Trends in Immediate Postmastectomy Breast Reconstruction in the United Kingdom

Abstract

Background: The study aimed to evaluate local and national trends in immediate breast reconstruction (IBR) using the national English administrative records, Hospital Episode Statistics. Our prediction was an increase in implant-only and free flap procedures and a decline in latissimus flap reconstructions.

Methods: Data from an oncoplastic center were interrogated to derive numbers of implant-only, autologous latissimus dorsi (LD), LD-assisted, and autologous pedicled or free flap IBR procedures performed between 2004 and 2013. Similarly, Hospital Episode Statistics data were used to quantify national trends in these procedures from 1996 to 2012 using a curve fitting analysis.

Results: National data suggest an increase in LD procedures between 1996 (n = 250) and 2002 (n = 958), a gradual rise until 2008 (n = 1398) followed by a decline until 2012 (n = 1090). As a percentage of total IBR, trends in LD flap reconstruction better fit a quadratic (R(2) = 0.97) than a linear function (R(2) = 0.63), confirming a proportional recent decline in LD flap procedures. Conversely, autologous (non-LD) flap reconstructions have increased (1996 = 0.44%; 2012 = 2.76%), whereas implant-only reconstructions have declined (1996 = 95.42%; 2012 = 84.92%). Locally, 70 implant-assisted LD procedures were performed in 2003 -2004, but only 2 were performed in 2012 to 2013.

Conclusions: Implants are the most common IBR technique; autologous free flap procedures have increased, and pedicled LD flap procedures are in decline.

Fig. 1.

Longitudinal variation in subcategories of immediate breast reconstruction performed at the Royal Marsden NHS Foundation Trust 2004–2013. Data episodes arranged sequentially according to financial year(s), such that 2004 data = number of reconstructive procedures performed from April 5, 2003, to April 5, 2004; 2005 data = April 5, 2004, to April 5, 2005, etc. LD Expander indicates latissimus dorsi plus expander/implant.

Fig. 2.

Longitudinal trends in National LD flap immediate breast reconstruction rates for financial years 1996–2012. A, Charts highlight trends in LD-expander rates. B, Proportion of LD flap procedures expressed as a percentage of the total postmastectomy breast reconstruction load. Lines of “best-fit” for linear and quadratic functions are superimposed.

Fig. 3.

Trends in the crude numbers of implant-assisted LD flap reconstructions across 4 UK NHS Trusts, 1996–2012. The plots for NHS Trusts reflect a similar trend to that observed at the Royal Marsden NHS Foundation Trust (2003–2012): RP5 Doncaster and Basseltow NHS Trust (A); RNZ Salisbury NHS Trust (B); RVJ North Bristol NHS Trust (C); and RYQ South London Healthcare NHS Trust (D).

Fig. 4.

Longitudinal trends in proportions (% of total IBR) of each subtype of breast reconstruction performed in United Kingdom and United States. Charts depict proportional decrease in LD- and implant-based reconstruction and increase in autologous free flap reconstruction (A), and the opposing trend observed in an insured population in the United States (C). Conversely, the reduction in LD flap reconstruction and increase in DIEP or free flap microsurgery observed at the RMH (B) is mirrored in certain academic institutes in the United States (D). Autog indicates autologous; autog+, autologous plus implant. Procedural schematic illustrations reproduced with permission from http://www.breastreconstruction.org.