Predictors of Aesthetic Outcomes in Bilateral DIEP Flap Breast Reconstruction: A Preliminary Analysis of Aesthetic Grading Tool Scores

BACKGROUND Objective assessment of aesthetic outcomes following post-mastectomy breast reconstruction remains challenging. The Aesthetic Grading Tool (AGT) was developed as a standardized tool to evaluate aesthetic outcomes independent of patient-reported satisfaction. This study aimed to identify factors associated with aesthetic outcomes using the AGT. METHODS 35 de-identified photographs of patients who underwent bilateral autologous reconstruction were included in the AGT. Respondents including attending physicians, advanced practice providers, nurses, trainees, and patients rated aesthetic outcomes on a 5-point Likert scale. Associations between aesthetic scores and clinical variables, including receipt of radiation, 90-day readmission, and mastectomy type, were assessed. Differences in scores by respondent training level were also analyzed. RESULTS 91 respondents completed the AGT. Of the 35 patients whose photographs are included in the AGT, 26% received radiation, and 91% underwent a skin-sparing mastectomy. Receipt of preoperative radiation was associated with lower scores (beta = -0.68, 95% CI: -1.3 -0.04, p=0.039). Patients with 90-day readmission (1.98 vs 3.15, p=0.11) and those who underwent conventional as opposed to skin-sparing or nipple-sparing mastectomy (2.25 vs 3.09 vs 3.21, p=0.5) trended towards lower AGT scores. Attending physicians consistently assigned higher scores across all variables, whereas patient respondents provided among the lowest scores. CONCLUSION Receipt of radiation is associated with worse aesthetic outcomes following bilateral autologous reconstruction. Patients with 90-day readmission and conventional mastectomy trend towards worse aesthetic outcomes. Providers should counsel patients who are undergoing bilateral DIEP flap reconstruction on expected aesthetic outcomes based on their treatment course.