1. Joint Hospital Surgical Grand Round
Breast Reconstruction after Surgery for Breast Cancer
Steven Law Pamela Youde Nethersole Eastern Hospital

2. 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

3. Management of Breast Cancer
Multidisciplinary approach
Surgery
Chemotherapy
Radiation therapy
Hormonal therapy
Surgery remains the mainstay of treatment for cure

4. 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:

5. Consequence of Mastectomy
Functional deficits
Inability to breast-feed
Psychosocial effects
Anxiety
Depression
Loss of feminity
Negative effects on body images and sexual function

6. 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

7. 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:
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

8. 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

9. 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

10. 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

11. 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:

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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:

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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): , 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

26. 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):

27. 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): , 2000

28. 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

29. 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.

30. 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

31. Thank You