Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4125–4132

The impact of delayed wound healing on

patient-reported outcomes after breast
cancer surgery
Lea Zehnpfennig a,1, Mathilde Ritter a,b,1,
Giacomo Montagna a,b,d, Tristan M Handschin b,e,
Barbara M Ling e, Ida Oberhauser a,b, Jérémy Lévy c,
Kristin Marit Schaefer b,e, Nadia Maggi a, Savas D Soysal a,b,
Liliana Castrezana López a,b, Madleina M Müller a,b,f,
Fabienne D Schwab a,b,f, Martin Haug a,b,e, Walter P Weber a,b,
Christian Kurzeder a,b,f,1, Elisabeth A Kappos a,b,e,1,∗
a
Breast Center, University Hospital of Basel, Basel, Switzerland
b
University of Basel, Basel, Switzerland
c
Biometrical Practice BIOP, Basel, Switzerland
d
Breast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
e
Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel,
Switzerland
f
Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland

Received 25 April 2021; accepted 7 June 2022

KEYWORDS Purpose: Postoperative complications after breast cancer surgery may be associated with de-
Breast cancer surgery; creased quality of life. It remains unclear whether oncoplastic breast-conserving surgery or
Oncoplastic breast mastectomy with reconstruction lead to more postoperative complications than conventional
surgery (OBS); breast surgery (CBS). As delayed wound healing (DWH) is one of the most frequent minor com-
Quality of life (QoL); plications, we sought to investigate the significance of DWH for patient-reported outcomes
Patient-reported after oncoplastic, reconstructive, and CBS.
outcomes; Methods: Our study is a retrospective cohort study of consecutive patients with stage I-II
Delayed wound healing breast cancer who underwent oncoplastic or CBS performed by three breast surgeons at a
(DWH) single tertiary referral hospital from June 2011 until May 2019. Patient-reported outcomes were

1These
authors contributed equally to this study
∗
Corresponding author at: Senior Consultant, Breast Center and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery,
University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
E-mail addresses: lea.zehnpfennig@stud.uni-due.de (L. Zehnpfennig), elisabeth.kappos@usb.ch (E.A. Kappos).

https://doi.org/10.1016/j.bjps.2022.06.106
1748-6815/© 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
 L. Zehnpfennig, M. Ritter, G. Montagna et al.

evaluated postoperatively using the BREAST-Q questionnaire. Comparisons were made between
patients with and without DWH.
Results: A total of 229 patients who met the inclusion criteria and 28 (12%) of them developed
DWH, 27/158 (17%) in the oncoplastic breast-conserving surgery and reconstruction group and
1/71 (1%) in the CBS group. The mean time from surgery to BREAST-Q assessment was compa-
rable in both groups (29 months in the DWH vs. 33 months in the normal wound healing group).
No statistically significant difference for any BREAST-Q scale was detected between patients
with and without DWH. This includes physical (p = 0.183), psychosocial (p = 0.489), sexual
well-being (p = 0.895), and satisfaction with breasts (p = 0.068).
Conclusion: Our study confirms that oncoplastic breast-conserving surgery and mastectomy
with reconstruction lead to significantly more DWH than CBS. However, neither quality of life
nor patient-reported outcomes following state-of-the-art reconstructive or oncoplastic breast-
conserving surgery at a specialized center seem to be compromised.
© 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Pub-
lished by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/)

