Breast Reconstruction Joint Hospital Grand Round 20th September, 2003 Catherine Choi United Christian Hospital

Breast Cancer Commonest cancer amongst females in Hong Kong Incidence increasing annually at 3.6% Incidence 1918 (397 deaths) Cumulative life-time risk (0-74yrs): 1 in 23 Hong Kong Cancer Registry 2000

Hong Kong Cancer Registry 2000

Treatment of Breast Cancer Multimodality & Multidisciplinary Management Surgery Chemotherapy Radiation therapy Hormonal therapy Surgery important in achieving cure

Evolution of surgery in the treatment of Breast Cancer Breast Conservation Treatment (BCT) in early breast cancer Fisher et la. Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Eng J. Med. 1989;320:822-8 National Institute for Health Consensus Conference. Treatment of early stage breast cancer. JAMA 1991; 265:391-5 Mastectomy still required in majority

Problems of BCT BCT aims to preserve as much of a patient’s natural appearance as possible. Deformity can be considerable with large tumor. This can be overcome by: Reshaping (large defect in large breast) + contralateral breast reduction. This is similar to reduction mammaplasty. LD myocutaneous flap if defect too large for correction With oncological and plastic surgeries indications for BCT and breast reconstruction can be widened Clough KB et al. Cosmetic sequelae after conservative treatment of breast cancer: classification and results of surgical correction. Ann. Plast.Surg. 1998; 41:471-81 Clough KB et al. An approach to the repair of partial mastectomy defects. Plastic and Reconstructive Surgery. 1999; 104: 409-20 Petit JY et al. Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumor excision. Recent Results Cancer Res. 1998; 152:202-11

Mastectomy Mutilating and destructive Loss of femininity Disturbance in marital/sexual relationship Limited selection in clothing & activities

Breast Reconstruction NOT A COSMETIC SURGERY Integral part of treatment Reduce psychosocial morbidity & improve quality of life Linda LR. Plast Reconstr Surg 1997

Immediate vs Delayed Reconstruction Immediate Reconstruction…… Oncologically safe Kroll SS. Ann Surg Oncol 1997 Easier operation Better aesthetic outcome Avoid disfigurement Avoid second operation Psychological, social, financial and time-saving advantages

Contraindication to Breast Reconstruction Patient in very poor health Patient with very poor disease prognosis (inflammatory carcinoma of breast) Ambivalence or unrealistic expectation

Surgical Options for Breast Reconstruction Implant or tissue expander Autologous tissue reconstruction Latissimus Dorsi (LD) myocutaneous flap Transverse Rectus Abdominus Myocutaneous (TRAM) flap – free or pedicle Deep Inferior Epigastric Perforator (DIEP) flap Superior Gluteal Artery Perforator (SGAP) flap Inferior Gluteal Artery Perforator (IGAP) flap

Other Autologous Tissue Reconstruction Rubens Fat Pad Free flap Transverse Fascia Lata flap Transverse Gracilis Flap Omentum Flap Groin Flap

When to choose autologous tissue instead of implants? It is difficult to recruit or expand more than 7 or 8cm of additional tissue with tissue expander. When the vertical tissue requirements exceed this amount, autologous tissue is needed.

Breast implants & tissue expanders Saline or silicon gel Simpler surgical procedure Lower cost Symmetry difficult to achieve Aesthetic result deteriorates over time Capsular contracture, implant failure, infection, etc Clough KB. Plast Reconstr Surg 2002 Problems associated with post-op radiotherapy Short-term advantage offset by Long-term disadvantage

Michigan Breast Reconstruction Outcome Study 49 implants/expander 163 TRAM flap TRAM flap recipient more satisfied Aesthetic satisfaction General satisfaction Alderman AK. Plast Reconstr Surg 2000

Latissimus Dorsi (LD) flap First described by Tansini in 1898 Standard method in the 1970s Technically easy, reliable Used alone for small breast reconstruction or with implant for large breast Change of position during surgery Complication of seroma common, others relating to implants

Extended LD flap Transfer addition tissues from back Breast implant not required For patient with previously abdominal surgery Suitable for Asians

