Our SSM and LD IBR without a prosthetic implant achieved a high level of patient satisfaction along with low complication rates. The procedure was safe, and none of our patients developed local recurrence.
SSM has been demonstrated as an oncologically safe procedure in patients with early stage breast cancer [10, 11], and in selected patients with locally advanced breast cancer [5, 12, 13]. Local recurrence rate after SSM was reported as 3 to 12% . Although concerns regarding local control and appropriate indications were raised , the available data do not support an increase in the risk of local recurrence with SSM when an accurate surgical dissection is performed [3, 5, 6]; and recently, in a meta-analysis of nine studies comprising 3,739 patients , no significant difference in local recurrence was noted between 1,104 patients with SSM and IBR, and 2,635 patients with conventional mastectomies without reconstruction. Most of our series included patients with early-stage breast cancer, and only one patient (1.5%) had locally advanced breast cancer. The local recurrence rate after a mean follow-up period of 34 months was 0%. Only one patient (1.5%) with initial stage IIA breast cancer developed an axillary metastasis and this occurred 84 months after operation. The patient received docetaxel and doxorubicin-based chemotherapy followed by radiation therapy, and remained safe without any evidence of disease progression at current follow-up.
Post-operative complications could compromise the aesthetic outcomes as well as the patient satisfaction. A recognized complication after SSM is skin flap necrosis reported to occur in 11% . However, there was no case of skin flap necrosis or flap loss in our series. Accurate dissection of the superficial layer of the superficial fascia could have contributed to the enhanced surgical outcomes.
IBR after SSM has a virtue of producing pleasing aesthetic results. Since the breast skin is maximally preserved, IBR using the native skin envelope could be performed to achieve an optimal aesthetic result through a single-stage procedure. IBR can reduce the need for a contralateral balancing procedure to achieve breast symmetry [3, 16]. Likewise, only three patients (4.6%) in our series received a contralateral balancing procedure. Alongside the superior aesthetic outcomes, IBR showed reduced psychological trauma to the patient, convenience of the operation, cost benefit, and patient safety .
Furthermore, IBR was reported to be oncologically safe [3–8], and not to result in delay or interference with the initiation of adjuvant chemotherapy . A study of 166 patients by Caffo et al. reported no marked increase in the rate of surgical complications due to adjuvant chemotherapy. Also in our series, none of the patients had to delay adjuvant chemotherapy after LD IBR.
Autologous LD myocutaneous flap has become a popular option for breast reconstruction since its introduction in the late 1970s [20, 21]. Almost any patient could be a potential candidate for LD flap due to its robust blood supply [22, 23], and ischemic complications after LD flap reconstruction are lower compared to other types of autologous flap reconstruction. Moreover, LD flap has produced a high level of patient satisfaction in a wide range of breast operations, from quadrantectomy to SSM or nipple-sparing mastectomy [24–26].
Rosson and colleagues  identified patients with small to moderately-sized breasts, inadequate amounts of abdominal tissue, or a history of previous abdominal surgery as ideal candidates for LD flap reconstruction. For most Korean women with a low to normal body mass index and small to moderately-sized breasts, LD flap could provide sufficient volume for breast reconstruction. And since a high proportion of Korean breast cancer patients are at child-bearing age , LD flap is an attractive option for Korean breast cancer patients.
A drawback of LD flap reconstruction is frequent formation of seroma at LD donor site, reported as 12 to 21% [29, 30]. Dorsal seroma was managed with a prolonged suction drainage or repeated percutaneous aspiration at the outpatient clinic. Dorsal seroma occurred in eight patients (12.3%) in our series, which was lower than other reports. The lower morbidity rate, however, was not significantly related to higher patient satisfaction.
PRO of breast reconstruction has become increasingly important in clinical research. Although traditional surgical outcomes focused on morbidity and mortality as important measure, they are no longer sufficient on their own. Patient satisfaction and quality of life has become a crucial concern. In the present study, 50 patients (76.9%) were satisfied (good and excellent) with the surgical outcomes, and 40% reported their degree of satisfaction as excellent (score 9 to 10), demonstrating SSM and LD IBR without an implant could produce sufficiently satisfactory results. However, contrary to our expectations, the type of skin incision, breast contour, and donor site scar length did not significantly contribute to excellent patient satisfaction. The breast size symmetry (P <0.001), visual difference of bilateral breasts (P = 0.021), and the nipple cosmesis (P <0.001) related to the highest patient satisfaction, and 53.8% of patients who did not report their degree of satisfaction as excellent, cited asymmetry as one of the main reasons. Studies [24, 31, 32] suggested that achievement of breast symmetry was the main factor for patient aesthetic satisfaction after breast reconstruction. We fully agree and again have confirmed the importance of achieving breast symmetry in our series.
Thirty-five patients (53.8%) did not receive nipple reconstruction. The reasons for not doing nipple reconstruction were: fear of the second operation (n = 16, 45.7%); lack of necessity of the nipple (n = 7, 20%); premature time for nipple reconstruction (n = 8, 22.8%); and others (n = 4, 11.4%). Nipple cosmesis was the factor that significantly related to the highest patient satisfaction (P <0.001). Taken together, these results suggest that immediate nipple reconstruction at the time of IBR could be another potential factor that possibly enhances patient satisfaction.
Assessment by the surgeon (P <0.001) and the breast clinic nurse (P <0.001) were factors affecting the highest patient satisfaction, and the average score among the three groups (surgeon, breast clinic nurse, and patient) showed similar results (7.7, 7.9, and 7.6). The assessment between surgeon and breast clinic nurse showed a significant correlation (0.917, P <0.001), however, each of them did not accord with the degree of patient satisfaction (Figure 3). The authors could not identify confounding factors to explain the reason. Probably, minor discrepancies could have existed between patient’s subjective satisfaction and objective assessment by a third party assessor. Because expression of patient satisfaction is related both to the patient’s expectation and the surgical outcomes after breast reconstruction, patient-reported satisfaction could not be fully explained by only considering objective assessment measures made by others.
A limitation of the study was the assessment of patient satisfaction regarding surgical and aesthetic outcomes, which was measured only by an analogue scale, and hence the measure used to assess patient quality of life was insufficient. A structured questionnaire including subscales and long term satisfaction might be needed to more objectively assess patient satisfaction. It is also acknowledged that this study is limited by its small sample size and retrospective study design. Also, we believe that a uniform period of assessment after operation, and serial long term follow-up of patient satisfaction data will be able to provide more reliable results. The results of this study, however, highlight low rates of surgical complication as well as high degree of patient satisfaction following SSM and LD IBR without a prosthetic implant. Larger standardized measures focusing on improving PRO as related to aesthetic outcomes are needed in the future.