Introduction
Over the past few decades, there have been major de-
velopments in breast cancer surgery with increased fo-
cus on esthetic results and associated patient satisfaction.
Oncoplastic breast-conserving surgery (OBCS) and mastec-
tomy with breast reconstruction are procedures that com-
bine oncological and plastic techniques that have been
shown to improve quality of life (QoL).1 As reconstruc-
tive techniques encompass volume replacement and vol-
ume displacement, so in this study, we refer to oncoplas-
tic breast surgery (OBS) including OBCS techniques and
mastectomy with autologous or implant reconstruction.2
Conventional breast surgery (CBS) includes conventional
breast-conserving surgery (CBCS) and total mastectomy
(TM).
It’s unclear whether OBS leads to more postoperative
complications than CBS.3–6 Higher complication rates fol-
lowing oncoplastic techniques could be explained by the
more complex surgical procedures employed to attain op-
timal cosmetic results.4
Postoperative complications after breast cancer surgery
can be associated with a decreased QoL.7–9 Delayed wound
healing (DWH) is one of the most frequent minor postoper-
ative complications after abdominal and breast surgery.10–12
Wound complications and infections are frequent compli-
cations, especially after breast reconstruction.3 However,
the significance of DWH after OBS and its impact on long-
term QoL and patient satisfaction remains unknown. Aside
from possible physical sequelae, postoperative complica-
tions can be detrimental to the emotional well-being of pa-
tients, especially shortly after surgery, but also in the long
term.7–9 We sought to investigate the significance of DWH on
patient-reported outcomes (PROs) after oncoplastic, recon-
structive, and CBS surgery.
We hypothesized that DWH has no negative impact on
the high QoL attained by the cosmetically pleasing results
of OBS. To test this hypothesis, we compared PROs in pa-
tients with and without DWH after CBS and OBS by using the
BREAST-Q, as a validated PRO assessment tool.13
Methods
Study design and patients
Consecutive patients with stage I-II breast cancer who were
treated by three breast surgeons at a tertiary referral hos-
pital between June 2011 and May 2019 were identified
from a prospectively maintained database. Patients were
eligible for inclusion if they had undergone either OBS
(OBCS or mastectomy with reconstruction) or CBS (CBCS
or TM). OBCS methods include oncoplastic reduction mam-
moplasty (n = 37), circumareolar mastopexy (n = 30), v-
mammoplasty (n = 14), hemibatwing (n = 14), and on-
coplastic tumorectomy (n = 11). Reconstructive techniques
include nipple sparing mastectomy (NSM) with autologous
reconstruction with a deep inferior epigastric perforator
(DIEP) flap (n = 46) and mastectomy with implant-based
reconstruction (n = 5). CBCS was considered as a conven-
tional, breast-conserving tumorectomy (n = 40). TM cases
(n = 31) include unilateral and bilateral TM without any
further reconstruction. The BREAST-Q was used to prospec-
tively assess postoperative health-related QoL via the out-
come collecting software Heartbeat®, which provides a sys-
tem to measure PROs using the Outcome Sets of the In-
ternational Consortium for Health Outcome Measurements
(ICHOM). Patient, tumor, treatment, and outcome variables
were recorded in a dedicated study database (secuTrial®).
Comparisons were made between patients with DWH, de-
fined as a wound healing process on the breast or abdomen
lasting longer than 21 days14, 15 and patients with “normal
wound healing”, which lasted shorter than 21 days (NWH).
Statistical analysis
Patient, tumor, treatment, and outcome characteristics of
both wound healing groups were compared. We analyzed
the following BREAST-Q scales: “physical well-being chest”,
“psychosocial well-being”, “sexual well-being”, and “satis-
faction with breasts.” Each scale is converted to a continu-

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4125–4132

Table 1 Patient, tumor, and treatment characteristics by wound healing group.

Delayed wound Delayed wound p-value∗
healing healing
Yes No
n = 28 n = 201
Patient age, mean (SD), years 57.82 (12.96) 61.91 (12.96) 0.120

Mean time from surgery to follow-up BREAST-Q 29.30 (20.41) 32.69 (22.96) 0.460
(SD), months
Type of surgery
OBS:
NSM with DIEP, n (%) 14 (50.0) 32 (15.9) 0.000

Implant, n (%) 3 (10.7) 2 (1.0)

