Options for immediate breast reconstruction following skin-sparing mastectomy

Postmastectomy radiation of latissimus dorsi myocutaneous flap reconstruction is well tolerated in women with breast cancer

Chest wall irradiation decreases locoregional recurrence and breast cancer-related mortality in women at high risk for recurrence after mastectomy. Many women undergoing mastectomy desire immediate breast reconstruction. Postmastectomy radiation therapy (PMRT), however, increases the risk of surgical complications and may adversely affect the reconstructed breast. We compared outcomes of immediate latissimus dorsi myocutaneous flap (Lat Flap) versus tissue expander/implant (EI) reconstruction after mastectomy followed by PMRT in 29 women with invasive breast cancer treated at a single institution between 2009 and 2011. Although patients undergoing EI reconstruction were slightly younger and more frequently underwent bilateral mastectomy, there were no major differences between the groups with respect to patient or tumor characteristics. With a median follow-up of 11 months (Lat Flap) and 13 months (EI) after completion of PMRT, there was a trend toward more wound complications requiring reoperation, including expander/implant loss (n=3), in the EI group. Capsular contracture was the most common sequela of PMRT in the Lat Flap group (67%) but this was easily treated with capsulotomy at the time of nipple-areola reconstruction. Immediate breast reconstruction with a latissimus dorsi myocutaneous flap is a viable option for women undergoing mastectomy who are likely to require chest wall irradiation.

Nipple reconstruction with banked costal cartilage after vertical-type skin-sparing mastectomy and deep inferior epigastric artery perforator flap

We recently used skin-sparing mastectomy (SSM), the deep inferior epigastric artery perforator (DIEP) flap, and delayed nipple reconstruction with banked costal cartilage. Eight patients who underwent these reconstructions between 2008 and 2010 were reviewed. SSM was performed by vertical-type incision. We transferred the DIEP flap using an internal thoracic vessel and banked costal cartilage into an abdominal wound. Three to 6 months later, we removed the cartilage and cut it into a cylindrical shape. We fixed the cartilage on the dermal base of a modified C-V flap. No flap necrosis or exposure of cartilage was seen and the scar was acceptable in all cases. At a mean follow-up of 12.6 months, 59% of the nipple projection was maintained in comparison to immediately postoperatively. Our new concept is the combination of SSM, DIEP, and banked cartilage, and furthermore putting the cartilage on a dermal base. With support from the dermis, a large, complicated cartilage form is unnecessary.

Reporting clinical outcomes of breast reconstruction: a systematic review

BACKGROUND

Breast reconstruction after mastectomy for cancer requires accurate evaluation to inform evidence-based participatory decision making, but the standards of outcome reporting after breast reconstruction have not previously been considered.

METHODS

We used extensive searches to identify articles reporting surgical outcomes of breast reconstruction. We extracted data using published criteria for complication reporting modified to reflect reconstructive practice. Study designs included randomized controlled trials, cohort studies, and case series. The Cochrane Risk of Bias tool was used to critically appraise all study designs. Other criteria used to assess the studies were selection and funding bias, statistical power calculations, and institutional review board approval. Wilcoxon signed rank tests were used to compare the breadth and frequency of study outcomes, and χ² tests were used to compare the number of studies in each group reporting each of the published criteria. All statistical tests were two-sided.

RESULTS

Surgical complications following breast reconstruction in 42,146 women were evaluated in 134 studies. These included 11 (8.2%) randomized trials, 74 (55.2%) cohort studies, and 49 (36.6%) case series. Fifty-three percent of studies demonstrated a disparity between methods and results in the numbers of complications reported. Complications were defined by 87 (64.9%) studies and graded by 78 (58.2%). Details such as the duration of follow-up and risk factors for adverse outcomes were omitted from 47 (35.1%) and 58 (43.3%) studies, respectively. Overall, the studies defined fewer than 20% of the complications they reported, and the definitions were largely inconsistent.

CONCLUSIONS

The results of this systematic review suggest that outcome reporting in breast reconstruction is inconsistent and lacks methodological rigor. The development of a standardized core outcome set is recommended to improve outcome reporting in breast reconstruction.

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.

[Breast reconstruction following amputation for cancer]

BACKGROUND/AIM

Today, breast reconstruction is a widely accepted method in the treatment of breast cancer after modified radical mastectomy. Reconstruction methods are associated with an acceptable number of complications and reconstruction favourably impacts quality of life. The aim of the study was to present our experience in breast reconstruction.

METHODS

We presented here a four-year experience with 84 patients with breast reconstruction after modified radical mastectomy.

RESULTS

Implant reconstructions were most common, 44 (52.3%), with primary reconstruction in 31 (70.4%) and secondary in 13 (29.5%) women. Lattisimus dorsi flap (LDF) and implant were utilized in 32 (38%) of the patients, with primary reconstruction in 24 (75%) and secondary in 8 (25%) women. Transversal rectus abdominis myocutaneous (TRAM) flap was rarely used -- just in 8 (9.5%) patients and only for secondary breast reconstruction. Postoperatively, some early complications such as hematoma, seroma, infections and partial flap necrosis were observed in 10 (11.9%) patients. Late complications, such as implant rejection, hypertrophic scarring and hernias at the flap elevation site, were noted in 10 (11.9%) cases. Implant loss occurred in 5 (5.9%) cases. All the complications were successfully managed, and patients rated their reconstruction as follows: excellent, 49 (59%) cases; very good, 20 (24%), and good, 14 (16.8%). In one case, disease progression was observed 6 months after the primary breast reconstruction.

CONCLUSION

Breast reconstruction is an acceptable method in the treatment of breast cancer in patients in the need for or with already performed mastectomy. The choice of reconstruction approach depends on the breast volume, patient's wish and experience of surgical team. Our results suggest the advantage of breast reconstruction with LDF with implant, since the technique is safe, complications relatively rare and easily manageable, and the results are excellent or very good in each woman.