Hani Sbitany, MD

Assistant Professor of Surgery University of California, San Francisco

Division of Plastic and Reconstructive Surgery

Current Strategies in Breast

Reconstruction

12th Annual School of Breast Oncology

Atlanta, Georgia

November 7, 2014

Repair of Partial Mastectomy Defects

with Oncoplastic Surgery

SOBO 2012 Presentation

SOBO 2012 Presentation

Oncoplastic Reconstruction – Effects of

Timing on Complication Rates

All

Reconstruction

following Partial

Mastectomy

Immediate

Reconstruction

Before XRT

Delayed

Reconstruction

after XRT

30%

26%

42%

Kronowitz, SJ, et.al. Determining the optimal approach to breast reconstruction after partial

mastectomy. Plast Reconstr Surg. Jan. 2006.

Techniques for Oncoplastic Surgery

• Local Tissue Rearrangement • B to C cup breast •Small tumor •Grade 1 ptosis •No skin resection

• Oncoplastic Reduction Mammoplasty •C to D cup breast •Grade 2 to 3 ptosis •Some skin resection

Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial

Mastectomy Defects. PRS 2008.

Local Tissue Rearrangement

Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial

Mastectomy Defects. PRS 2008.

Local Tissue Rearrangement

Oncoplastic Reduction Mammoplasty

-Use of neoadjuvant

chemotherapy

-Breast conservation

therapy (BCT)

-Oncoplastic mammoplasty

-Extends BCT option

-Improved cosmetic results

-Minimizes adverse

effects of XRT

Indications

- Minimal Skin Resection or Tumor within Wise

Pattern

- C-Cup Breast Size with ptosis or Small Tumor

- D-Cup Breast size

SOBO 2012 Presentation

Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to

Repair Partial Mastectomy Defects. PRS 2008.

Locally advanced breast cancer

- Neoadjuvant chemotherapy

- Post-operative radiation therapy

Oncoplastic mammoplasty

(N = 37)

Mastectomy with immediate breast

reconstruction

(N = 64)

Two-stage TE

(N = 40)

Autologous (N = 24)

Review of prospectively-maintained surgical

outcomes database

20(3), 2014; 302-307

Oncoplastic mammoplasty

(N = 37)

Mastectomy/reconstruction

(N = 64)

Mean age 52.3 years 45.5 years

Mean BMI 29.2 kg/m2 25.2 kg/m2

Diabetes 2 (5.4%) 1 (1.6%)

Tobacco use 1 (2.7%) 0

Tumor stage

I 0 0

II 20 (54.1%) 29 (45.3%)

III 14 (37.8%) 33 (51.6%)

IV 3 (8.1%) 2 (3.1%)

Median follow-up 32 months (4 – 116) 30.5 months (8 – 74)

20(3), 2014; 302-307

Oncologic Outcomes

Recurrence-free survival

Cancer-specific survival

Oncoplastic mammoplasty

Mastectomy/reconstruction

P = 0.29

P = 0.27

Oncoplastic mammoplasty

Mastectomy/reconstruction

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic

mammoplasty as a strategy for reducing reconstructive

complications associated with post-mastectomy radiation

therapy. Presented at the 2013 American Society of Plastic

Surgery Meeting, San Diego, California. October 12, 2013.