Endoscopic techniques Harvesting latissimus dorsi myocutaneous flap Same scar for axillary dissection or a separate incision about one inch in the middle or lower back

TRAM flap First described by Hartrampf in 1982 Commonest option Substantial amount of tissue and skin for reconstruction Symmetry & Tissue consistency Change of appearance and size similar to the natural breast Added benefit of abdominoplasty Clough KB. Plast & Reconstr Surg 2001

TRAM – pedicled flap Superior epigastric artery Skin and subcutaneous tissue by subdermal plexus

TRAM – pedicled flap Blood supply improves by: Bipedicled flap (absence of zones II & IV) Aagner DS. Plast Reconstr Surg. 1991 Supercharging Harashina T. Br J Plast Surg. 1987 Flap delay procedure Codner MA. Plast Reconstr Surg. 1995

TRAM - complications Donor site Recipient site Abdominal weakness / hernia Abdominal wall bulging Recipient site Fat necrosis Partial flap necrosis Total flap necrosis

TRAM flap - risk factors Smoking Microcirculatory problems Magnified in obese patients Obesity increased risk of flap loss with pedicle flap Moran SL. Plast Reconstr Surg 2001

TRAM – risk factors Unfavorable abdominal scar from previous surgery TRAM flap pedicles divided Perforators interrupted Subdermal plexus damaged Rt subcostal scar Vertical midline scar Pfannenstiel scar

TRAM – free flap Popularized since 1990s Deep inferior epigastric artery Robust blood supply

TRAM – free flap Advantages Disadvantages Less fat necrosis / partial flap loss Less sacrifice of donor site muscle, so less weakening & less pain Avoid epigastric bulge Better aesthetic outcome Disadvantages Microvascular anastomosis Risk of TOTAL flap loss Long & tedious operation Post-op monitoring requires effort and expense

DIEP (deep inferior epigastric perforator) flap Variation of free TRAM flap Only one or more perforating branches dissected from rectus Rectus muscles left intact Less donor site morbidity More time consuming and tedious Indicated for bilateral reconstruction & small breast

Preferred choice of TRAM….. Pedicle flap VS Free flap

Literature search Keyword: TRAM Medline / EMBASE / Cochrane library 5 out of 698 articles comparing outcome of free vs pedicled TRAM Results No RCT comparing free vs pedicled TRAM Prospective non-randomized comparison

Comparisons on… Patient’s general & aesthetic satisfaction Larson DL. Plast & Reconstr Surg 1999 Edsander N. Plast & Reconstr Surg 2001 Recipient site morbidity Kroll SS. Plast & Reconstr Surg 1998 Donor site morbidity Edsander N. Plast & Reconstr Surg 1998 Cost Serletti JM. Plast & Reconstr Surg 1997

Study Results Free Pedicled Patient & aesthetic satisfaction Recipient site morbidity (fat necrosis)† Donor site morbidity (abd strength) Pedicled Shorter operation time, hospital stay, less blood transfusion† † Statistical significant result

Skin-sparing total mastectomy with immediate breast reconstruction Oncologically safe Kroll SS. Surg Gynecol Obstet 1991 Traditional type involves skin overlying tumor, biopsy scar and nipple-areola complex (skin at risk of recurrence) Patch like defect at NAC, transverse scar

Skin-sparing total mastectomy with immediate breast reconstruction Periareolar approach All breast skin preserved Optimal aesthetic result Gabka CJ. Plast & Reconstr Surg 1998

Conclusion Breast reconstruction reduces psychosocial morbidity & increases quality of life after mastectomy Immediate reconstruction should be offered to patient requiring mastectomy Autologous tissue reconstruction superior to implants

Conclusion TRAM (free/pedicled) Free TRAM flap ……At the expense of superior aesthetic outcome Free TRAM flap fewer recipient & donor site morbidity ……At the expense of Risk of TOTAL flap loss Cost Special expertise Post-op monitoring effort & expense

Conclusion Pedicled flap is justified to be used Free flap considered in selected patients obese smoker unfavorable abdominal scar

Conclusion Periareolar approach skin-sparing mastectomy with immediate breast reconstruction gives the best possible aesthetic outcome without compromise oncological safety Gabka CJ. Plast & Reconstr Surg 1998