OBCS, n (%) 10 (35.7) 97 (48.3)
CBS:
TM, n (%) 1 (3.6) 30 (14.9)
CBCS, n (%) 0 (0.0) 40 (19.9)
Surgical complications
No complications, n (%) 0 (0.0) 174 (86.6) 0.000
Clavien-Dindo classification:
I, n (%) 10 (35.7) 16 (8.0)
II, n (%) 0 (0.0) 0 (0.0)
IIIa, n (%) 2 (7.1) 2 (1.0)
IIIb, n (%) 16 (57.1) 9 (4.5)
IV, n (%) 0 (0.0) 0 (0.0)
V, n (%) 0 (0.0) 0 (0.0)
Neoadjuvant/adjuvant treatment
Neoadjuvant chemotherapy, n (%) 3 (10.7) 18 (9.0) 0.728
Adjuvant chemotherapy, n (%) 7 (25.0) 33 (16.4) 0.288
Adjuvant endocrine therapy, n (%) 21 (75.0) 138 (68.7) 0.662
Adjuvant radiotherapy, n (%) 22 (78.6) 125 (62.2) 0.097
Preoperative T stage∗∗
cTis, n (%) 6 (21.4) 31 (15.4) 0.138
cT0, n (%) 0 (0.0) 2 (1.0)
cT1, n (%) 8 (28.6) 97 (48.3)
cT2, n (%) 11 (39.3) 57 (28.4)
cT3, n (%) 3 (10.7) 8 (4.0)
BMI
Mean BMI (SD) 26.99 (7.82) 25.49 (5.07) 0.177
Smoking∗∗∗
Yes, n (%) 6 (21.4) 34 (16.9) 0.596
No, n (%) 16 (57.1) 100 (49.8)
Prior, n (%) 5 (17.9) 52 (25.9)
Diabetes∗∗∗∗
Yes, n (%) 2 (7.1) 9 (4.5) 0.631
No, n (%) 26 (92.9) 190 (94.5)
∗ Mean values were compared using a t-test. Occurrences were compared using a Fisher’s exact test for association.
∗∗ Missing: 6
∗∗∗ Missing: 16
∗∗∗∗ Missing: 2

OBS = oncoplastic breast surgery (including NSM with DIEP, implant-based reconstruction and OBCS)
NSM = nipple-sparing mastectomy
DIEP = deep inferior epigastric perforator (flap)
OBCS = oncoplastic breast-conserving surgery (including V-, B-, hemibatwing and round block mammoplasty as well as oncoplastic tu-
morectomy)
CBS = conventional breast surgery (including CBCS and TM)
CBCS = conventional breast-conserving surgery
TM = total mastectomy
Delayed wound healing = wound healing lasting longer than 21 days

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 L. Zehnpfennig, M. Ritter, G. Montagna et al.

Fig. 1 BREAST-Q scales by wound healing group.

ous scale scoring from zero to 100, with higher values rep-
resenting greater QoL. Continuous variables were reported
by mean, standard deviation (SD), and minimum and maxi-
mum values. Mean values were compared using t-test. Cate-
gorical variables were summarized by absolute frequencies
and percentages. Occurrences were compared using Fisher’s
exact test for association. A p-value below 0.05 was con-
sidered statistically significant. All statistical analyses were
conducted with SAS version 9.2.
Results
From June 2011 until May 2019, 229 patients met the in-
clusion criteria. Twenty-eight patients (12%) experienced
DWH, and 201 (88%) did not. In the DWH group, the mean
wound healing duration was 88 days (SD 74). Postoperative
complications were classified by Clavien-Dindo16 and ranged
from grades I to IIIb (Table 1). Grade I includes seroma,
hematoma, and DWH without the need for special phar-
macological treatment or surgical intervention. Grade II
includes pharmacologically treatable complications. Grade
IIIb includes complications such as skin necrosis, infection,
or flap loss that require surgical revision not under general
(IIIa) or under general anesthesia (IIIb). Fourteen (50%) pa-
tients with DWH underwent NSM with DIEP, 10 (36%) un-
derwent OBCS, 3 (11%) had an implant-based reconstruc-
tion, and 1 (4%) had a TM. In the NWH group, 32 (16%)
patients had a NSM with DIEP flap reconstruction, 97 (48%)
OBCS, 40 (20%) CBCS, 30 (15%) a TM, and 2 (1%) received an
implant-based reconstruction. The mean time from surgery
to follow-up BREAST-Q assessment was 29 (20) months in the
DWH and 33 (23) months in the NWH group (Table 1). The
mean BMI was similar in both groups (27 (SD 8) in the DWH
group and 25 (SD 5) in the NWH group). In the DWH group 2
(7%) and in the NWH group 9 (5%) had diabetes. A total of
11 patients (39%) in the DWH group were smokers or prior
smokers, compared to 86 (43%) in the NWH group. Within

