Current concepts in breast reconstruction.

Current concepts in breast reconstruction.

Abstract:	Breast cancer affects many women, but with advances in detection and treatment, survival rates have increased. Thus, it is important to understand that there are many reconstructive options available to help ease the psychological burden of mastectomy. Reconstructive options include tissue expander/implants, biologics, and several autologous tissue options, including pedicled latissimus and TRAM flaps, free TRAM flaps, and perforator flaps. We present a discussion of reconstructive techniques, the risks and benefits of each, and individual patient considerations that will help physicians to guide treatment options.

Article Type:	Report
Subject:	Breast cancer (Care and treatment) Breast cancer (Patient outcomes) Breast implants (Usage) Breast implants (Health aspects) Breast prosthesis (Usage) Breast prosthesis (Health aspects) Mammaplasty (Methods) Mammaplasty (Health aspects)
Authors:	Rawson, Ashley E. McClellan, W. Thomas
Pub Date:	10/01/2009
Publication:	Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 West Virginia State Medical Association ISSN: 0043-3284
Issue:	Date: Oct, 2009 Source Volume: 105 Source Issue: S1
Geographic:	Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number:	218949136
Full Text:	Objectives The reader should be able to discuss the current concepts of breast reconstruction with their patients, including the most common techniques and explain the difference between implant and autologous reconstruction. Additionally the reader should have a better understanding as to the services a plastic surgeon can offer women with breast cancer and when referral is appropriate. Introduction Breast cancer continues to be a prevalent diagnosis in our society, affecting one out of every eight women throughout their lifetime. Breast cancer is the second most common malignant tumor in females and the second leading cause of death of females in the United States (1). However, due to advances in detection and treatment options, breast cancer death rates have decreased, and as of 2008, there are approximately 2.5 million breast cancer survivors in the United States (2). This extraordinary number of survivors should expand the physician's focus not only to breast cancer survival but also to quality of life after breast cancer. Therefore, it is important for physicians to be aware of the reconstructive options available following mastectomy to assist their patients in making informed decisions. Studies have shown that fewer than 10 percent of those undergoing mastectomy for breast cancer elect for reconstruction (3). Reconstruction has been shown to have a positive psychological benefit, eliminates a constant reminder of their disease and helps to alleviate feelings of deformity that follow mastectomy.(5) Importantly, research has also shown that one of the major reasons for not choosing breast reconstruction was lack of education about the procedure (4). This article summarizes current concepts in breast reconstruction for physicians in order to better educate their patients about surgical options. We present many reconstructive options, associated morbidities, and risk factors that influence selection and outcome. Implant Reconstruction Implant reconstruction is currently the most common form of breast reconstruction. However, it is important to understand patient selection. Implants are best used for thin women with smaller breasts who are in need of a bilateral reconstruction in order to improve symmetry and avoid the need for a donor site. Donor abdominal or gluteal tissue is often inadequate for breast reconstruction in thin women. Implant reconstruction is typically preceded with a tissue expander (TE) placed deep to the pectoralis muscle and expanded on a weekly or biweekly basis until approximately 30 percent over-expansion is reached (6). Once the desired size and breast homeostasis has been reached, the inflated expander is replaced with an implant. The two stage nature of this procedure may be considered as a disadvantage to some patients. Now that skin sparing mastectomy has become more accepted, it is possible to fill the TE to near capacity at the time of mastectomy. It obviates or reduces the need for postoperative expansion and does reduce the chance of infection or TE loss due to filling. Some surgeons will perform immediate placement of a permanent implant following skin sparing mastectomy, however the risk of infection is greater (6). There are two implant options available-silicone and saline. It is important for patients to understand that research has demonstrated that silicone is a safe and effective reconstructive option and has not been linked to connective tissue disease. Silicone implants have a more natural feel and appearance, but are heavier and require a longer incision for placement. On the other hand, saline implants are less expensive and can be adjusted for size intra-operatively, but carry the risk of subsequent deflation. Please see Figure 1. [FIGURE 1 OMITTED] The advantages of implant reconstruction include reduced operating times, decreased surgical morbidity, and no need for a donor site (6). However, there are certain complications specific to implants including capsular