Breast Reconstruction: Immediate versus delayed breast reconstruction

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For further in depth information on breast reconstruction surgery, the following pages can be can also be consulted:

Breast Reconstruction: Reduction Mammaplasty

Breast Reconstruction: Local and Remote Flaps

Breast Reconstruction: Breast Reconstruction after Mastectomy

Breast Reconstruction: Latissimus dorsi and thoracodorsal artery perforator flaps

Kronowitz and others have reported on their experience with 69 patients. Of these, 50 patients underwent immediate repair of the partial mastectomy defect that included local tissue rearrangement in 14 patients, a breast reduction in 33 patients, and a latissimus dorsi myocutaneous or thoracoepigastric skin flap in 3 patients. Nineteen patients had delayed reconstruction after radiation, of whom 6 had tissue rearrangement, 8 had a breast reduction, and 5 had a flap reconstruction. Positive margins were demonstrated in 5% of patients and 75% of these underwent a completion mastectomy. Overall, 6% of patients developed a local recurrence over the mean follow-up time of 35 months.

Considering the type of reconstruction, flap reconstruction had a recurrence rate of 13%. The other forms of reconstruction had a recurrence rate of 5%.8 The flap technique had a higher complication rate than tissue rearrangement and breast reduction in the immediate setting. In the delayed setting, the flap technique had a lower complication rate than the other two. These findings support what other series have shown. After radiation, a muscle flap is likely the best technique for deficit repair, whereas tissue remodeling is a better choice in the immediate or immediate delayed setting.

Patient selection is important at all points in the process. The use of oncoplastic techniques encourages surgeons to perform larger-volume resections and the rate of positive margins in this and most series is acceptable if the patients with positive margins are willing to accept a subsequent mastectomy. Planning for delayed immediate reconstruction allows patients to undergo a reexcision of margins or to choose a mastectomy without loss of a flap and its associated morbidity.

The most recently published large series was from Italy by Rietjens et al, which compared itself to the NSABP B07 trial and the Institut Curie data by Clough et al, presented above. There were 148 patients who had breast conservation with oncoplastic technique and tissue remodeling, and 4 patients with a larger defect where a latissimus dorsi musculocutaneous flap or silicone gel implant was used. Concomitant contralateral side remodeling was performed in all patients. Again 1 cm macroscopic margins were obtained. The positive margin rate of 8% was similar to that observed in other series. All the positive margins were positive with DCIS. The local recurrence rate of 3% at 5 years compared favorably to the 9.4% reported by the Institut Curie and 14.3% in the NSABP trial.

The factors most frequently associated with local recurrence were young age, positive margins, ulticentric disease, and vascular invasion; however, none of these factors reached statistical significance. Only tumor size greater than 2 cm was statistically significant in the rates of local and distant recurrence.

Asgeirsson and others performed a review of the literature for oncoplastic surgery. Their hypothesis in performing the review was that oncoplastic surgery would allow surgeons to feel comfortable in performing larger resections and reduce the incidence of margin involvement, as well as having a favorable cosmetic outcome. Most of the series were small and reported a single surgeon’s experience. Although these series show acceptable results, recommendations were made for a multi-institutional prospective trial, for longer oncologic follow-up and to establish criteria for more accurate patient selection.

Patient selection in breast reconstruction

Losken et al have developed a management algorithm for patients who are potential candidates for oncoplastic surgery. Breast size in relationship to tumor size is the initial criterion. Patients are divided into those who need volume replacement procedures such as a local or distant flap and those who qualify for a volume displacement procedure such as tissue remodeling or breast reduction. Volume replacement procedures are best performed in a delayed or immediate–delayed fashion. The advantages of a one-stage procedure are that it potentially avoids scar tissue, radiation changes and fibrosis, as well as a second trip to the operating room. The main disadvantage of a one-stage procedure when there is a positive margin noted on the final pathology report is that re-excision of a positive margin post-tissue rearrangement may not be accurate and mastectomy may be necessary.

The second consideration relates to the malignancy. Local recurrence is proportional to the size of the tumor and inversely proportional to the margin distance. In those patients chosen for immediate reconstruction, all attempts should be made to minimize the incidence of positive margins. This can be done through careful patient selection. Tumor size, location, and nodal status all play a role in decision making. The ideal candidate is one in whom the tumor can be excised within a breast reduction specimen and the patient is happy to have a smaller breast. It is most common to have DCIS rather than invasive tumor at the margins. In the series of Losken et al, all patients who failed re-excision of margins were under 40 years of age. It is those authors’ recommendation that these two groups – those with extensive DCIS and those younger than 40 – be managed by a staged procedure.

When immediate reconstruction is desired, preoperative and intraoperative assessment of margins radiographically, macroscopically, cytologically, and pathologically should be performed. A generous resection, supplemented with cavity sampling and placement of clips to mark the original cavity, is recommended, especially in a onestage procedure where re-excision of margins may be necessary.

Patient preference and satisfaction must be a factor in decision making. In a retrospective review of the NSABP B-06 data, postoperative evaluation of cosmesis was determined. Four groups evaluated the cosmesis: plastic surgeons, general surgeons, radiotherapists, and patients. Evaluation of cosmesis by the patient and radiotherapist was one grade above the surgeon and one or two grades above the plastic surgeon. Patient satisfaction was quite high and was based not on objective criteria (such as shape of the breast) but by success in retaining their original breast.

Other studies have compared partial mastectomy to breast reconstruction post mastectomy in terms of psychosexual impact. Schover et al found that most of the differences in psychological impact of treatment appears to diminish after 1 year post surgery. Local treatment was not the crucial factor in psychosexual adjustment to the disease. There was no difference in level of sexual activity between the two groups. The authors concluded that if women are given medically appropriate treatment options and feel comfortable with their choices, the majority return to a good level of psychological and sexual
functioning.

The patient’s psychological state is very important to keep in mind when selecting patients for oncoplastic surgery. Oncoplastic surgery is more complex and time consuming and so leads to longer operative times and longer recovery periods. For some patients the necessity of having multiple operations is daunting. Having positive margins after breast-conserving surgery, especially if done with oncoplastic techniques, is devastating. A patient who is strongly motivated to preserve her breast will better tolerate the uncertainty and the potentially more difficult process.

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