Miller, C.L., Colwell, A.S., Horick, N., Skolny, M.N., Jammallo, L.S., O'Toole, J.A., . . . Taghian, A.G. (2016). Immediate implant reconstruction is associated with a reduced risk of lymphedema compared to mastectomy alone: A prospective cohort study. Annals of Surgery, 263, 399–405. 

To determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone

Patients were screened for lymphedema prospectively, and lymphedema rates were compared between those who had immediate breast implantation, immediate autologous reconstruction, and those who had mastectomy alone. Each breast was considered individually in analysis. Follow-up was a median of 22.2 months.

• N = 616 women with breast cancer, 891 mastectomies
• MEAN AGE = 48 years
• AGE RANGE = 28–81 years 
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer who underwent mastectomy and immediate breast reconstruction or mastectomy alone
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with breast cancer with risk of lymphedema; 65% (580 of 891) had an immediate implantation, 11% (101 of 891) had immediate autologous reconstruction, and 24% (210 of 891) had no reconstruction.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Massachusetts General Hospital, Boston, MA

PHASE OF CARE: Late effects and survivorship

Prospective cohort study

Arm measurements were performed preoperatively and during postoperative follow-up using a perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Measurement was adjusted for body weight.

Overall incidence of lymphedema was 10.58%. Among those who had immediate breast reconstruction, the incidence of lymphedema was 5.13% compared to 26.66% among those with no immediate reconstruction. Both immediate implantation (HR = 0.172, p < 0.0001) and autologous (HR = 0.467, p = 0.0077) were associated with reduced risk of lymphedema compared to no reconstruction. Factors associated with increased risk of lymphedema were a body mass index greater than or equal to 30, axillary lymph node dissection (ALND), and number of lymph nodes dissected.

Immediate implantation reconstruction does not appear to increase the risk of lymphedema compared to mastectomy alone; however, the findings are limited by significant differences in cohort characteristics shown to be associated with lymphedema incidence.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Key sample group differences that could influence results
• Measurement/methods not well described
• Findings not generalizable
• Defining lymphedema as more than a 10% limb volume increase indicate moderate to severe lymphedema; the lower incidence of lymphedema should be cautioned since 5% of limb volume increase has a negative effect on patients’ quality of life. A significantly lower proportion of those in the immediate reconstruction group had a body mass index of greater than or equal to 30 and had ALND (p < 0.0001). Patients in the no-reconstruction group were significantly older, and age at surgery was a univariate predictor of lymphedema hazard.

Nurses should be advised that although immediate reconstruction may not increase the risk of lymphedema, risk reduction for this population should continue.