Keeping Options Open for Patients with Anticipated Postmastectomy Chest Wall Irradiation: Immediate Tissue Expansion Followed by Reconstruction of Choice

Immediate Two-Stage Prosthetic Breast Reconstruction Failure: Radiation Is Not the Only Culprit

BACKGROUND

Immediate prosthetic breast reconstruction produces a satisfactory aesthetic result with high levels of patient satisfaction. However, with the broader indication for postmastectomy adjuvant radiation therapy, many patients are advised against immediate breast reconstruction because of concerns of implant loss and infection, particularly as most patients also require chemotherapy. This retrospective cohort study examines outcomes for patients who underwent immediate two-stage prosthetic breast reconstruction after mastectomy with or without adjuvant chemotherapy or radiotherapy.

METHODS

Between 1998 and 2010, 452 patients undergoing immediate two-stage prosthetic breast reconstruction involving a total of 562 breasts were included in this study. Stage 1 was defined as insertion of the temporary expander, and stage 2 was defined as insertion of the final silicone implant. Postoperative adjuvant radiotherapy was recommended with a tissue expander in situ for 114 patients. Complications, including loss of prosthesis, seroma, and infection, were recorded and analyzed. Cosmetic result was assessed using a four-point scale.

RESULTS

Postoperative prosthesis loss was 2.7 percent, 5.3 percent for patients undergoing adjuvant chemotherapy and increasing to 11.3 percent for patients receiving chemotherapy plus radiotherapy. Chemotherapy and radiotherapy independently were the main, statistically significant risk factors for expander or implant loss [incidence rate ratio, 13.85 (p = 0.012) and 2.23 (p = 0.027), respectively]. Prosthesis loss for patients undergoing combination chemotherapy plus radiotherapy was also significant [incidence rate ratio, 4.791 (p < 0.001)].

CONCLUSIONS

These findings serve to better inform patients on risk in weighing treatment options. Postmastectomy radiation therapy doubles the risk of prosthesis loss over and above adjuvant chemotherapy but is an acceptable option following immediate two-stage prosthetic breast reconstruction in a multidisciplinary setting.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current opinions on indications and algorithms for acellular dermal matrix use in primary prosthetic breast reconstruction

Acellular dermal matrix (ADM) is widely used in primary prosthetic breast reconstruction. Many indications and contraindications to use ADM have been reported in the literature, and their use varies by institution and surgeon. Developing rational, tested algorithms to determine when ADM is appropriate can significantly improve surgical outcomes and reduce costs associated with ADM use. We review the important indications and contraindications, and discuss the algorithms that have been put forth so far. Further research into algorithmic decision-making for ADM use will allow optimized balancing of cost with risk and benefit.

Analysis of risk factors for complications in expander/implant breast reconstruction by stage of reconstruction

BACKGROUND

Expander/implant breast reconstruction is a common approach to breast reconstruction. Although several studies evaluate risk factors for complications during the overall reconstructive process, no studies currently evaluate risk factors by stage of reconstruction. This information is important, as it can help guide physician and patient decision making.

METHODS

This is a retrospective review of the records of 876 patients who underwent expander/implant breast reconstruction. Average follow-up time was 42 months. Multivariate analysis and odds ratios were used to calculate the significance of the variables of interest and to compare the risk of complications attributable to each of the independent variables during each stage of the procedure.

RESULTS

During the expander stage, body mass index greater than 30 kg/m had the strongest effect on the development of complications leading to explantation/conversion to flap (OR, 3.07). During the permanent implant stage, history of prereconstruction irradiation had the strongest association with the development of complications leading to explantation/conversion to flap (OR, 3.45). The only risk factors that had a statistically significant effect on the development of complications during both stages were age older than 50 years, smoking within the past month, and a history of premastectomy or postmastectomy radiation therapy.

CONCLUSIONS

The results of this study indicate that the risk factors for complications during expander/implant breast reconstruction differ during each stage of the procedure. The individual impact of risk factors must be considered within the context of each patient's oncologic and surgical needs so that surgeons and patients may make more informed decisions toward their goal of a successful breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy

A common sequence for performing staged tissue expander breast reconstruction is to immediately insert a tissue expander, complete expansion before radiotherapy, and then perform the definitive reconstruction after radiotherapy is complete. This study evaluates the outcomes of this treatment regimen in 237 patients over a 10-year period at Northwestern Memorial Hospital. Overall, 62% of the patients successfully completed tissue expander/implant reconstruction, 22.3% experienced major complications leading to explantations or conversions to flap, and 13.5% completed tissue expander/elective autologous reconstruction. Of the patients who underwent second-stage tissue expander to implant exchange, 87.5% successfully completed reconstruction without experiencing complications leading to explantation or conversion to autologous reconstruction. Thus, this study indicates that immediate tissue expander followed by reconstruction of choice breast reconstruction in the setting of postmastectomy radiation therapy can be successfully performed in most of the patients.

