For women with early-stage breast cancer, breast-conserving therapy (BCT), including radiation therapy (RT), leads to progressive reduction in breast size over time, reports a study in the April issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons. 

“Our findings suggest that women undergoing BCT/RT may lose approximately 20% of breast volume within a year, with continued reductions through five years,” says Chris Reid, MD, of University of California San Diego, in a release. “Anticipating these changes may help guide patient expectations and assist surgical planning to restore women after breast cancer treatment.”

New Data on Changes in Breast Size after BCT for Early Breast Cancer

BTC—consisting of limited surgery (lumpectomy) and RT—is the preferred treatment for many women with early-stage breast cancer. It offers survival rates similar to those of mastectomy, with more favorable physical, psychological, and quality of life outcomes.

However, RT has adverse effects on breast tissue, including breast shrinkage due to radiation-induced tissue atrophy and fibrosis. While this long-term side effect is well-recognized, there are few data on the extent or time course of breast volume loss after BCT.

Reid and colleagues measured changes in breast volume in 113 patients who underwent BCT/RT for early-stage (T1) breast cancer between 2005 and 2023. Measurements were made using mammograms obtained before and after BCT and up to five years later. The researchers also examined the impact of initial breast size and other factors on volume loss.

Reflecting the size of the tumor, breast volume decreased by an average of 9.2% after lumpectomy. Breast volume continued to decrease over time, even after the immediate side effects of radiation resolved. After one year, the average decline in breast volume was 19.3%, in addition to the tissue removed at surgery.

Implications for Patient Expectations and Treatment Planning

“Additional volume change was observed yearly for five years,” the researchers write. By that time, the average decrease in breast size was 26.6%. Consistent with previous studies of breast shrinkage following BCT, “progressive volume loss was seen in all patients.”

Women with larger breasts and relatively smaller tumor volumes (measuring less than 10% of breast volume) had greater total breast shrinkage: 29.5%, compared to 21.7% for those with smaller breasts. Other factors associated with greater volume loss included smoking, diabetes, and receiving cytotoxic chemotherapy in addition to RT.

The study provides new evidence on breast shrinkage after BCT. Expected breast shrinkage is approximately 20% within the first year, progressing to about 26% by five years. Especially with the growing emphasis on patient satisfaction in evaluating the outcomes of breast cancer treatment, the findings highlight the need to discuss long-term changes in breast volume in patients receiving undergoing BCT/RT.

The greater volume loss in patients with larger breasts raises concerns about breast asymmetry—which is a common concern after BCT. “Anticipating these changes may help guide patient expectations and assist surgeons in planning reconstructive procedures to attain symmetry post-treatment,” Reid says in a release. 

The authors discuss key areas for further research, including the effects of different treatment techniques on breast volume changes and the need for more objective approaches to measuring breast volume.

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Related Read:

For patients undergoing nerve transfer surgery for facial palsy, Botox injections can improve facial symmetry by reducing overactivity of the muscles on the unaffected side, suggests a study in the March issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons. 

The added benefit of Botox reflects modifications in brain functional network connectivity, according to the new research, led by Ye-Chen Lu, MD, PhD, and Wei Wang, MD, PhD, of Shanghai Jiao Tong University School of Medicine, China. They write, “These findings imply that enhanced connectivity between brain functional networks play a vital role in the recovery process from neurological disorders.”

BoNT-A Improves Outcomes of Surgery for Facial Palsy

Facial nerve injury can cause paralysis on the affected side of the face, leading to functional and cosmetic impairments. For patients with this condition, nerve transfer surgery is recommended to restore facial nerve function and symmetry.

However, many patients have persistent impairment after surgery, especially drooping of the corner of the mouth (oral commissure) on the affected side. This condition has been linked to overactivity of the muscles on the opposite side, leading to facial asymmetry even at rest.

Such patients have been successfully treated using botulinum toxin-A (BoNT-A; best known by the brand name Botox) to produce temporary relaxation of overactive muscles on the unaffected side. Previous studies suggest lasting improvement, even after the effects of BoNT-A fade.

Benefits Linked to Changes in Brain Network Connectivity

“We hypothesize that BoNT-A treatment triggers extensive cortical plasticity, offering a potential explanation for its long-lasting therapeutic impact on patients with facial asymmetry,” the researchers write. 

They used functional magnetic resonance imaging (fMRI) scans to assess functional activity of brain networks before and after surgery and BoNT-A treatment.

The study included 38 patients with facial palsy and “severe oral commissure drooping” after surgery for benign tumors (acoustic neuromas). All underwent nerve transfer surgery followed by facial training and rehabilitation. In addition, patients were randomly assigned to a treatment group receiving a series of BoNT-A injections of the facial muscles on the unaffected side or a control group receiving no BoNT-A.

Patients receiving BoNT-A had significant improvement in facial asymmetry. “BoNT-A injections improved facial static function without affecting smile function,” the researchers write. As in previous studies, the benefits persisted beyond six months, after the effects of BoNT-A wore off.

