet H. Yueh, BA, Eran D. Bar-Meir, MD, Hasan S. Merali, BA, Adam M. Tobias, MD, Bernard T. Lee, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Background: The deep inferior epigastric perforator (DIEP) flap has become an increasingly popular and reliable option for autologous breast reconstruction after mastectomy. Despite its reported advantages, perforator flap breast reconstruction has been slow to integrate as considerable technical expertise is necessary. Due to the lack of availability, many patients may go to great effort and travel far to find surgeons that offer this operation. In February 2004, the Beth Israel Deaconess Medical Center developed a microsurgery program for perforator flap breast reconstruction. By providing the full spectrum of reconstructive techniques, our institution became a referral center for the New England region. The purpose of this study is to analyze the impact of this program before and after initiation with attention to reconstruction rates, patient satisfaction, and referral patterns.
Methods: A retrospective chart review was performed on all women who had undergone mastectomy or breast reconstruction at our accredited ACS Commission-on-Cancer hospital between 1999 and 2006. 1073 women underwent 1341 complete mastectomies at our center for treatment of breast cancer or prophylactic removal of the breast. 101 women had 118 complete mastectomies at an outside institution but chose to have delayed reconstruction at our center. Patients who had breast reconstruction received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. A 75.6 percent response rate was obtained. Statistical analysis was performed using student’s two tailed t test and chi square test as applicable. Statistical significance was defined as p < 0.05.
Results: Since the inception of the perforator flap program in 2004, there has been a significant increase in the immediate reconstruction rate from 51.5 percent to 63.9 percent (p < 0.001). While the percentage of prosthetic-based reconstructions have remained constant, the proportion of latissimus dorsi and transverse rectus abdominis myocutaneous flaps have significantly decreased as the proportion of microsurgical flaps have significantly increased. Between the two time periods, general patient satisfaction after breast reconstruction increased from 58.5 percent to 74.4 percent (p < 0.001), while aesthetic satisfaction increased from 58.5 percent to 69.9 percent (p = 0.010). Analysis of patient addresses at the time of reconstruction shows a greater than 10 percent increase (p < 0.001) in patients seeking mastectomy and reconstruction at our institution from outside of Massachusetts. Furthermore, we have seen at 4.1 fold increase in the number of patients per year coming from outside institutions seeking to have delayed or secondary breast reconstruction.
Conclusions: The addition of a perforator flap breast reconstruction program to accredited cancer centers can increase both patient satisfaction and reconstruction rates. The availability of microsurgical breast reconstruction at an institution will not only dramatically shift the proportion of reconstructive techniques performed, but also attract patients from outside the institution and state. This shift in referral patterns further emphasizes the role of breast reconstruction within a regional referral center.