contraction, leaking/deflation, migration of the implant and a two stage surgical repair (6). It is also important to understand that implant reconstruction is not an option for those who have inadequate tissue envelope or when adjuvant radiation is anticipated. Biologic Reconstruction Another recent advancement in plastic surgery is the utilization of a biologic dermal matrix to support implant reconstructions. These dermal matrices are immunologically inactive, safe for use in humans, and serve to provide a structural framework for revascularizion (7). This material has enhanced the effectiveness of many reconstructive options, especially immediate and delayed implant reconstruction. In order to facilitate implant reconstruction, the dermal sling is sutured to the chest wall and anterior rectus abdominus fascia, creating a pocket or hammock for subsequent implant or tissue expander placement. Then, the superior portion of the graft is sutured to the inferior aspect of the pectoralis muscle in order to completely cover the implant. The dermal graft serves many functions in improving the outcome of implant reconstruction. It serves as a protective barrier between the implant and skin and because of its superior tensile strength, it controls the position of the implant and inframammary fold (7). The biologic graft also decreases the force transmission to the implant itself. One study showed that the long term implications of biologic grafts include overall patient satisfaction with few complications, including no capsular contracture, hematoma, or seroma in a 6 month to 3 year follow up (7). Part of this long term success with dermal grafts may be partly attributed to its successful incorporation into native tissue. This is evidenced by graft revascularization with granulation tissue formation 3 months after expander placement (7). Recent evidence suggests that this dermal hammock may be used with TE and implant reconstruction following radiation. (8) This would be a a significant change from previous thoughts in which radiation was a relative contraindication for TE/implant reconstruction. Please see figure 2 and figure 3. [FIGURE 2 OMITTED] [FIGURE 3 OMITTED] Autologous Reconstruction Autologous reconstruction involves the transfer of tissue from various anatomical sites, while preserving its native vasculature. The use of autologous tissue offers a more natural appearing breast while avoiding implant related complications. In addition, this type of reconstruction provides better symmetry for women with larger, more pendulous breasts. Although autologous tissue has many advantages, it is important to understand that it also requires longer surgical times in addition to longer post-operative hospitilization. Autologous reconstruction comes in many forms, including pedicled, free, and perforator flaps, each with their own advantages and disadvantages. Pedicled TRAM Flap/Pedicled Latissimus Flap The pedicled transverse rectus abdominis (TRAM) flap is currently the most common type of autologous breast reconstruction. Originally described at Emory in 1982 by Hartramph, this approach involves the transfer of infraumbilical skin and subcutaneous tissue to the mastectomy defect. This is achieved by tunneling the tissue subcutaneously while preserving the deep superior epigastic vascular pedicle found within the rectus abdominus muscle. Because this represents the non-dominant blood supply to infraumbilical tissue, vascularization via the superior epigastric artery may need to be increased to improve outcomes in patients who are obese, smoke, or have a history of prior radiation. This can be achieved by division of the deep inferior epigastric artery approximately 10 to 14 days prior to reconstruction, resulting in increased vessel diameter of the superior epigastric artery. Complications of TRAM flap include abdominal wall laxity and weakness, fat necrosis, flap necrosis, bulging of inframedial breast fold, pulmonary embolus, and seroma (6). Please see figure 4 and figure 5. [FIGURE 4 OMITTED] [FIGURE 5 OMITTED] Another type of pedicled flap is the latissimus flap. This approach involves tunneling the latissimus dorsi muscle and thoracodorsal vascular pedicle through the axilla to cover the mastectomy defect (6). Due to its reliable blood supply, this method is good for patients who are obese or who have a smoking history. Latissimus flaps can also be used for salvage surgeries in which other methods fail in addition to replacing radiation-damaged tissue (6). This flap is also a good option for thin women who do not have sufficient abdominal tissue to achieve the TRAM flap, but usually requires implant placement in addition to the autologous tissue (8). Complications include capsular contracture, flap dehiscence, implant extrusion, necrosis, infection, seroma, and hematoma (9). Free TRAM Flap The free TRAM flap uses the same donor site as the pedicled TRAM flap but uses the dominant inferior epigastric artery as its blood supply. Therefore, larger amounts of tissue can be used without the fear of necrosis, which may be advantageous in the reconstruction of larger breasts. In addition, the use of dominant blood supply increases the vascularity of the flap making this an excellent option for smokers, obese, and those with a history