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Joint Hospital Surgical Grand Round
Breast Reconstruction
after Surgery for Breast Cancer
Steven Law
Pamela Youde Nethersole Eastern Hospital
Breast Cancer
• The most common cancer in females in
Hong Kong
• Incidence 2945/year (24% of all cancers)
• Mortality 555/year
• Life time risk before age of 75: 1 in 19
Hong Kong Cancer Registry 2009
Management of Breast Cancer
• Multidisciplinary approach
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Surgery
Chemotherapy
Radiation therapy
Hormonal therapy
• Surgery remains the mainstay of treatment
for cure
Surgery for Breast Cancer
• Breast-conservation treatment in early
breast cancer
• Mastectomy
• Important factor for patients in choice of
treatment
– Cosmetic concern vs fear of recurrence
Molenaar et al. Br J Cancer 2004;90:2123-30
Consequence of Mastectomy
• Functional deficits
– Inability to breast-feed
• Psychosocial effects
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Anxiety
Depression
Loss of feminity
Negative effects on body images and sexual
function
Breast Reconstruction
• Goal of reconstruction is to restore a breast mound
and to maintain the quality of life without
affecting the prognosis or detection of recurrence
of cancer
Elder EE et al. Breast 2005;14:201-8
Clinical Evidence for Reconstruction
• Support for breast reconstruction has been derived from
cohort studies: reduce anxiety, depression, improve quality of
life
• Benefits of reconstruction are dependant on individual
circumstances and patients’ preference
Harcourt DM et al. Plast Reconstr Surg 2003;111:1060-8
Nano MT et al. ANZ J Surg 2005;75:940-7
Roth RS et al. Plast Reconstr Surg 2005;116:993-1002
• Limitations of these studies
– Patients who elect for reconstruction differ significantly from those
who do not
– Different expectation
Breast Reconstruction
• Restoration of breast mound
– Implant
– Autologous tissue
• Reconstruction of nipple-areolar complex
– When both reconstruction of breast mound and
administration of adjuvant therapy complete
• Surgery may be performed on the contralateral
breast to maximize symmetry
– Breast reduction, augmentation
Breast Reconstruction
• Restoration of breast mound
– Implant
– Autologous tissue
• Reconstruction of nipple-areolar complex
– When both reconstruction of breast mound and
administration of adjuvant therapy complete
• Surgery may be performed on the contralateral
breast to maximize symmetry
– Breast reduction, augmentation
Implants
• Surgical options
– Immediate reconstruction with a standard or
adjustable implant
– Two stage reconstruction with a tissue expander
followed by an permanent implant
– Combination of implant and autologous tissue
Reconstruction with Implants
• Materials: saline or silicone gel
• Can be anatomically shaped (tear drop) or round
• No association with cancer, immunologic or neurologic
disorders
Evans et al. Plastic Reconstr Surg 1995;96:1111-8
Deapen et al. Plastic Reconstr Surg 2000;105:535-40
• Potential association in case of rupture: connective tissue
disease, fibromyalgia
Gaubitz et al. Rheumatology 2002;41:129-35
• Cumulative incidence of rupture at 10 years has been
reported up to 38% in some studies
Brown et al. J Rheumatol 2001;28:996-1003
Single-stage Implant Reconstruction
• Only suitable for small, non-ptotic breast
with adequate amount of good quality skin
and muscle
• Disadvantage:
– aesthetic outcome usually not as good as two
stage reconstruction
– Revisionary procedure is required in many
instance
Two-stage Implant Reconstruction
• A tissue expander is placed in
submuscular position (pectoralis major
and serratus anterior muscles)
• Tissue expander is serially inflated with
saline, weekly up to 8 weeks
• Adjuvant chemotherapy can be given
• Then final implant is inserted as
outpatient
• Most common approach
American Society of Plastic Surgeon 2007
Combination of Implant and
Autologous Tissue
• In patient with the skin-muscle envelope not
adequate for expansion
• Autologous tissue (most commonly latissimus
myocutaneous flap) is used for adequate coverage
• Contributing factors:
– large skin resection at time of mastectomy
– multiple scars
– radiation injury resulting in non-expansile pocket
• Increased morbidity compared with implant alone
Autologous Tissue-based
Reconstruction
• Donor sites: abdomen, back, buttock, thigh
• Skin, fat and muscle transferred as
– pedicled flap with it own blood supply
– a free flap requiring microvascular anastomosis
at the recipient site
Transverse rectus abdominis
myocutaneous (TRAM) Flap
• Skin, soft tissue and
rectus abdominis
muscle in the
infraumbilical region
• Superior epigastric
vessel
• Low, horizontal scar
American Society of Plastic Surgeon 2007
Latissimus Dorsi Flap
• Skin, fat overlying latissimus dorsi
muscle with thoracodorsal vessel as
pedicle
• Rotated from back to chest
• Usually used in smaller breast size
• Can be used in combination with
implant in patient with insufficient
skin
American Society of Plastic Surgeon 2007
Free Flap Reconstruction
• Most common recipient
vessels
– Thoracodorsal vessel via
axillary dissection
– Internal thoracic vessel
require removal of 3th or
4th rib cage with access