Microvascular autologous breast reconstruction in the context of radiation therapy: comparing two reconstructive algorithms

BACKGROUND

When postmastectomy radiation therapy is anticipated, delaying autologous reconstruction prevents radiation delivery issues and radiation-induced contour irregularities. Delayed-immediate autologous breast reconstruction may allow for maintenance of the breast skin envelope as compared with delayed reconstruction with the temporary insertion of a tissue expander. The authors compared perioperative complications and revision surgery rates of comparative cohorts to determine which method is preferable.

METHODS

Delayed-immediate reconstruction was defined as placement of a temporary tissue expander in the first stage at the time of mastectomy before flap reconstruction, which occurred following postmastectomy radiation therapy. Delayed reconstruction was categorized as mastectomy with primary closure in the first stage followed by flap reconstruction.

RESULTS

One hundred fifty-two patients and 192 breasts met the study criteria for this retrospective review (delayed reconstruction, 118 breasts; delayed-immediate autologous breast reconstruction, 74 breasts). Patient age and body mass index were similar between groups (p>0.05). Perioperative first-stage complication rates were 8.5 percent in the delayed group and 10.8 percent in the delayed-immediate cohort (p=0.81). Total flap loss (2.5 versus 4.1 percent; p=0.68) and arterial (1.7 versus 1.4 percent; p=0.82) and venous (4.3 versus 5.4 percent; p=0.73) anastomotic revision rates were similar between the cohorts, respectively. Reoperative surgery occurred in 11.9 percent versus 9.6 percent in the delayed and delayed-immediate cohorts, respectively (p=0.69).

CONCLUSIONS

In comparing two treatment algorithms, flap-related complication rates are comparable. First-stage surgery results in a slightly increased complication rate in the delayed-immediate cohort. Improved overall results with delayed-immediate reconstruction are implied, given significantly decreased rates of revision surgery following flap reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010

BACKGROUND

We conducted a retrospective survey of American Society of Plastic Surgeons to ascertain the current trends in breast reconstruction (BR).

METHODS

Surveys were sent to 2250 active American Society of Plastic Surgeons members by e-mail with a cover letter including the link using Survey Monkey for the year 2010. In all, 489 surveys (a response rate of 21.7%) were returned. Three hundred fifty-eight surveys from respondents performing BR in their practices were included in the study. The survey included questions on surgeon demographics, practice characteristics, BR after mastectomy, number of BR per year, type and timing of BR, use of acellular dermal matrix, reconstructive choices in the setting of previous irradiation and in patients requiring postmastectomy radiation therapy, timing of contralateral breast surgery, fat grafting, techniques used for nipple-areola reconstruction, the complications, and physician satisfaction and physician reported patient satisfaction. Returned responses were tabulated and assessed.

RESULTS

After prophylactic mastectomy, 16% of BRs were performed. In all, 81.2% of plastic surgeons predominantly performed immediate BR. In patients requiring postmastectomy radiation therapy, 81% did not perform immediate BR. Regardless of practice setting and laterality of reconstruction, 82.7% of respondents predominantly performed implant-based BR. Half of the plastic surgeons performing prosthetic BR used acellular dermal matrix. Only 14% of plastic surgeons predominantly performed autologous BR. Surgeons in solo, plastic surgery group practices, and multispecialty group practices preferred implant-based BR for both unilateral and bilateral cases more frequently than those in academic practices (P < 0.05). Overall, plastic surgeons in academic settings preferred autologous BR more frequently than those in other practice locations (P < 0.05). Of total respondents, 64.8% did not perform microsurgical BR at all; 28% reported performing deep inferior epigastric perforator flap BR. Pedicled transverse rectus abdominis myocutaneous flap was the most often used option for unilateral autologous reconstruction, whereas deep inferior epigastric perforator flap was the most commonly used technique for bilateral BR. The overall complication rate reported by respondents was 11%.

CONCLUSION

The survey provides an insight to the current trends in BR practice with respect to surgeon and practice setting characteristics. Although not necessarily the correct best practices, the survey does demonstrate a likely portrayal of what is being practiced in the United States in the area of BR.