0

10

20

30

40

50

Oncoplastic mammoplasty

Mastectomy/reconstruction

**

19%

45%

3%

38%

11%

30%

16%

36%

5% 8%

Complications

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

•Oncoplastic mammoplasty with equivalent oncologic safety

and fewer complications in setting of neoadjuvant chemo and

PMRT

•Early evaluation by plastic surgeon/multi-disciplinary

approach

•Role in pre-operative patient

counseling/decision-making

Conclusions – Oncoplastic

Reduction

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

Treatment Algorithm

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

Oncoplastic Reduction Mammoplasty

Breast Reconstruction

After Mastectomy

Immediate Reconstruction

Immediate Reconstruction

Bilateral DIEP free flaps

Delayed Reconstruction

Delayed Reconstruction

Implant-Based Breast

Reconstruction

• Two-Stage Implant

• One-Stage Implant

Two-Stage Breast Reconstruction

Tissue Expander Followed By Permanent Implant

Two-Stage Breast Reconstruction

Tissue Expander Followed By Permanent Implant

Two-Stage Implant Example of Outcome

Two-Stage Implant: 2nd Stage

Additional Enhancements

ADM: Acellular Dermal Matrices

Acellular Dermal Matrix

Plast Reconstr Surg. 134: 396, 2014

Autologous Fat Grafting

Microsurgical Breast

Reconstruction

TRAM/DIEP Flap Breast

Reconstruction

Pedicled TRAM Flap

Free (Microvascular)

TRAM Flap

Free & Pedicled TRAM Flap

ABDOMINAL DONOR SITE

DIEP: Deep Inferior Epigastric

Perforator Flap

GAP: Gluteal Artery Perforator

Perforator Flaps

Abdominal Wall Perforators

Abdominal Wall Perforators

Deep Inferior Epigastric Perforator

Deep Inferior Epigastric Perforator

(DIEP) Flaps

SOBO 2012 Presentation

SOBO 2012 Presentation

Case example: DIEP

flap

Autologous Tissue +

PMRT

Redesigned GAP Flap

Kronowitz, SJ. The Gluteal Artery Perforator Flap Re-designed for Breast Reconstruction. PRS,

March 2008.

Case Example: Redesigned GAP flap

SOBO 2012 Presentation

Case Example: Redesigned GAP flap

SOBO 2012 Presentation

Total Skin

Sparing

Mastectomy

Annals of Plastic Surgery. Accepted for Publication - In Press. Epub ahead of print, 2014 Jul 23.

Total skin-sparing

mastectomy Preservation of entire breast

skin envelope with excision

of nipple-areolar complex

(NAC) tissue

Benefits

Aesthetic

Psychological

Purpose

Review 12-year experience with nipple-sparing mastectomy

(NSM) and immediate reconstruction

-Oncologic outcomes

-Surgical complications

Methods

Prospectively-maintained database of TSSM and

immediate reconstruction (2001-2012)

Outcomes

Tumor recurrence

-Local-regional

-NAC

Post-operative complications

-NAC necrosis

-Mastectomy skin flap necrosis

Tumor characteristics Total patients 599

Total cases 924

Indication for mastectomy

Therapeutic 604 (65.4%)

Prophylactic 320 (34.6%)

Contralateral 60%

Bilateral 40%

Tumor stage

In situ 148 (16%)

Stage I 204 (22.2%)

Stage II 162 (17.5%)

Stage III 84 (9.1%)

Stage IV 6 (0.6%)

Prophylactic 320 (34.6%)

Treatment characteristics

Chemotherapy

Any 294 (49%)

Neoadjuvant 195 (66%)

Adjuvant 99 (34%)

Radiation therapy

Any 181 (20%)

Prior history 67 (37%)

Post-mastectomy 114 (63%)

TSSM incisions

0%

20%

40%

60%

80%

100%

1st 100 cases Next 557 cases

IMF

Radial

Lateral

Mastopexy (< 30% of NAC)

Mastopexy (>30% of NAC)

Free graft

NAC crossing

Inframammary Radial Lateral/

Inferolateral

Mastopexy Type

Involving < 30% of the NAC

Preferred

Involving > 30% of the NAC

Circumareolar/ Free

Graft NAC

Crossing

No longer

recommended

Reconstructions performed

Two-stage

expander-implant Microvascular

(abdominal, gracilis)

Transverse rectus

abdominis myocutaneous

(TRAM) flap

Immediate

permanent implant

0%

20%

40%

60%

80%

100%

1st 100 cases Next 557 cases

Immediate implant

TRAM flap

Microvascular

2-stage expander-implant

Ischemic complications

(n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125) (n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125)

(n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125) (n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125)

