Flap-based breast reconstruction: clinical studies on donor sites, patient satisfaction, and health economics

Abstract

Background: Breast cancer is the most common cancer in women. Surgical treatment involves resection of a portion or the whole breast. There are multiple ways to reconstruct a breast, most commonly with implants or transfer of tissue from adjacent or distant parts of the body. This type of tissue transfer is called a flap, and it entails a donor site that might have postoperative concerns, so called donor site morbidity Comparisons between methods in terms of patient-reported outcome measurements and cost-effectiveness can provide more information and aid in the choice of reconstructive method. Aim: The aims of this thesis were to compare the outcomes in terms of donor-site satisfaction and breast satisfaction after surgeries with latissimus dorsi (LD) flap and deep inferior epigastric artery perforator (DIEP) flap, measured with validated questionnaires, as well as to compare cost-effectiveness in DIEP flap and implant-based reconstruction. Method: Patients reconstructed with an LD flap or DIEP flap during the years 2007-2017 were identified and invited to the study. Included patients were sent questionnaires in the form of the BREAST-Q reconstruction module and the WOOS. A systematic review was performed on studies comparing DIEP flap with implant-based reconstruction in terms of cost-effectiveness. Results: The response rate was 75 % in the LD group and 60 % in the DIEP group. Paper I showed greater functional satisfaction of the donor site in the DIEP group whereas the esthetic satisfaction was higher in the LD group. Paper II showed greater satisfaction with the breast in the DIEP group. Paper III showed a worse function in the shoulder following LD flap surgery as compared to a control group consisting of DIEP flap patients. Paper IV included 7 articles in the systematic review, which showed that DIEP flap may be cost-effective when compared to implant-based reconstruction in the long term, however the scientific evidence was low. Conclusion: The DIEP flap is superior to the LD flap in terms of breast satisfaction and functional satisfaction of the donor site, whereas the esthetic concerns of the donor site are lower following LD flap surgery. LD flap surgery is related to a lower function of the shoulder compared to DIEP flap surgery, the clinical implications of this is unclear. The results of the systematic review favored DIEP flap vs. implants in the long term with regards to cost-effectiveness, albeit with a low level of scientific certainty.