of radiation. However, free TRAM flaps do have several disadvantages including: increased difficulty, microvascular thrombosis, and longer surgical time as compared to its pedicled counterpart (6). Perforator Flap Perforator flaps are the newest type of flap reconstruction. The advent of perforator flaps evolved due the need to decrease the donor site morbidity that is often involved with the TRAM flaps. These flaps allow for the transfer of autologous skin and subcutaneous tissue from many different sites with minimal donor site morbidity. The multitude of donor site options essentially allows all patients to be potential candidates for this type of reconstruction. However, these flaps are challenging due to the wide variability in vascular anatomy, require significant microsurgical expertise with a large learning curve of 50-100 procedures, and are significantly longer procedures. Contraindications for perforator flaps include liposuction, active smoking, and BMI >30 (10). Two of the most common donor sites utilized in this type of reconstruction are infraumbilical abdominal tissue and gluteal tissue. The same infraumbilical tissue used for the TRAM flap reconstruction is used in the deep inferior epigastric perforator (DIEP) flap, with the advantage of avoiding disruption to the muscle and fascia. The perforating vessels that supply the skin and subcutaneous tissue are dissected in the plane of the muscle fibers, with subsequent transplant of the flap to the mastectomy defect and anastamosis of the vessels to the internal mammary artery and vein. This reconstructive option decreases donor-site morbidity, pain, and recovery time (10). Gluteal tissue is another potential donor site, but with a higher fat-to-skin ratio as compared to the abdomen. This flap is an ideal option for women with larger buttock regions or when abdominal tissue is not an option for the patient, in such cases as previous abdominal surgery or liposuction. Please see figure 6. [FIGURE 6 OMITTED] Like the DIEP flap, the gluteal artery perforator (GAP) flap minimizes donor-site morbidity and spares the underlying muscle. There are several ways of achieving this flap, including a superior and inferior approach. In both cases, an ellipse shaped incision is made and the transplant of tissue is made in the same fashion as the DIEP flap, with the gluteal artery serving as the vascular supply. Using the superior approach, the scar is concealed in swimsuits and undergarments but the pedicle length is shorter than the inferior approach, making the anastamosis more difficult. The inferior approach utilizes the natural crease of the inferior buttock, but leads to increased wound dehiscence and causes more pain while sitting due to the location of the incision (1). Smoking Active smokers with breast cancer who present for surgical reconstruction have significant potential complications for all types of breast reconstruction. Smoking puts the patient at risk for delayed wound healing and poor surgical results and its effects on reconstructive surgery are well documented. For example, TRAM flap reconstructions in this population are at increased risk for multiple flap complications, infections, delayed wound healing, and total flap necrosis (11). In addition, when tissue expanders are used there is an increased risk of infection and skin necrosis (6). Therefore, all smokers should be counseled about these risks and strongly encouraged to stop smoking at least four weeks prior to surgery. Even this short amount of smoking cessation leads to substantial risk modification, decreasing complication rates to that of a nonsmoker following TRAM reconstruction (11). This represents an important opportunity for both plastic surgeons and primary care providers to provide beneficial patient information while subsequently decreasing the complication rate accompanying breast reconstruction. Obesity Obesity continues to be a nationwide epidemic and an even greater problem in West Virginia. Therefore, it is critical for physicians to be aware of the complications unique to this population following reconstructive surgery. Overweight patients are at much higher risk of complications including flap failure, donor site complications, and skin flap necrosis. However, although obese patients do have higher complication rates, many plastic surgeons are still willing to perform breast reconstruction in this patient population in order to improve patient outcomes. Autologous reconstruction with a TRAM flap is a good option for obese patients. Research has shown no difference in satisfaction between normal weight and obese individuals who undergo TRAM flap reconstruction (12). However, obese patients do have decreased aesthetic satisfaction with expander/ implant options. This difference in satisfaction is most likely due to the TRAM flap's ability to recreate more variable breast shapes and achieve greater symmetry than implants in larger breasts (12). Therefore, it is important to educate obese patients that they do have reconstructive options following mastectomy that lead to positive outcomes. Radiation The patient's potential need for radiation in conjunction with mastectomy presents an interesting challenge for plastic surgeons. Radiation not only increases complications such as capsular