Before surgery and one year later, patients underwent fMRI scans to assess changes in in brain functional network connectivity. Of nine resting state networks (RSNs) studied, five showed “significant differences of spatial distribution” between groups. Patients receiving BoNT-A “displayed an overall stronger interaction between several RSNs” – notably including the sensorimotor and visual networks.

“Our research provides evidence of long-term and widespread changes in cerebral networks among facial paralysis patients,” Lu and Wang and coauthors write. These effects may explain why the improvement persists even after the effects of BoNT-A dissipate.

BoNT-A injections “may create a “window of time for nerve reanimation, allowing the brain to learn and restore proper facial muscle activity.” The researchers conclude, “These findings imply that enhanced connectivity between brain functional networks play a vital role in the recovery process from neurological disorders.”

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Xironetic announced the publication of data from a recent study evaluating the potential benefits of augmented reality (AR) guidance with Xironetic’s IntraOpVSP system in patients undergoing craniofacial surgery. 

The results of the study were published in FACE, founded by the American Society of Maxillofacial Surgeons and the American Society of Craniofacial Surgeons. IntraOpVSP is a US Food and Drug Administration (FDA)-cleared system for AR guidance that provides three-dimensional patient imaging data to the surgeon during surgery. 

Study Methodology and Results

In a retrospective cohort study, the amount of blood loss was compared between patients who received AR guidance in their surgery (n = 17) and patients who did not (n = 62). Analysis of calculated blood loss data from these cohorts indicated that AR guidance provided statistically significant blood loss reduction as measured by estimated red cell volume (ERCV), with an ERCV of 43.7% for the cohort with AR guidance and an ERCV of 61.9% for the cohort without (p < 0.05). 

Additional benefits reported in the study were reduced sinus proximity bleeding, reduced dural injuries, and reduced transfusion volumes.

“We are able to navigate around the multitude of blood vessels in the craniofacial area because we can visualize them more intuitively,” says Christian El-Amm, MD, chief of pediatric plastic surgery at Oklahoma Children’s Hospital, in a release. “Our patients suffered less blood loss, and there was a trend towards fewer blood units transfused and less donor exposure. Larger multicenter studies are now underway to confirm and explore potential benefits towards patient safety.”

The results from the study suggest that AR can increase surgical safety through reduced blood loss and sinus proximity bleeding during a craniotomy, promoting improved patient outcomes. Additional investigations are underway to confirm these results and further evaluate the benefits of AR guidance in craniofacial surgery.

Summary:

Xironetic announced new study findings demonstrating that its IntraOpVSP augmented reality (AR) system significantly reduces blood loss in craniofacial surgery. The retrospective cohort study, published in FACE, compared 17 patients who received AR-guided surgery to 62 who did not, showing a statistically significant reduction in estimated red cell volume (ERCV) loss—from 61.9% to 43.7% (p < 0.05). The study also reported less sinus proximity bleeding, fewer dural injuries, and reduced transfusion volumes in patients who underwent AR-assisted procedures. Researchers suggest that AR visualization allows surgeons to navigate complex vascular structures more intuitively, improving patient safety and outcomes. Larger multicenter studies are now underway to further evaluate these benefits.

Key Takeaways:

• AR Guidance Reduced Blood Loss – Patients who underwent AR-guided craniofacial surgery had a significant decrease in estimated red cell volume loss (61.9% to 43.7%).
• Additional Benefits Observed – The study reported less sinus proximity bleeding, fewer dural injuries, and reduced transfusion volumes in AR-assisted procedures.
• Further Research Underway – Larger multicenter studies are being conducted to confirm AR’s role in improving surgical safety and patient outcomes.

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Summary:

Surgeons at Rutgers New Jersey Medical School and University Hospital are the first in New Jersey to perform robotic-assisted breast reconstruction, offering a less invasive alternative to traditional surgery. The technique, used in latissimus dorsi flap reconstruction, allows surgeons to access back muscles through a small underarm incision rather than a large back incision, reducing scarring and recovery time. The team is evaluating the approach’s broader applications in reconstructive surgery and plans to publish their findings.

Key Takeaways:

1. Robotic-assisted breast reconstruction debuts in New Jersey. Rutgers surgeons are the first in the state to use robotics for latissimus dorsi flap reconstruction, potentially improving patient recovery and outcomes.
2. Minimally invasive technique reduces scarring and recovery time. The robotic approach replaces a large back incision with a small cut under the arm, limiting tissue damage and expediting healing.
3. Surgeons see potential for broader reconstructive applications. The team is exploring robotics for other procedures, including abdominal flaps and thigh muscle harvests, and plans to track patient outcomes for future study.

Two surgeons at Rutgers New Jersey Medical School and University Hospital are the first in the state to use robotics in breast reconstruction after cancer treatment. Surgery with the robot is less invasive than traditional surgery, so patients typically heal faster and have smaller scars.