The use of human acellular dermal matrices in irradiated breast reconstruction

This article examines the effects of radiation on prosthetic breast reconstruction when human dermal allograft is used in the reconstruction. A brief review of radiation terminology and techniques as applied to the breast is given, followed by a review of the effects of radiation on wound healing in human tissue. The effects of radiation on prosthetic breast reconstruction before the advent of dermal allografting are reviewed. The addition of dermal allograft in reconstruction has led to a reduced number of complications. An algorithm for surgical treatment of irradiated prosthetic breast reconstructions is presented, with a discussion of the authors technique.

Does partial expander deflation exacerbate the adverse effects of radiotherapy in two-stage breast reconstruction?

Background

The optimum protocol for expander volume adjustment with respect to the timing and application of radiotherapy remains controversial.

Methods

Eighteen New Zealand rabbits were divided into three groups. Metallic port integrated anatomic breast expanders of 250 cc were implanted on the back of each animal and controlled expansion was performed. Group I underwent radiotherapy with full expanders while in Group II, expanders were partially deflated immediately prior to radiotherapy. Control group did not receive radiotherapy.

The changes in blood flow at different volume adjustments were investigated in Group II by laser Doppler flowmetry. Variations in the histopathologic properties of the irradiated tissues including the skin, capsule and the pocket floor, were compared in the biopsy specimens taken from different locations in each group.

Results

A significant increase in skin blood flow was detected in Group II with partial expander deflation. Overall, histopathologic exam revealed aggravated findings of chronic radiodermatitis (epidermal atrophy, dermal inflammation and fibrosis, neovascularisation and vascular changes as well as increased capsule thickness) especially around the lower expander pole, in Group II.

Conclusions

Expander deflation immediately prior to radiotherapy, may augment the adverse effects, especially in the lower expander pole, possibly via enhanced radiosensitization due to a relative increase in the blood flow and tissue oxygenation.

Does post-mastectomy radiotherapy represent a contraindication to skin-sparing mastectomy and immediate reconstruction: an update

The use of skin-sparing mastectomy (SSM) to facilitate breast reconstruction is increasing due to a wide acceptance of improved cosmetic outcomes and evidence of equivalence in oncologic outcomes. The rates of patients undergoing mastectomy for whom post-mastectomy radiotherapy (PMRT) will be recommended is increasing as evidence of decreased loco-regional recurrence and increased survival mounts. PMRT may adversely effect complication rates and cosmetic outcomes for patients undergoing immediate breast reconstruction and PMRT--although the evidence for this is methodologically flawed. This article summarises the above evidence and highlights a reconstructive algorithm that may be used to mitigate the possible deleterious effects of PMRT on results.

Postmastectomy radiation therapy and breast reconstruction: an analysis of complications and patient satisfaction

The indications for postmastectomy radiotherapy (PMRT) have expanded over the past decade. This study examines PMRT and reconstruction compared with a control group without radiotherapy. There were 919 reconstructed breasts identified (1999-2006) and separated into 3 groups: mastectomy with PMRT before reconstruction (n = 57), immediate reconstruction then PMRT (n = 59), and reconstruction without PMRT (n = 665). A validated questionnaire assessed patient satisfaction (response rate 73.7%). Overall complication rates for patients undergoing PMRT (before and after reconstruction) were higher than that of the controls (39.66% vs. 23.16%, P < 0.001). Immediate reconstruction before PMRT had increased overall and late (>90 days) complication rates, compared with controls (47.46% vs. 23.16%, P < 0.001; 33.90% vs. 15.59%, P < 0.001, respectively); however general and aesthetic satisfaction was similar. In contrast, PMRT before reconstruction has similar complication rates and general satisfaction with controls, but decreased aesthetic satisfaction (50% vs. 66.88%, P < 0.035).

A review of the surgical management of breast cancer: plastic reconstructive techniques and timing implications

The oncologic management of breast cancer has evolved over the past several decades from radical mastectomy to modern-day preservation of chest and breast structures. The increased rate of mastectomies over recent years made breast reconstruction an integral part of the breast cancer management. Plastic surgery now offers patients a wide variety of reconstruction options from primary closure of the skin flaps to performance of microvascular and autologous tissue transplantation. Well-coordinated partnerships between surgical oncologists, plastic surgeons, and patients address concerns of tumor control, cosmesis, and patients' wishes. The gamut of breast reconstruction options is reviewed, particularly noting state-of-the-art techniques, as well as the advantages and disadvantages of various timing modalities.