'The sooner the better' or 'too much too soon'? A pilot prospective longitudinal study to evaluate quality of life and body image following immediate latissimus dorsi breast reconstruction

Background

Immediate breast reconstruction (BR) is currently advocated by the National Institute of Clinical Excellence on the basis of improved psychosocial outcomes with benefit of a single operative intervention. Tissue-based procedures are largely preferred due to cosmetic superiority, particularly in the context of postoperative radiotherapy (RT). The impact of this approach on quality of life (QoL), however, has never been fully evaluated. We present a pilot prospective longitudinal study that questions this practice.

Methods

Patients undergoing immediate latissimus dorsi (LD) BR, the most commonly offered reconstructive procedure in the UK, completed validated QoL questionnaires (EORTC C30+BR23/FACT B+4) together with the Body Image Scale preoperatively and at 3 months, 6 months, 12 months and 24 months post surgery. QoL and body image were compared in women undergoing extended (ELD) and implant-assisted (LDI) procedures ± postoperative RT.

Results

Sixty-two women underwent 46 (74%) implant-assisted and 16 (26%) extended LD BR with RT in 13 (28%) and seven (44%) cases, respectively. One hundred and ninety-four questionnaires were completed with a median follow-up of 6 months (range 3–24 months). The QoL in all groups declined initially before improving, with patients undergoing implant-assisted procedures reporting a more rapid return to baseline levels of QoL than those in the extended group (Figure 1). Body image was superior in the extended group when compared with LDIs at 12 months, but QoL was comparable (Figure 2). Irradiation of ELD but not LDI reconstructions produced dramatic and persistent deteriorations in both QoL and body image.

Figure 1

Variation in Global EORTC scores with time.

Figure 2

Variation in body image scores with time.

Conclusion

Body image is superior following tissue-based reconstruction, but this difference is not reflected by superior QoL. Combining ELD with RT, however, has a profound effect on both body image and QoL. Surgeons should consider patientreported outcomes as well as cosmesis when recommending surgical options.