Edward Lee, MD, a plastic surgeon, and Danbee Kim, MD, a robotic surgeon, are the first to perform the procedure in New Jersey, and they believe it will significantly improve patient outcomes. More importantly, they think it demonstrates that robotic machines may soon improve many other reconstructive surgeries.

“This is just the beginning,” says Lee, a division chief who also directs the school’s plastic surgery residency training program, in a release. “We’re exploring ways to use the robot for thigh muscle harvests, abdominal flaps, and more. The potential to improve outcomes across reconstructive procedures is enormous.”

A Less Invasive Approach to Breast Reconstruction

The pair, who perform the procedures at University Hospital in Newark, began with the breast surgery, known as a latissimus dorsi flap reconstruction, several months ago. The procedure removes muscles from the patient’s upper back to help replace tissue lost to mastectomy.

This type of reconstructive surgery has traditionally required a long incision stretching halfway across the back that takes months to heal and leaves a large scar. The surgical robot allows them to cut under the patient’s armpit and access the back muscle without any incision on the back. This technique does less damage, so patients heal faster and with less scarring.

“The robot has four arms, one for a camera and three more you can manipulate to operate. If you’ve ever hung a painting, you’ll know how nice it would be to have a third arm,” Kim says in a release.

The extra arms also reduce the need for surgical support staff who typically hold cameras, retractors, and other surgical tools, so robotic surgery could potentially cut medical costs going forward.

“And the robot camera’s high-definition allows us to better identify tissue and perform more precise surgeries than in traditional surgery,” Kim says in a release.

Expanding the Role of Robotics in Surgery

Breast reconstruction alone is a significant potential use case for robotic surgery. Surgeons in the US perform more than 100,000 reconstructions every year after cancer treatment. Latissimus dorsi flap surgeries are only one of many techniques for reconstructing breast tissue, but they are a common procedure for patients who will receive radiotherapy after cancer removal.

“Radiation cooks the skin and tissue, making it shrivel and tighten,” Lee says in a release. “Adding an extra layer of soft tissue to the surgery site provides more padding to the implant that provides most of the volume in the reconstruction.”

The robot-assisted surgery initially took longer than traditional surgery, but Lee and Kim have seen operative times decrease with experience. Other surgeons using the robot for other surgeries like prostate removal, colon cancer, and other surgeries see a similar learning curve.

“We’re building on the innovative work of our international colleagues,” says Kim, who trained in South Korea. “Our goal is to refine the technique, expand its applications, and make it more widely available to patients who can benefit from it.”

Training and the Future of Robotic Surgery

Robotic surgeries were slow to catch on—the surgical robot from Da Vinci, which dominates the US market, appeared in 2000 but was used in less than 1% of surgeries a decade later—but their popularity has exploded in recent years. Robotic surgery now accounts for 22% of all US surgeries, with its application to different types of surgeries rapidly expanding.

Ultimately, robotic surgery may replace human surgeons, at least in part. A new presentation from Johns Hopkins showed that AI-equipped surgery robots could learn to do some surgical procedures automatically after watching surgeons perform.

Even now, existing robots may enhance productivity by reducing the physical demands of surgery. Unlike traditional procedures, which force surgeons to stand for hours, robotic surgery can be performed from the comfort of a chair.

The robot’s control panels typically sit in the operating room but can be anywhere with an internet connection. At least one patient needing a rare procedure has already undergone surgery from an expert half a world away.

The robotic technique also helps experienced surgeons train students and residents. The system features dual consoles, allowing a teacher to guide a resident through the procedure in real time.

“There are actually two consoles, one that the surgeon uses and a duplicate in a different area of the room,” Kim says in a release. “This lets your residents or anyone else you’re training sit in the same position and see exactly what the surgeon sees. If you need a second qualified surgeon, they can also work on the robot simultaneously.

“At the end of every case, the robot sends information to the apps on our phones that track all the time spent by the student, the teaching surgeon, and how many moves each one made. That information helps you gradually give trainees more autonomy and track our progress so that we can constantly improve our techniques.”

Assessing Long-Term Impact and Limitations

As with any new surgical technique, questions remain about long-term outcomes and cost-effectiveness. The Rutgers team is studying their results and plans to publish their findings to contribute to the growing evidence surrounding robotic reconstruction.

“We’re carefully tracking our outcomes and plan to publish a case series once we have more data,” says Kim in a release. “It’s crucial that we demonstrate not just the feasibility of this approach, but its long-term benefits for patients.”

While the robotic technique shows promise, both surgeons emphasize that it’s not appropriate for every patient. For example, the robot’s ability to cut less skin provides no advantage in procedures where surgeons must transfer a significant amount of skin to the repair site.

Careful patient selection and thorough discussion of all reconstructive options remain important factors in the decision-making process.

“In the end, it’s all about providing our patients with the best possible results and experience,” says Lee in a release. “If we can achieve that with smaller scars and faster recoveries, that’s a win for everyone involved.”

