Research in the journal Plastic and Reconstructive Surgery challenges the traditional view that older women have a greater risk of complications following both implant-based and autologous breast reconstruction.
The number of women who have breast reconstruction following mastectomy has risen in recent years. However, many still forego the procedure, even though studies have shown that women of all ages experience improved quality of life following reconstruction.
The Age Discrepancy
A 2012 study in the Journal of the American College of Surgeons noted that age is the greatest predicting factor for breast reconstruction — women over age 70 are almost nine times less likely to have the surgery. The February study in Plastic and Reconstructive Surgery, which compares 30-day complication rates in younger and older patients, confirms that age still plays a significant role in reconstruction rates.
“The most positive message of this paper is that complication rates in general — whether you’re looking at older versus younger women or implant-based reconstruction versus autologous reconstruction — are very favorable and in the range of less than 5–10 percent for most complications.”
— Katharine Yao, MD, breast surgeon at NorthShore University HealthSystem and study author
Using data from the American College of Surgeons National Surgery Quality Improvement Program Participant Use Files, the Chicago-based research team studied the records of 40,769 women who underwent a unilateral mastectomy, with or without immediate reconstruction, between 2005 and 2012. Approximately 40 percent of women younger than 65 had reconstruction, whereas only about 11 percent of patients over 65 had the operation.
Some of the reasons older women decline reconstruction are intuitive, say researchers involved in the study. Aesthetically, breast reconstruction may be less important to them. Older women may also fear a longer surgery and recovery time, especially if they don’t live near loved ones who can provide postoperative support. In addition, referral bias within the medical community may play a role, as fewer oncologists, general surgeons and internists may refer older patients to plastic surgeons.
Investigations in Safety
Many studies cite age as a risk factor for complications following breast reconstruction, according to Daniel Butz, MD, a plastic surgery resident at NorthShore University HealthSystem and lead author of the paper in Plastic and Reconstructive Surgery. Therefore, the research team sought to determine what types of complications may occur with advancing age and how age affects postsurgical outcomes. They hypothesized that, after adjusting for comorbidities, complication rates would be similar among women of all ages.
That hypothesis was partially correct. Complication rates following unilateral mastectomy and implant-based reconstruction were comparable between older and younger women. Older women did have a higher risk of developing venous thromboembolism (VTE) after autologous reconstruction: Women over 65 were nearly four times more likely to develop VTE, while women over 70 were more than six times more likely to experience the condition. However, overall rates were low in both age groups — VTE occurred in 2.2 percent of older women and 0.8 percent of younger women.
Age, a cancer diagnosis, obesity, a lengthy surgery and prolonged hospital stay, and decreased ambulation are among VTE risk factors. Autologous reconstruction tends to be a longer procedure and to entail a lengthier recovery.
While hesitant to make clinical recommendations based on the results of one study, Mark Sisco, MD, plastic surgeon and Clinical Assistant Professor for the Division of Plastic and Reconstructive Surgery at NorthShore University HealthSystem and senior author of the paper, believes VTE in older women who undergo autologous reconstruction is largely preventable with early ambulation. If risk factors beyond age are present, older patients may also benefit from prophylactic use of anticoagulants following surgery and hospital discharge. Overall, the research team doesn’t believe that the risk of VTE is high enough to recommend older patients refrain from autologous breast reconstruction.
“The incidence of complications after reconstruction is very low regardless of age or type of reconstruction,” Dr. Sisco says. “For otherwise healthy women, age shouldn’t be a consideration in assessing the risk of short-term perioperative complications, with the caveat being that if they are having these bigger surgeries, there may be a higher risk of this one, specific type of preventable complication.”