contracture, delayed wound healing, infection, and implant extrusion, but has also been a factor that has limited patient's breast reconstruction options (6). It is important to understand that historically, irradiated tissue was a contraindication for implant reconstruction, mainly due to inadequate tissue expansion to envelope the implant following radiation. This array of complications left irradiated patients with only autologous muscle flap as a reconstructive option, which still has higher complication rates than those without radiation (13). However, recent advances utilizing biologic slings have allowed patients who require adjuvant radiation in conjunction with mastectomy alternative choices. In the past, it was feared that leaving the skin behind during the mastectomy would leave the patient at increased risk for recurrence. Contrary to this belief, new research has shown that skin-sparing mastectomy does not affect the regional recurrence of breast cancer and instead, recurrence is a function of both the stage of disease and biology of the tumor itself (14). This new development, in addition to the advent of tissue expander/biologic reconstruction, has allowed patients to undergo a skin sparing mastectomy with immediate reconstruction. This procedure leaves the skin envelope intact with placement of a full tissue expander at the time of mastectomy. The TE is then replaced by implant at a later date, after the patient has completed radiation. Thus, this procedure eliminates the need for tissue expansion following radiation, making implant reconstruction a possibility for this population. However, it is important to note that while this is now an acceptable option, these patients are at higher risk for implant related complications (13). [FIGURE 7 OMITTED] Immediate versus Delayed Reconstruction When discussing reconstructive options with patients, it is important to include information regarding immediate versus delayed reconstruction. As previously mentioned, skin sparing mastectomy has played a huge role in the emergence of immediate breast reconstruction as an attractive option for many patients. In addition to preservation of the skin envelope and improved results with recent advances in tissue expanders and biologics, this option avoids the psychological trauma of an absent breast. Research has shown that women who undergo immediate reconstruction demonstrate significant gains in emotional well being, vitality, general mental health, and social functioning (15). Immediate reconstruction also decreases the number of required procedures, decreasing the cost and reducing the risk of multiple exposures to anesthesia. However, it is important that the patient is aware that there is a higher rate of infection as compared to delayed reconstruction. In addition, immediate reconstruction involves a longer initial surgery and subsequent radiation need may also be problematic. Delayed reconstruction has a lower rate of infection and also allows time to modify the surgical method to account for radiation therapy. In addition, this approach allows time for smoking cessation to decrease potential complications. However, delaying the reconstruction would require serial tissue expansion if implant reconstruction was preferred by the patient. Another disadvantage of delayed reconstruction is that it does not diminish psychological impact of breast absence for the patient. Women who chose delayed reconstruction had significant psychosocial gains after reconstruction, but they also had significantly worsened preoperative body image compared to women who chose immediate reconstruction with no interim period without a breast (1). Patient expectations Another important aspect to address during the pre-operative period is the patient's expectations of the reconstruction. Patients must understand that the reconstructed breast will not exactly match the unaffected breast. Patients must also understand surgical options, risks, and benefits in order to make an informed decision. In order to better inform the patient, the plastic surgeon's goal should be clearly outlined for the patient. The senior author's goals include the patient's ability to wear a bathing suit or a low cut dress without others knowing that reconstruction has taken place, with full understanding that the patient and intimate partner will be able to see the difference. Overall, good communication ensures that the patient's goals and surgeon's goals are congruent and is an important part of overall patient satisfaction with the results. Conclusion Although breast cancer remains a prevalent issue, advances in reconstructive surgery have enabled women to ease the psychological burden that accompanies the loss of a breast to cancer. With all of the reconstructive options that are available, it is crucial for physicians to understand the risks and benefits of each, and account for individual differences in patients that may impact their outcome. Both primary care physicians and general surgeons have an important opportunity to provide these patients with information about potential options and access to resources through referrals. The healthcare community must work together in order to ensure that these patients are not only survivors of breast cancer, but instead, give