• Donor sites
– Abdomen: Free TRAM flap,
DIEP flap, SIEA flap
– Bottocks: SGAP flap
American Society of Plastic Surgeon 2007
Oncological Safety of
Reconstruction
• No difference in the incidence of locoregional recurrence
up to 8 years post op in breast cancer patients who undergo
reconstruction compared with those patients who do not
Mc Carthy et al. Plast Reconstr Surg 2008;121:381-8
• Immediate breast reconstruction is oncologically safe for
stage 1 and 2 breast cancer patient up to 15 years
European Journal of Surgical Oncology. 33(10):1142-5, 2007 Dec
• Prosthetic breast reconstruction does not hinder detection
of locoregional cancer recurrence
Huang et al. Plast Reconstr Surg 2006;118:1079-88
Complications: Implant
• Early complication
– Skin flap necrosis, Infection (1-24%)
• Late complication
– Capsular contracture (Baker grade II to IV, incidence
14-40%)
– leak or rupture
– rippling
• Risk increased with history of irradiation or postoperative
radiotherapy
Ascherman et al. Plastic & Reconstructive Surgery. 117(2):359-65, 2006 Feb
Cordeiro et al. Platic Reconstr Surg 2006;118:825-31
Complications: Autologous Tissue
• Risk of fat necrosis, flap loss (0.5-5% in literature)
• Donor site scar, abdominal weakness or hernia
• High risk patients
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old age
Obesity
Smoker
diabetes
Blondeel N et al. Br J Plast Surg 1997;50:322-30
Nahabedian et al. Ann Plast Surg 2005;54:124-9
Complications:
Implant vs Autologous Tissue
• No difference in complication rates between tissue
expander/implant and autologous tissue reconstruction
• No difference in complication rates between specific types
of autologous tissue used
Alderman et al. Plast Reconstr Surg 109:2265, 2002
Timing for Reconstruction
• Immediate reconstruction has the potential benefits of
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Fewer operation
Decreased cost
Less psychological impairment
No impairment on survival, recurrence and monitoring by
mammogram
Holley et al. Am. Surg 61:60, 1995
Noone et al Plast Reconstr Surg 93:96, 1994
• Disadvantage of immediate reconstruction
– Higher complication rates (49-60% vs 31-37% in delayed group)
Alderman et al. Plast Reconstr Surg 109:2265, 2002
Literature Review: Immediate vs
Delayed Reconstruction
• Latest review in Cochrane found only one RCT in
the literature addressing effect of the timing of
reconstruction on patient’s outcomes
– Immediate reconstruction reduce psychiatric morbidity
at 3 months postoperatively (Dean et al. Lancet
1983;1(8322):459–62)
Immediate versus delayed reconstruction following surgery
for breast cancer. Cochrane Review 2011
Immediate vs Delayed Reconstruction
• Immediate reconstructions had significantly higher
morbidity rate compared with delayed procedures
– Higher morbidity in implant patients who received radiotherapy
Alderman Plastic & Reconstructive Surgery. 109(7):2265-74, 2002 Jun.
• Delayed reconstruction decrease ischemic complications in
pedicle TRAM flap
Atisha et al. Annals of Plastic Surgery. 63(4):383-8, 2009 Oct.
• Reason for higher morbidity in immediate reconstruction
– Contamination of the surgical field during mastectomy
– Marginal mastectomy skin flap viability
– Increased inflammation in local tissue after mastectomy
Immediate vs Delayed Reconstruction
• No difference in breast pain between immediate vs delayed
reconstruction at 2 years
Roth et al. Annals of Plastic Surgery. 58(4):371-6, 2007 Apr.
• No statistical difference in complication rate between
immediate vs delayed reconstruction using DIEP and SIEA
flaps
Cheng et al. Plastic & Reconstructive Surgery. 117(7):2139-42
Immediate vs Delayed Reconstruction
• No statistical difference in risk of depression or anxiety
between immediate vs delayed reconstruction
Fernandez-Delgado et al Annals of Oncology. 19(8):1430-4, 2008 Aug
Harcourt et al Plastic & Reconstructive Surgery. 111(3):1060-8, 2003 Mar.
• No difference in psychological impact between immediate
vs delayed reconstruction at 1 year
Wilkins et al Plastic & Reconstructive Surgery. 106(5):1014-25, 2000
Decision
• The decision to choose or decline breast reconstruction
should be made by the patient
Surgeon
Patient
Decision
Medical oncologist
Radiation oncologist
• Patient’s satisfaction is highest when the patient is
adequately informed with the decision being consistent
with her own wishes and expectations
Sheehan J et al. Psychooncology 2007;16:342-51
Lantz PM et al. Health Serv Res 2005;40:745-67
Patient satisfaction
• Women with pedicle TRAM flaps, free TRAM
flaps, and expander/implants had similar levels of
general satisfaction in the long-term
Alderman et al. Michigan result outcome study. Journal of the American
College of Surgeons. 204(1):7-12, 2007 Jan.
Conclusion
• Immediate implant reconstruction is associated with
significant morbidity, especially in patient who received
radiotherapy
• No difference in outcome between different types of
autologous reconstruction
• Currently no strong evidence in the literature in addressing
the effect of timing for reconstruction
• Preoperative multidisciplinary counseling is important,
addressing patient expectation and enhancing postoperative
satisfaction
Thank You