0%

5%

10%

15%

20%

Nipple necrosis (partial or complete) Skin flap necrosis

1st 100 cases

Next 557 cases

Latest cohort

Local-regional recurrence N Local recurrence, n

(%)

All patients

(median follow-

up: 28 months)

Total

Invasive cancer

In situ cancer

412

301

111

8 (1.9)

5 (1.7)

3 (2.7)

Patients with

minimum 36

months follow-up

(median: 45

months)

Total

Invasive cancer

In situ cancer

126

95

31

3 (2.4)

2 (2.2)

1 (3.2)

No recurrences in the NAC

Distant recurrence

N Distant recurrence,

n (%)

All patients

(median follow-

up: 28 months)

Total

Invasive cancer

In situ cancer

412

301

111

12 (2.9)

11 (3.7)

1 (0.9)

Patients with

minimum 36

months follow-up

(median: 45

months)

Total

Invasive cancer

In situ cancer

126

95

31

2 (1.6)

2 (2.2)

0 (0)

Conclusions

Low rates of local-regional recurrence

No recurrences in the NAC

Low rates of ischemic complications

Targeted technical improvements

-Incisions avoiding NAC

-Minimal pressure on NSM skin flaps

--2-stage tissue expander reconstruction

--Delayed autologous reconstruction

Expanded Experience

Plast Reconstr Surg. 134: 396, 2014

Plast Reconstr Surg. 134: 169, 2014

Plast Reconstr Surg. 134: 169, 2014

FIGURE 1. Complication rates for inframammary fold incisions (IMF) compared to all other types of incisions *

* Other incision types includes sub-areolar, radial, lateral, circumareolar incisions

!!!!!!!!!!!!!! !

21.0% 21.0%

11.3%

29.0%

11.3%

0.0%

10.3% 10.3%

0.0%

17.2%

6.9%

0.0% 0% 5%

10% 15% 20% 25% 30% 35%

Incisional

breakdown

p=0.2

Unplanned OR for

incisional

breakdown

p=0.2

Implant loss

due to incisional

breakdown

p=0.06

Significant

infection

p=0.2

Implant loss from

infection

p=0.5

NAC necrosis

p=1.0

Inframammary Fold Incision (IMF) All Other Incision Types *

• Review of prospectively-collected complications database of TSSM/expander-

implant reconstruction from 2005-2012

• Compared IMF incision to all incisions in non-dependent areas of breast

No Hormonal

(n=342)

Hormonal

(n=425)

P-value

Chi-Square

Wound

Breakdown

26 (8%) 42 (10%) .3

Infections

PO Antibiotics 35 (10%) 78 (18%) .002

IV Antibiotics 33 (10%) 52 (12%) .3

Procedure 18 (5%) 35 (8%) .1

Implant Exposure 14 (4%) 21 (5%) .6

Implant Loss 24 (7%) 31 (7%) .9

Expanded Experience

Effects of Hormonal and Anti-HER Therapy

Wang F, Peled A, Alvarado M, Ewing C, Fowble B, Esserman L, Foster R, Sbitany H. The Impact of Hormonal and Anti-HER Therapy

on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Reconstruction. Plast Reconstr Surg. Submitted

for Publication

Overall Complications by hormonal therapy (n=767)

No Anti-HER

(n=675)

Anti-HER (n=92) P-value

Chi-Square

Wound

Breakdown

63 (9%) 5 (5%) .2

Infections

PO Antibiotics 102 (15%) 11 (12%) .4

IV Antibiotics 78 (12%) 7 (8%) .3

Procedure 48 (7%) 5 (5%) .6

Implant Exposure 31 (5%) 4 (4%) .9

Implant Loss 48 (7%) 7 (8%) .9

Expanded Experience

Effects of Hormonal and Anti-HER Therapy

Wang F, Peled A, Alvarado M, Ewing C, Fowble B, Esserman L, Foster R, Sbitany H. The Impact of Hormonal and Anti-HER Therapy

on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Reconstruction. Plast Reconstr Surg. Submitted

for Publication

Overall Complications by anti-HER therapy (n=767)

Thank You