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4125–4132
Table 2 Comparison of BREAST-Q scales between wound healing groups.
Delayed wound
healing
Yes, n = 28
Physical well-being chest∗∗
n 26
Mean (SD) 74.31 (19.55)
Min - Max 33.00–100.00
Psychosocial well-being∗∗
n 27
Mean (SD) 82.59 (21.48)
Min - Max 44.00–100.00
Satisfaction with breasts∗∗
n 26
Mean (SD) 66.46 (19.47)
Min - Max 36.00–100.00
Sexual well-being∗∗
n 15
Mean (SD) 68.33 (29.90)
Min - Max 24.00–100.00
∗ Mean values were compared using a t-test. Occurrences were compared using a Fisher’s exact test for association.Delayed wound
healing = wound healing lasting longer than 21 days
∗∗ BREAST-Q scores from 0 - 100 with higher values representing greater QoL
the cohort of patients receiving autologous reconstruction
(n = 46, 20%), DWH was observed in n = 14 (30%) patients,
affecting the breast site only in n = 10 (22%) patients, the
donor site only in n = 2 (4%) patients, and the breast and
donor site in n = 2 (4%) patients.
Comparison of BREAST-Q scales
For the scale physical well-being chest, mean scores in the
DWH group (74 (SD 20)) and in the NWH group (79.71 (SD 19))
were not statistically different (p-value=0.183) (Fig. 1a)
(Table 2). The same was true for psychosocial well-being
(82.59 (SD 21) vs. 85.18 (SD 18), respectively, p = 0.489)
(Fig. 1b) (Table 2), satisfaction with breast (66 (SD 19) vs.
74 (SD 21), respectively, p = 0.068) (Fig. 1c) (Table 2), and
sexual well-being (68 (SD 30) vs. 69.25 (SD 25), respectively,
p = 0.895) (Fig. 1d) (Table 2). Fig. 2
Discussion
In this study, we analyzed PROs in 229 consecutive stage I-II
breast cancer patients following OBS and CBS. We compared
the BREAST-Q scales between patients who developed DWH,
and patients who did not. In line with Jagsi et al. and Clough
et al.3, 5, we found that OBS was associated with a higher
rate of DWH compared to CBS. Nonetheless, in our analysis,
patient satisfaction was not affected by DWH.
Impact of DWH on QoL
Numerous studies have shown an association between post-
operative complications and worse decreased QoL.3, 8, 9, 17, 18
However, most of these studies merely analyzed short-term
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Delayed wound p-value∗
healing
No, n = 201
201
79.71 (19.41) 0.183
13.00–100.00
200
85.18 (17.75) 0.489
21.00–100.00
201
74.43 (21.02) 0.068
0.00–100.00
135
69.25 (25.08) 0.895
0.00–100.00
QoL (four to six weeks after surgery)8, 9, and not all of these
studies actually considered body image or esthetic satisfac-
tion at all.9
Thus far, there is no study on this subject matter in the
literature that specifies DWH as a main postoperative com-
plication and analyzes it individually. In this study, we de-
cided to focus on DWH as it is one of the most important
and frequent minor complications in breast surgery.10 We
focused on long-term QoL after OBS and CBS and found
no significant association between DWH and QoL. This is in
line with previous studies with long-term follow-up, which
suggested that postoperative complications have no signifi-
cant impact on QoL in the long term.12, 17–19 Our findings are
most likely explained by the fact that women who devel-
oped postoperative complications are able to develop cop-
ing strategies that allow them to overcome the short-term
burden of DWH.17, 18
Risk factors for DWH have been described in the litera-
ture and include smoking, elevated BMI, diabetes, advanced
age, and adjuvant radiotherapy.20–23
Interestingly, all of these variables were similar in both
of our groups, which might suggest no significant impact on
DWH. This needs further investigation with greater sample
sizes.
Twenty-two patients of the DWH group received adjuvant
radiotherapy. Postoperative complications with a significant
delay of wound healing could lead to a delay of adjuvant
radiotherapy.24 Whether a short delay impacts survival rates
remains unclear.25, 26
Impact of OBS on QoL
There is evidence that PROs can be improved by the applica-
tion of OBS.1, 27 We therefore cannot exclude that a probable
detrimental effect of DWH on QoL might be compensated by
 L. Zehnpfennig, M. Ritter, G. Montagna et al.

