Joint Hospital Surgical Grand Round

Breast Reconstruction after Surgery for Breast Cancer

Steven LawPamela 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– 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– 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;111:1060-8Nano 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

disordersEvans 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, fibromyalgiaGaubitz 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

– old age– Obesity– Smoker– diabetes

Blondeel N et al. Br J Plast Surg 1997;50:322-30Nahabedian 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– Fewer operation– Decreased cost– Less psychological impairment– No impairment on survival, recurrence and monitoring by

mammogramHolley 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

Radiation oncologist

PatientDecision

Medical oncologist

Surgeon

• 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