Photo caption: Surgeons Edward Lee and Danbee Kim use this surgical robot to speed healing and minimize scarring from breast reconstruction.

Photo credit: Jeff Arban/Rutgers

Key Takeaways

• Increased Complications: Older age correlates with a higher risk of complications such as infection, skin flap necrosis, and seroma formation.
• Lower Satisfaction with Breast Appearance: Older patients report decreased satisfaction regarding the natural appearance and fit of their reconstructed breasts.
• Enhanced Psychosocial Well-being: Despite physical complications, older women often experience better psychological adjustment and body image confidence post-reconstruction compared to younger patients.

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For women undergoing breast reconstruction after mastectomy, older age is associated with small but significant increases in certain complications, reports a study in the January issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Older women may be less satisfied with the appearance of the reconstructed breasts but may have better psychologic adjustment after breast reconstruction compared to younger patients, according to the new research by Jonas A. Nelson, MD, MPH, and colleagues of Memorial Sloan Kettering Cancer Center in New York. “These findings clarify how age affects the outcomes of breast reconstruction, which may help in minimizing the risks and maximizing the benefits for older women considering reconstructive surgery after mastectomy,” Nelson comments.

Increased Complications of Breast Reconstruction in Older Women

Breast reconstruction has important benefits for women undergoing mastectomy for treatment of breast cancer. Previous studies have suggested that age “should not be a deterring factor” to post-mastectomy breast reconstruction (PMBR), but the true impact of age on patient outcomes remains unclear. While about one-half of patients undergo breast reconstruction after mastectomy, only about 6% are older than 60 years.

Toward “a more thorough and rigorous assessment” of how age affects breast reconstruction outcomes, Nelson and colleagues analyzed 4,730 patients who underwent PMBR at the authors’ cancer center between 2017 and 2022. After adjustment for other factors, older patients were at higher risk of three types of complications: infection, breakdown (necrosis) of the skin flap used for reconstruction, and fluid buildup (seroma) under the wound.

For all three complications, risk increased slightly per year of age. For every 10-year increase in age, infection risk increased by 10% while skin necrosis and seroma risk increased by 20%.

Age Variably Affects Patient-Reported Outcomes of PMBR

The study also looked at how age affected patient satisfaction and quality-of-life outcomes, assessed using the validated BREAST-Q questionnaire. Older age was associated with lower scores in satisfaction with the breasts, such as the natural appearance of the breasts and clothing fit.

In contrast, older age was linked to higher scores for psychosocial well-being, addressing factors such as body image and confidence in social settings. The researchers suggest that older patients may have fewer concerns about factors such as their career and finances, and a more “matter-of-fact” attitude toward aging and their cancer diagnosis. Age was unrelated to physical well-being related to the chest, such as pain or activity limitations, or to sexual well-being.

Subgroup analyses suggested some differences in complications and patient-reported outcomes for women undergoing implant-based reconstruction versus autologous reconstruction using the patients’ own tissues. There were also differences in outcomes for older women who had other health conditions associated with frailty.

“Our findings suggest that age should be considered alongside other factors when determining whether an older patient is a suitable candidate for breast reconstruction,” Nelson says. The increased complication rates associated with older age may reflect risk factors such as high blood pressure and diabetes. The researchers suggest that optimized care for these conditions might help to reduce the risk of complications.

The study also provides insights into age-related differences in patient-reported outcomes—viewed as an important factor in assessing the benefits versus risks of breast reconstruction. “This comprehensive analysis may also help to maximize postoperative physical functioning and patient satisfaction among older women who opt for PMBR,” Nelson adds.

Plastic Surgery Practice: What was the driving force behind developing the MemoryGel Enhance Breast Implants, particularly the focus on larger volume options?

Alenka Brzulja: Simply put, an unmet patient need. The development of MemoryGel Enhance reflects our unwavering commitment to meaningful innovation, bringing a product to market that addresses the diverse needs of breast reconstruction patients. For years, women with larger cup sizes undergoing breast reconstruction had limited options, as the largest implant available was 800cc—an option that didn’t meet the needs for all body types or reconstruction goals.

MemoryGel Enhance was specifically designed to bridge this gap by offering a line of implants that were larger than 800cc, providing a critical solution for women needing greater volume restoration after a mastectomy. Larger volume implants are essential for delivering the proportional outcomes these patients deserve. We want to support women at every stage of their journey by continually pushing the boundaries of what’s possible in breast aesthetics and reconstruction.

PSP: How do the new implant sizes align with the unmet needs of patients and surgeons in breast reconstruction post-mastectomy?

Brzulja: Breast reconstruction is an inherently personal journey, with every patient bringing her unique anatomy, preferences, and goals. With over 150,000 women in the U.S. undergoing breast reconstruction annually, the demand for diverse solutions continues to grow.