Fig. 2 Study-flowchart of participants.

higher PRO scores resulting from better esthetic outcomes
of OBS.
The time factor
Another possible explanation for our findings is the rela-
tively long interval from surgery to follow-up (mean time
29.30, (SD 20) months in the DWH group and 32.69, (SD 23)
months in the NWH group). Previous studies have shown that
postoperative QoL tends to increase over time.27–29 In fact,
some studies analyzing PROs after postoperative complica-
tions have demonstrated that, in the majority of cases, QoL
deterioration reverses over time.30 As a result, it is conceiv-
able that an acute event occurring shortly after surgery may
not impact QoL in the long term.
A study analyzing QoL after breast cancer surgery with
a similar mean time to follow-up as in our study, post-
operative complications in general were not associated with
overall patient satisfaction.19
Study limitations and strengths
Limitations of this study include the relatively small sample
size, its retrospective nature, and the monocentric design.

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4125–4132
The small sample size is due to the fact that we included
only patients treated by three senior surgeons. This choice
was made to increase generalizability of the results as it en-
sures standardized treatment of very experienced surgeons.
Plastic surgeons were, by default, involved in all breast re-
constructions and sometimes in more complex OBS or CBCS.
On the other hand, a major strength of this study lies in
the inclusion of different types of surgical procedures in-
cluding mastectomy, breast reconstruction, but also breast
conservation procedures. Previous studies have had only in-
cluded patients who had a mastectomy and breast recon-
struction. To the best of our knowledge, our study is the
first to analyze the impact of DWH on QoL and to compare
different OBS techniques and CBS procedures such as mas-
tectomy and CBCS.
In addition to analyzing the impact of complications on
QoL like previous studies in the literature, we centered our
focus on DWH as one of the most important minor complica-
tions after abdominal and breast surgery.6–8
Therefore, our findings allow for more precise informa-
tion about the impact of DWH in particular.
Conclusion
Our results suggest that superior PROs and QoL after state-
of-the-art OBS at a specialized center are not compromised
by an increased rate of DWH. These circumstances may be
explained by the excellent esthetic outcome achieved with
oncoplastic procedures. Another explanation might be that
the effect of wound healing complications on patient satis-
faction decreases over time.
In times of personalized health care, patients should
be informed of the possible complications related to more
extensive surgeries such as oncoplastic procedures with
due diligence. If postoperative complications — particularly
DWH — occur, intensive and adequate care should be given.
Nevertheless, based on the results of our study, patients
ought to be reassured that such possible complications may
not negatively impact their QoL in the long term.
Declaration of Competing Interest
E.A. Kappos has received research support from the “Frei-
willige Akademische Gesellschaft Basel.” W.P. Weber has re-
ceived research support from Takeda Pharmaceuticals In-
ternational via Swiss Group for Clinical Cancer Research
(SAKK), honoraria from Genomic Health, Inc., USA, and sup-
port for conferences and meetings from Sandoz, Genomic
Health, Medtronic, Novartis Oncology and Pfizer.
C. Kurzeder has received honoraria from Tesaro, GSK, As-
traZeneca, Novartis, PharmaMar, Genomic Health, Roche,
Eli Lilly S.A., Pfizer, and Daichi, support for attending meet-
ings and/or travel from GSK, AstraZeneca, and Roche and
participation on a data safety monitoring board or advisory
board from Tesaro, GSK, AstraZeneca, Novartis, PharmaMar,
Genomic Health, Roche, Eli Lilly S.A., Merck MSD, and Pfizer.
J. Lévy has received renumeration for his work from the
Department of Plastic, Reconstructive, Aesthetic and Hand
Surgery and the Department of Breast Surgery, University
Hospital of Basel.
4131
All other authors report no conflict of interest.
Acknowledgments
We thank the quality management team of the University
Hospital of Basel for their help and support in the imple-
mentation of the outcome collecting software Heartbeat®.
We also thank Constantin Sluka and his team of the Clinical
Trial Unit Basel for the maintenance of the online clinical
data management system secuTrial®.
Funding
This work was funded by the Department of Surgery, Univer-
sity Hospital of Basel. This financial backer had no involve-
ment in study design; the collection, analysis, and interpre-
tation of data; the writing of the report; nor in the decision
to submit the article for publication.
Ethical approval
We have obtained ethical approval by the Ethikkommis-
sion Nordwest- und Zentraischweiz (EKNZ). Approval num-
ber BASEC ID 2016–01525
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2022.06.
106.
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