Controversy in breast reconstruction

Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction

BACKGROUND

Two-stage tissue expander-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure.

METHODS

A retrospective review of tissue expander-based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap.

RESULTS

A total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation).

CONCLUSIONS

Women with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.

Recent advances in the surgical care of breast cancer patients

A tremendous improvement in every aspect of breast cancer management has occurred in the last two decades. Surgeons, once solely interested in the extipartion of the primary tumor, are now faced with the need to incorporate a great deal of information, and to manage increasingly complex tasks.

As a comprehensive assessment of all aspects of breast cancer care is beyond the scope of the present paper, the current review will point out some of these innovations, evidence some controversies, and stress the need for the surgeon to specialize in the various aspects of treatment and to be integrated into the multisciplinary breast unit team.

Implant breast reconstruction after salvage mastectomy in previously irradiated patients

The most common surgical approach in case of local tumor recurrence after quadrantectomy and radiotherapy is salvage mastectomy. Breast reconstruction is the subsequent phase of the treatment and the plastic surgeon has to operate on previously irradiated and manipulated tissues. The medical literature highlights that breast reconstruction with tissue expanders is not a pursuable option, considering previous radiotherapy a contraindication. The purpose of this retrospective study is to evaluate the influence of previous radiotherapy on 2-stage breast reconstruction (tissue expander/implant). Only patients with analogous timing of radiation therapy and the same demolitive and reconstructive procedures were recruited. The results of this study prove that, after salvage mastectomy in previously irradiated patients, implant reconstruction is still possible. Further comparative studies are, of course, advisable to draw any conclusion on the possibility to perform implant reconstruction in previously irradiated patients.

Breast reconstruction with alloplastic implants

This article reviews immediate and delayed breast reconstruction with prosthetic implants, and the effect of irradiation therapy. Despite widespread use of breast conserving surgery for early breast cancer, many breast cancer patients still undergo mastectomy. Some of these patients choose breast reconstruction. Over the last 30 years, techniques for breast reconstruction have evolved significantly with new alternative techniques and improved surgical devises. Immediate or delayed breast reconstruction with silicone prosthesis can be an excellent option. Implant reconstruction may be single or two stage procedures. Traditionally, small breasts with minimal ptosis are suited for single-stage reconstruction. Large breasts or inadequate skin require expanders followed by implants. Minimal excision mastectomy and biological spacers are allowing larger breast single stage reconstruction and improved aesthetics for two stage procedures. With recent studies suggesting survival advantage of post-mastectomy irradiation, many candidates for breast reconstruction are receiving radiotherapy, which complicates healing after breast reconstruction.

Radiotherapy for breast cancer in patients undergoing breast reconstruction or augmentation

Due to increasing indications for postmastectomy radiotherapy and a growing demand for breast reconstruction or augmentation, increasing numbers of patients are currently being exposed to both these treatments. In view of the wide range of available techniques for breast reconstruction, either prosthetic or autologous, and their various sequencing in relation to radiotherapy, physicians can be faced with numerous clinical situations requiring comprehensive knowledge of the topic. This review discusses physical, radiobiological and clinical aspects of combining breast reconstruction and radiotherapy. The available data indicate the feasibility of such combinations, although at the expense of increased risk of complications and less satisfactory cosmesis. Of the two methods of breast reconstruction: using autologous tissue or prosthesis, the former seems to provide better cosmesis and a lower risk of complications in conjunction with radiotherapy. To minimize the risk of unfavourable outcome, the techniques and timing of both breast reconstruction and radiotherapy should be given meticulous attention.

Optimal management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) represents a breast lesion that is diagnosed with increasing frequency, mainly due to the wide use of screening mammography. Today, DCIS comprises 15-25% of all breast cancers detected at population screening programs. Consequently, the concepts of properly managing such patients assume a greater importance in everyday practice. Mammographically detected microcalcifications are the most common presentation of DCIS. Despite recent technological advances (including Stereotactic-guided directional vacuum-assisted biopsy), mammographically guided wire biopsy remains the "gold-standard" for obtaining a histological diagnosis in patients with non-palpable, mammographically detected DCIS. Management options include mastectomy, local excision combined with radiation therapy, and local excision alone. Given that DCIS is a heterogeneous group of lesions rather than a single entity, and because patients have a wide variety of personal needs that must be addressed during treatment selection, it is obvious that no single approach will be appropriate for all forms of DCIS or for all patients. Careful patient selection is of key importance in order to achieve the best results in the management of the individual patient with DCIS. Axillary lymph node dissection is unnecessary in the treatment of pure DCIS, but it is indicated when microinvasion is present. In these cases, sentinel lymph node biopsy may be an excellent alternative. In the NSABP B-24 trial, tamoxifen reduced both the invasive and non-invasive breast cancer events in either breast by 37%. Nearly all patients who develop a non-invasive recurrence following breast-sparing surgery are cured with mastectomy, and approximately 75% of those with an invasive recurrence are salvaged. Selected patients initially treated by lumpectomy alone may also undergo breast-conservation therapy at the time of relapse according to the same strict guidelines of tumor margin clearance required for the primary lesion; radiation therapy should be given following local excision. The use of systemic therapy in patients with invasive recurrence should be based on standard criteria for invasive breast cancer.

Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy

The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined. All female mastectomy patients were followed-up in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi musculocutaneous flaps with or without implants, or transverse rectus abdominis musculocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearson's chi-square and analysis of variance. Of the 1,444 mastectomies performed from 1988 to 1997, 1,262 breasts (87%) were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in the delayed reconstruction group, two recurrences (1.3%) in the immediate reconstruction group, and nine recurrences (0.7%) in the mastectomy without reconstruction group (p=0.746). Analyses of an additional time period from 1992 to 2000 yielded similar results. There is little relationship between local recurrence of breast cancer after mastectomy and reconstruction.

The acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous flap used in immediate breast reconstruction

PURPOSE

To analyze the acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous (TRAM) flap reconstruction following modified radical mastectomy for breast cancer.

METHODS AND MATERIALS

Twenty-five consecutive patients were treated with postoperative radiation therapy after TRAM flap reconstruction between 1985 and 1999. The radiation records for these patients were retrospectively reviewed. Information regarding treatment techniques, timing, and dose was obtained and correlated with the extent of erythema, desquamation, and the need for treatment break.

RESULTS

The median age was 48 years. The median dose of chest wall radiation was 5040 cGy. Additional boost doses were delivered in 13 patients. Twelve patients (48%) developed mild erythema in the treatment field during the course of treatment and 13 patients (52%) developed moderate (40%) or brisk (12%) erythema. Only 10 patients (40%) developed any kind of desquamation; 5 patients (20%) developed dry desquamation and another 5 patients (20%) developed moist desquamation. No patients required a break in the course of treatment because of acute side effects. None of the parameters evaluated (the use of chemotherapy prior to radiation, the interval between surgery and radiation, smoking, prior incidence of fat necrosis, the use of bolus during radiation, and the use of a boost) were predictive of an increased incidence of either the extent of erythema or the development of desquamation in the treatment field.

CONCLUSION

Postmastectomy radiation for TRAM flap reconstruction is well tolerated and is not associated with an increased incidence of acute side effects. Radiation technique and the use of preradiation chemotherapy do not appear to be correlated with an increased incidence of acute side effects.

Surgeon perspectives on surgical options for early-stage breast cancer

To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.

Free versus the pedicled TRAM flap: a cost comparison and outcome analysis

Proponents for the free TRAM flap have advocated enhanced tissue vascularity, easier inset, and limited abdominal dissection. Equal aesthetic results without increased morbidity and without the risks of microvascular surgery have been suggested by surgeons using the pedicled technique. The free TRAM flap has been criticized for its considerably higher costs. The purpose of this study was to provide a cost comparison and outcome analysis of the free versus the pedicled TRAM flap. All patients who had had a TRAM flap performed in the authors' teaching institutions between March of 1990 and April of 1995 were evaluated. Outpatient and hospital records, and hospital and surgeon billing records, were reviewed for patient demographics, TRAM technique, delayed versus immediate, operating room time, length of stay, hospital and surgeon reimbursement, and surgical complications and their costs. All patients were sent a questionnaire asking about time back to work, abdominal strength, fitness, symmetry, and satisfaction. During the 5-year period, 125 TRAM flaps were performed. Of these flaps, 72 were free flaps and 53 were pedicled. Seventy percent were immediate reconstructions regardless of the technique used. Four percent of the free and 17 percent of the pedicled TRAM flaps were bilateral. There were no significant differences between the two techniques with regard to patient age, weight, or percentage of smokers, diabetes, hypertension, or preoperative chemotherapy or radiotherapy. Average operating room time was 7 hours with both techniques either delayed or immediate. Average length of stay was 7 days with the free (immediate and delayed) and 8 days with the pedicled (immediate and delayed) technique, although the difference was not significant. Average hospital reimbursement was $5300 for both the free and pedicled TRAM patients. Average surgeon reimbursement was significantly different, with $5000 for the free and $3500 for the pedicled TRAM flap. There were no differences in the occurrence of hematoma, partial/total flap loss, wound infection, hernia/bulge, fat necrosis, deep vein thrombosis, and pulmonary embolus with regard to the technique used. The cost of the treatment of the complications was not significantly different between the two techniques. There was a significant difference in the complication rate for the free TRAM patients compared with those treated by a routine reconstructive microsurgeon versus a more occasional microsurgeon. Ninety percent of both the free and pedicled patients responded to the questionnaire. There were no statistical differences between the free flap and pedicled flap survey results. The free flap patients returned to work 9 weeks after surgery; the pedicled flap patients returned at 10 weeks. Abdominal strength and overall fitness ranged from 74 to 79 percent for both groups. Symmetry and overall satisfaction averaged 3.4 of 4 for all. Average follow-up for the survey respondents was 20 months. This study did not demonstrate any significant differences in outcome or complications between the free and pedicled TRAM flaps. A modest cost difference of $1500 occurred for the free TRAM patients. An experienced microsurgeon had significantly fewer complications with the free TRAM patients. The authors recommend that surgeons use the technique with which they are comfortable and obtain predictable results.