This FDA approval marks a significant advancement in breast reconstruction options for women with larger cup sizes and a step toward equitable healthcare, ensuring that all women, regardless of body size or racial background, have access to high-quality reconstruction options. Minority women, particularly those with higher BMIs or larger body frames, face significant barriers to accessing appropriate breast reconstruction options, including the availability of larger implants. The lack of suitable implant options means many of these women either forego reconstruction or receive suboptimal results, leading to significant disparities in post-mastectomy care.

PSP: Could you elaborate on the insights gained from the ATHENA study and how they influenced the development and approval process for these implants?

Brzulja: The ATHENA study has been pivotal in shaping our understanding of patient outcomes in breast reconstruction. This prospective, multicenter, ongoing 10-year study has enrolled 400 women who underwent primary or revision reconstruction, providing us with invaluable data on safety, effectiveness, and patient satisfaction with these larger-volume implants. The FDA approval was supported by three-year data, which demonstrated that MemoryGel Enhance larger-volume silicone breast implants are safe, effective, and a viable option for patients with larger breasts who request postmastectomy, implant-based reconstruction.

Introducing MemoryGel Enhance to the market underscores the importance of incorporating feedback from patients and surgeons and leveraging real-world insights to deliver solutions that address their needs. By prioritizing inclusivity and meaningful innovation, we aim to support comprehensive care and ensure all breast reconstruction patients, regardless of race or body type, have access to the highest standard of care.

PSP: How does Mentor plan to address the concerns and considerations of patients and surgeons regarding the safety of larger implants?

Brzulja: Nothing is more important to us than the health and safety of the patients who choose our products. We adhere to the highest standards of safety. Every product we make undergoes rigorous testing, and the process never stops. MemoryGel™ Enhance Implants have been thoroughly tested and are backed by robust clinical data from the ATHENA study. For larger implants, we’ve incorporated advanced materials and engineering techniques to ensure structural integrity and durability while maintaining a natural feel.

Additionally, we prioritize education and transparency, providing surgeons with comprehensive resources and training to support informed decision-making. This ensures patient safety and well-being remain a top priority throughout the process. We’re proud of the long-standing safety of our implants and the respect we’ve earned from the breast aesthetics community worldwide for our high standards and leadership.

PSP: What steps is Mentor taking to ensure surgeons are equipped to use these new implants effectively, considering their unique size and features?

Brzulja: We understand how crucial it is for plastic surgeons to be fully equipped and familiar with our new implants, particularly given their unique sizes and features. To that end, we have implemented several robust initiatives to ensure surgeons are prepared to use our products safely and effectively:

• Required Device Training: Before placing an order for MemoryGel™ Enhance products, surgeons must complete comprehensive device training. This ensures they are knowledgeable about the specific features and functionalities of the implants.
• Peer-to-Peer Training from ATHENA Study Surgeons: We leverage the expertise of surgeons from the ATHENA study to provide valuable insights and guidance. These peer-to-peer training opportunities allow surgeons to learn from their colleagues’ experiences and techniques.
• HCP Surgical Pearls and Best Practices: We provide healthcare professionals with a collection of surgical pearls and best practices that highlight effective techniques and considerations specific to our implants.
• Surgical Videos and Commentary: To further support learning, we offer surgical videos showcasing real procedures with commentary from expert surgeons. These videos provide practical tips and insights to enhance surgical outcomes.
• Product Catalog with Dimensions: Our comprehensive product catalog includes detailed dimensions for each implant, serving as a resource for surgeons to make decisions that best suit their patients’ unique anatomies.

Through these professional education initiatives, we are committed to equipping surgeons with the knowledge and confidence to use MemoryGel Enhance Implants successfully. We believe continuous education and support are essential to achieving the highest standards of patient care and surgical excellence.

PSP: What are the anticipated challenges in launching these implants in the U.S. market in mid-2025, and how is Mentor preparing to address them?

Brzulja: Bringing innovative products like MemoryGel Enhance to market involves ensuring seamless manufacturing, distribution, and preparation to meet demand. Our manufacturing teams are ramping up production to ensure a reliable supply and timely delivery in mid-2025. Equally important is supporting surgeons through education and training to ensure they have the tools and knowledge to use our new MemoryGel™ Enhance Implants successfully.

PSP: How does this innovation fit into Mentor’s broader strategy for advancing breast aesthetics and reconstruction within Johnson & Johnson MedTech?

Brzulja: The launch of MemoryGel Enhance Breast Implants represents a pivotal step in our mission to shape the future of breast aesthetics and reconstruction, while exemplifying Johnson & Johnson MedTech’s purpose to transform medical intervention. Together, we are dedicated to driving breakthrough innovation that addresses unmet needs, reimagines health, and empowers everyone to live their best life. This innovation highlights our commitment to delivering smarter, more personalized solutions that improve patient outcomes, elevate surgical possibilities, and transform care for women worldwide with unique reconstruction needs.