these patients a chance to once again be whole. CME Post-Test 9. Currently, what is the most common form of breast reconstruction? a. Free TRAM flap reconstruction b. Implant reconstruction c. Pedicled Latissimus Dorsi flap reconstruction d. DIEP flap reconstruction 10. Which reconstruction method is a good option for salvage surgery? a. Pedicled Latissimus Dorsi flap reconstruction b. Implant reconstruction c. Biologic reconstruction d. Free TRAM flap reconstruction 11. What are two disadvantages of a free TRAM flap as compared to its pedicled counterpart? a. decreased vascularity b. longer operative times c. requires microsurgery d. requires addition of implant 12. T or F Silicone implants are a safe reconstructive option and have not been linked to connective tissue disease. References (1.) General Information About Breast Cancer. National Cancer Institute. 2008. Available at: http://www.cancer.gov/cancertopics/ pdq/screening/breast/Patient/page2. Accessed April 6, 2009. (2.) Breast Cancer Statistics. Breastcancer.org. 2008. Available at: http://www. breastcancer.org/symptoms/understand bc/statistics.jsp. Accessed April 6, 2009. (3.) Kronowitz, S., Hunt, K., Kuerer, H., et al. Delayed-Immediate Breast Reconstruction. Plast Reconstr Surg. 113: 1617, 2004. (4.) Reaby, L. Reasons Why Women Who Have Mastectomy Decide to Have or Not to Have Breast Reconstruction. Plast Reconstr Surg. 101: 1810, 1998. (5.) Bostwick, J. Breast Reconstruction Following Mastectomy. CA Cancer J Clin. 45: 289, 1995. (6.) Sigurdson, L. and Lalonde, D. CME Article: Breast Reconstruction. Plast Reconstr Surg. 121: 1, 2008. (7.) Breuing, K., Colwell, A. Inferolateral AlloDerm Hammock for Implant Coverage in Breast Reconstruction. Ann Plast Surg. 59: 250, 2007. (8.) Komorowska-Timek, E., Oberg, K., Timek, T., et al. The Effect of AlloDerm Envelopes on Periprosthetic Capsule Formation with and without Radiation. Plast Reconstr Surg. 123: 807, 2009. (9.) Kronowitz, S., Robb, G., Youssef, A., et al. Optimizing Autologous Breast Reconstruction in Thin Patients. Plast Reconstr Surg. 112: 1768, 2003. (10.) Granzow, J., Levine, J., Chiu, E., et al. Breast Reconstruction with Perforator Flaps. Plast Reconstr Surg. 120: 1, 2007. (11.) Spear, S., Ducic, I., Cuoco, F., et al. The Effect of Smoking on Flap and Donor-Site Complications in Pedicled TRAM Breast Reconstruction. Plast Reconstr Surg. 116: 1873, 2005. (12.) Atisha, D., Alderman, A., Kuhn, L., et al. The Impact of Obesity on Patient Satisfaction with Breast Reconstruction. Plast Reconstr Surg. 121: 1893, 2008. (13.) Ascherman, J., Hanasono, M., Newman, M., et al. Implant Reconstruction in Breast Cancer Patients Treated with Radiation Therapy. Plast Reconstr Surg. 117: 359, 2006. (14.) Singletary, S. Skin-sparing mastectomy with immediate breast reconstruction: the M. D. Anderson Cancer Center experience. Ann Surg Oncol. 3: 411, 1996. (15.) Wilkins, E., Cederna, P., Lowery, J., et al. Prospective Analysis of Psychosocial Outcomes in Breast Reconstruction: OneYear Postoperative Results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 106: 1014, 2000. Ashley E. Rawson, MS-IV West Virginia University School of Medicine W. Thomas McClellan, M.D Plastic Surgeon Private Practice Morgantown Plastic Surgery Associates United Center, Suite 350 1085 Van Voorhis Road Morgantown, WV Table 1: Summary of the methods for breast reconstruction METHOD ADVANTAGES TE/Implant no need for donor site improved symmetry with bilateral mastectomy can be done at time of mastectomy reduced total operative time and surgical morbidity can be done prior to radiation if expander is fully inflated Biologic provides positioning and support for implant additional protective layer between implant and skin useful when pectoralis major is damaged/ congenitally absent decreased radiation-induced inflammation decreased capsular contracture Autologous Tissue avoids implant complications can achieve ptosis can be used in the face of radiation can treat with antibiotics if infected Pedicled Latissimus good for savlage surgery Flap reliable coverage for those without sufficient abdominal tissue Pedicled TRAM Flap better symmetry for larger breasts compared to implant Free TRAM Flap improved vascularity for smokers/obese less donor muscle required than TRAM decreased donor site morbidity Perforator Flaps decreased donor site morbidity greater range of potential donor sites METHOD DISADVANTAGES TE/Implant decreased aesthetic satisfaction in obese less natural feel and appearance risk of capsular contracture, migration, deflation requires multiple expansions in delayed reconstruction must be completed in multiple phases higher risk of infection Biologic expensive Autologous Tissue requires longer post-operative hospitalization Pedicled Latissimus requires addition of implant Flap requires noticeable scar on back intra op position change Pedicled TRAM Flap weakness in trunk flexion if bilateral abdominal wall hernia/laxity Free TRAM Flap longer surgical time compared to pedicled requires microsurgery Perforator Flaps large learning curve (50-100 surgeries) variability of vasculature technically demanding requires long operative times (> 7 hours) GAP requires 2 separate procedures (if bilateral)
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