Nearly 25% of breast cancer patients who start breast reconstruction after mastectomy don't complete the reconstructive process. The concept of reconstructive burnout is introduced and discussed in a study in the January issue of Plastic and Reconstructive Surgery.

Certain patient characteristics and complications are risk factors for developing reconstructive burnout, according to the report by ASPS Member Surgeons Nicholas T. Haddock, MD and Sumeet S. Teotia, MD, and colleagues of the University of Texas Southwestern Medical Center, Dallas. They write, "It is critical to tailor each patient's reconstructive journey to meet both their emotional and physical needs to avoid reconstructive burnout."

Experience shows high rate of reconstructive burnout

Breast reconstruction has demonstrated benefits for women undergoing mastectomy for breast cancer. However, the reconstructive process "can be a long road with many hurdles to achieve an ideal aesthetic result," according to the authors. Cancer treatment, surgical complications, and other medical conditions can affect patients both physically and emotionally.

"[T]here are a subset of patients who begin the reconstructive journey but do not complete it—a term we introduce as reconstructive burnout," Drs. Haddock and Teotia and coauthors write. They reviewed their experience with 530 patients between 2014 and 2017. All of the women underwent skin-sparing mastectomy as a first step toward breast reconstruction.

At follow-up, 76.6% of the patients had completed breast reconstruction. The remaining 24.4% were classified as having reconstructive burnout—defined by the authors as "either no breast mound reconstruction or completion of the breast mound without completion of all major revisions."

Key risk factors for not completing breast reconstruction

More than 80% of patients underwent initial reconstruction using tissue expanders (TEs) to maximize the amount of skin available for reconstruction. In this group, the overall global complication rate (minor and major) was about 48% among women with reconstructive burnout, compared to 36% for those who completed reconstruction. Reconstructive burnout was also associated with a higher rate of complications requiring surgical treatment, 36% versus 17%; and complications requiring removal (explantation) of TEs, 23% versus 5%.

About 35% of patients underwent implant-based reconstruction, while 65% underwent autologous (using the patient's own tissues) reconstruction. Risk of reconstructive burnout were similar for these two groups: 17% and 19%, respectively. Even though it is "an inherently more complicated procedure," patients undergoing autologous reconstruction were twice as likely to complete reconstruction.

Older age, higher body mass index (BMI), diabetes, and TE-related complications were associated with a higher risk of reconstructive burnout. On adjusted analysis, the most important risk factors were radiation therapy, higher BMI, and TE explantation.

The researchers note some limitations of their study, including a lack of information on the women's reasons for deciding to stop reconstruction prematurely. "During the course of breast reconstruction after mastectomy, patients can be overwhelmed either emotionally, mentally, and/or physically and prematurely stop reconstruction due to reconstructive burnout," Drs. Haddock and Teotia write.

The authors hope their study will increase awareness of reconstructive burnout, and the relevant risk factors, among women undergoing mastectomy. They conclude: "These findings will help guide pre-operative and pre-reconstructive conversations with patients in order to manage expectations for patients that may be highly susceptible to burnout."

Drs. Haddock and Teotia also emphasize that increased access to all breast reconstruction methods—implant-based and/or autologous—would lead to a better informed patient and decision making, which can translate towards more completion of breast reconstruction. Additionally, since the study found autologous breast reconstruction patients are more likely to complete all phases of reconstruction including revision surgeries, it is beneficial that patients continue to have an increased and unencumbered access to autologous breast reconstruction at all levels of their care at different settings.