Key Takeaways

• Preference-Driven Choices: Factors like age, health concerns, safety of breast implants, and trends toward alternative options (e.g., “aesthetic flat closures”) contribute to stabilized rates, emphasizing the need to understand patient preferences and address barriers to equitable care.
• Stabilization of Breast Reconstruction Rates: Rates of immediate breast reconstruction after mastectomy increased until 2012 but have since stabilized, with nearly one-third of patients undergoing reconstruction during the study period.
• Reduction in Disparities: Disparities in breast reconstruction rates based on race and insurance have decreased, with higher rates observed among Black, Asian/Pacific Islander, and Native American patients, and increased access for patients with public insurance.

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The percentage of patients opting for breast reconstruction after mastectomy has leveled off in recent years, reports a study in the December issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“Our analysis of US national databases shows that rates of immediate breast reconstruction have stabilized over the past decade,” says Jonas A. Nelson, MD, MPH, of Memorial Sloan Kettering Cancer Center in New York City. “In addition, previously documented disparities based on race and insurance also appear to have decreased—albeit slowly—with a more equitable distribution of postmastectomy breast reconstruction.”

Changing Trends in National Breast Reconstruction

For women undergoing mastectomy for treatment of breast cancer, breast reconstruction has important benefits, including improvement in body image and sexual functioning. Under the Women’s Health and Cancer Rights Act (WHCRA), insurance payer coverage for breast reconstruction has been mandated in the United States since 1998.

Subsequent studies have reported rising rates of immediate breast reconstruction after mastectomy from 1998 to 2014. Those studies have also found disparities in breast reconstruction linked to patient factors, including age, race, income, and insurance status.

To assess more recent trends, Nelson and colleagues analyzed data on more than 1.5 million patients undergoing mastectomy for breast cancer from 2005 through 2017, based on three national databases. In addition to changes in breast reconstruction rates, factors associated with reconstruction choices were analyzed.

During the study period, nearly one-third of patients (32.7%) underwent immediate breast reconstruction after mastectomy. In all data sources, reconstruction rates increased each year from 2005 to 2012. However, reconstruction rates stabilized in subsequent years, with little or no change from 2013 to 2017.

Decreases in Breast Reconstruction Disparities

At all times, most patients undergoing immediate breast reconstruction were white. However, the proportion of mastectomy patients opting for breast reconstruction decreased among white women while increasing for Black, Asian/Pacific Islander, and Native American patients. After adjustment for other factors, Black and white patients had similar breast reconstruction rates.

Most patients undergoing breast reconstruction had private insurance. However, this proportion decreased over time: from 85% to 75.1%. Meanwhile, the proportion of breast reconstruction patients increased among those with public health insurance: from 3.3% to 6.6% for patients on Medicaid and 9.9% to 15.6% for those on Medicare.

The researchers discuss several possible explanations for the stabilization of breast reconstruction, including population-level increases in age and accompanying health problems (comorbidity). Other contributors may include patient concerns about the safety of breast implants and the trend toward less-intensive treatments such as breast conservation.

“An alternative explanation…is that we have simply reached market saturation for the number of women interested in pursuing breast reconstruction after mastectomy,” according to the authors. They also note the possible effect of “go flat” campaigns, with some women opting for “aesthetic flat closures” rather than breast reconstruction.

The findings highlight the “preference-sensitive” nature of breast reconstruction and the need for “a greater qualitative understanding of the reasons—whether by personal choice or due to limited access—why women do not undergo reconstruction after mastectomy.”

Nelson and coauthors conclude: “Work remains to be done to ensure that underrepresented groups in breast reconstruction receive timely and equal access to care.”

Key Takeaways

1. Non-white children are significantly more likely to face delays, complications, and prolonged hospital stays after cleft lip surgery compared to white children.
2. Disparities in cleft lip surgery outcomes are influenced by factors like underlying health conditions, income, and geographic location, rather than just race/ethnicity alone.
3. The study emphasizes the need for surgeons to advocate for policies that promote equity in pediatric care, addressing both medical and socioeconomic disparities.

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Children of non-white racial/ethnic backgrounds experience significant disparities in access to and outcomes of surgery to repair cleft lip, reports a study in the November issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“Our data show that non-White children with cleft lip are substantially more likely to experience delays, complications and prolonged hospital stays than White children,” comments ASPS Member Surgeon Derek Steinbacher, DMD, MD, of West River Surgery Center in Guilford, Conn. “Importantly, our analyses also provide key insights as to why such disparities may exist in a historically safe and routine procedure.”

Discrepancies in Cleft Lip Surgery

Surgery to repair cleft lip and/or palate is performed to restore form and function in children with these common congenital malformations. In a previous study, Steinbacher’s group reported disparities in cleft palate care. The new study builds on those findings by assessing outcomes of cleft lip repair surgery in U.S. children of varied racial/ethnic backgrounds.

