Joint Hospital Surgical Grand Round Breast Reconstruction after Surgery for Breast Cancer Steven Law Pamela 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;111:1060-8 Nano 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 cohort studies Women seeking reconstruction is usually younger, having a partner, well educated

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 disorders Evans 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, fibromyalgia Gaubitz 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 Modified baker classification for capsular contracture

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;50:322-30 Nahabedian 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 mammogram Holley 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 Radiation oncologist Patient Decision Medical oncologist The decision to choose or decline breast reconstruction should be made by the patient Radiation oncologist Patient Decision 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

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