The analysis included 5,927 children who underwent reconstructive surgery for cleft lip (without cleft palate repair) between 2006 and 2012. Data were drawn from the nationwide Kids’ Inpatient Database. About 63% of patients were white, 22% Hispanic, 5% Black, 5% Asian/Pacific Islander and 6% “other” race/ethnicity. Timing and outcomes of cleft lip repair surgery were compared among groups.

Data analyses demonstrated that non-white children were more likely to have delays to cleft lip surgery (after age six months)—between 23% and 29%, compared to just 8% for white children. Non-white children were also nearly twice as likely to experience complications following surgery, and more frequently had prolonged hospitalizations, although the rates of both complications and prolonged hospital stays were low.

Surgery Delays Tied to Health and Income

The researchers used several stepwise regression statistical models to adjust for the possible conflicting influence of many other medical and sociodemographic factors. While some differences by race/ethnicity persisted even after adjusting for these factors—such as delays in surgery among Hispanic and Asian children—most seemed to be more closely linked to other factors.

For example, having more underlying medical comorbidities was associated with significant delays in care, increased postoperative complications, prolonged hospital stays and increased costs. Other contributing factors included patient income status and location in the United States.

Like the previous study of cleft palate, the results show that non-white children with cleft lip are more likely to have delays in care, complications, and prolonged hospitalization, compared to white children. However, “differences in baseline health status may account for much of this disparity in combination with factors such as income, insurance type and location,” the researchers write.

“Taken together, these data suggest a significant but complicated relationship between patient race/ethnicity and outcomes in cleft lip repair,” Steinbacher and his coauthors conclude. “The findings highlight the critical role of surgeons as advocates for policies and structures that increase equity in all facets of pediatric care.”

Key Takeaways

1. BRA Day focuses on raising awareness of breast reconstruction options after mastectomy or lumpectomy, emphasizing education, events, and access to information to help women make informed decisions.
2. Breast reconstruction options vary from implants to alternatives like going flat, prostheses, or using the patient’s own tissue, and it can significantly improve psychological, social, and sexual well-being post-surgery.
3. The campaign highlights the importance of a team approach in breast cancer care, where specialists collaborate to ensure patients are informed about all reconstruction options, with fundraising efforts supporting research and grants for better outcomes.

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The American Society of Plastic Surgeons (ASPS) in partnership with The Plastic Surgery Foundation (PSF) announces the 13th annual Breast Reconstruction Awareness Day USA (BRA Day) on Wednesday, October 16.

Reconstruction Awareness

Breast cancer can be a devastating disease that affects 1 in 8 women in the United States. The choice to undergo breast reconstruction following mastectomy or lumpectomy is a personal one, and every woman should be aware of her options. BRA Day seeks to raise awareness about the full spectrum of breast reconstruction options available to patients and promote access to vital information through education, events, and fundraising activities.

The path forward for many women after being diagnosed with breast cancer can seem uncertain or overwhelming. Understanding available options for breast reconstruction is crucial to making informed decisions and ensuring a complete recovery. While many breast reconstruction patients opt for breast implants, a range of alternatives exist that include “going flat,” using a bra prosthesis or building new breasts using the patient’s own tissue.

Studies show breast reconstruction significantly improves patients’ quality of life by enhancing their psychological, social, and sexual well-being after breast cancer surgery. It is essential that patients receive accurate and comprehensive information to empower them to reclaim their bodies in a way that aligns with their personal goals. BRA Day is dedicated to increasing awareness and ensuring access to all reconstruction options, giving patients the knowledge and confidence to make choices that best suit their individual needs.

“Breast reconstruction is not just a medical procedure,” says Alan Matarasso, MD, president of The PSF. “It’s an integral part of the healing journey for many women after breast cancer. Our goal with BRA Day is to ensure that every woman is educated about her reconstructive options, so she can make the decision that is right for her body and her future. We want to give patients the resources they need to regain their confidence and sense of self by increasing awareness.”

Boosting Quality of Life After Cancer

BRA Day is a movement that seeks to reduce patient barriers to education and access to care. BRA Day events on October 16 across the country are designed to help close the information gap and ensure every woman is aware of her options. BRA Day efforts strive to inform patients, families, caregivers, and media that the breast cancer loop remains open until a woman is aware of all her breast reconstruction options.

Every patient deserves to learn about the full complement of breast reconstruction options at the time of diagnosis. In fact, the two main reasons women do not undergo breast reconstruction are because they are not referred to plastic surgeons and are not informed of their reconstructive options. Breast reconstruction is part of a comprehensive team approach and treatment for breast cancer patients.

Members of this team of specialists are plastic surgeons, oncologists, radiologists, general surgeons, breast surgeons, pathologists, radiation oncologists, geneticists, nurses, patient care coordinators, and more. Their collective insights guarantee that patients are not only aware of, but also have access to, a full range of reconstructive procedures, with decisions based on consensus among the team and ultimately the patient. Integral to this cohesive team approach are frequent meetings to discuss each patient and her individualized treatment plan.

“Every woman deserves the right to choose what happens to her body after breast cancer surgery and having access to information regarding the full complement of reconstructive options is the first step in that journey,” says Lynn Damitz, MD, ASPS’ board vice president of health policy and advocacy. “Through BRA Day we emphasize the importance of a team approach to care in which specialists collaborate with the patient, so they can make personalized, informed decisions. We must continue to advocate for better access and awareness, in addition to ensuring that every woman feels supported in her unique choice.”

Raising $120,000 for Reconstruction Research

Funds raised during BRA Day events support research and grants to improve breast reconstruction outcomes. In 2024, the BRA Campaign has raised approximately $120,000 thanks to the generous support of gold sponsor Allergan Aesthetics, an AbbVie company; Silver sponsor CareCredit; and bronze sponsor Integra Foundation along with many regional and local events. These contributions to the National BRA Fund support vital research, charitable giving, and awareness grants.

Fundraising continues throughout the month thanks to the CareCredit donation program. CareCredit will donate $1 to the Breast Reconstruction Awareness campaign every time a CareCredit cardholder purchases $200 or more on their card with an ASPS-member surgeon in the CareCredit network during October. Additionally, the Breast Reconstruction Awareness 5K, held in San Diego, during Plastic Surgery: The Meeting 2024, was another key event contributing to the cause.

ASPS and The PSF launched the Breast Reconstruction Awareness Campaign and the annual BRA Day USA in 2012. The inaugural BRA Day started in Canada in 2011. For more information on breast reconstruction, visit http://www.breastreconusa.org.

Key Takeaways

• An online patient decision aid (pDA) helps women with breast cancer make informed decisions about immediate breast reconstruction (IBR), improving their preparedness for discussions with plastic surgeons.
• The study showed that both the online pDA and standard informational leaflets reduced decisional conflict, with women using the pDA feeling more confident in their decision-making process.
• The pDA format is adaptable to future developments in breast reconstruction, providing tailored information based on patients’ personal situations and evolving scientific evidence.

For women with breast cancer undergoing mastectomy, an online decision aid can help in making informed decisions regarding immediate breast reconstruction (IBR), reports a randomized trial in the October issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“In our study, use of a patient decision aid helped women feel better prepared to discuss their options on whether or not to undergo IBR with the plastic surgeon,” comments Eveline M.A. Bleiker, PhD, of Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam.

Evidence-based Information on Reconstruction Options

For women with breast cancer undergoing mastectomy, breast reconstruction can improve psychosocial outcomes such as body image and sexual functioning. Among the complex decisions facing these patients is whether to undergo breast reconstruction immediately after mastectomy or later, or not to have reconstruction. Rates of IBR have increased in recent years, although considerable variations remain.

Patient decision aids (pDAs) are tools to support the process of shared decision-making between patients and doctors. Although pDAs have been shown to reduce decisional conflict for a range of treatment decisions, “there are limited interventions to support patient decision-making about breast reconstruction available, particularly when the healthcare context is considered,” the researchers write.

Bleiker and colleagues evaluated a newly developed pDA to support informed decision-making about IBR. The study included 250 patients with breast cancer scheduled for mastectomy at eight Dutch centers. Patients were randomly assigned to receive the online pDA or a standard informational leaflet.

The pDA provided evidence-based information on breast reconstruction options and support in clarifying patients’ personal values affecting their treatment decision. On completing the pDA, patients received a summary sheet including their breast reconstruction preferences.

Women Using pDA ‘Feel Better Prepared for Decision Making’

The two groups were compared on measures of decisional conflict—uncertainty about choosing between competing options—and other aspects of the decision-making process. Nearly all patients assigned to the pDA used the online tool; just over half discussed their summary sheet with the plastic surgeon.

With either the pDA or informational leaflet, decisional conflict decreased over time. In both groups, about 13% of patients had clinically significant decisional conflict.

Women assigned to the decision aid “reported feeling better prepared for decision making than those in the control group,” the researchers write. Other assessments were similar between groups, including shared decision-making and satisfaction with breast reconstruction information. Knowledge increased in both groups, with no difference in decision regret. With either source of information, about 70% of women opted for IBR.

“Our findings indicate that both the online pDA and the information leaflet are helpful for breast cancer patients having to make a decision about IBR,” Bleiker and coauthors write. They add: “The online format of the pDA more easily allows for adaptions required by future developments in breast reconstruction options and scientific evidence, and for the further tailoring of information to patients’ personal situation and information needs.”

Publication of the new study is timed to coincide with Breast Cancer Awareness Month and Breast Reconstruction Awareness Day. Celebrated October 16 this year, “BRA Day” is designed to educate women about post-cancer breast reconstruction options and outcomes—including the federal requirement for insurance coverage for breast reconstruction surgery. BRA Day events worldwide bring attention to the varied options and procedures available, plus give information to patients and their supporters so they can make informed decisions about their care.