An Overview of Breast Reconstruction

Canadian Association of General

Practitioners in OncologyPractitioners in Oncology

Annual meeting

Dr. Renee Hanrahan, MD, FRCSC

Oct 17th-20th, 2013

Objectives

• Describe the goals of reconstructive surgery.

• Describe the patient/procedure selection process.

• Discuss the issue of timing of breast reconstruction.

• Provide a overview of both autologous and prosthetic reconstruction.p

• Review outcomes of breast reconstruction.

Introduction

• With the majority of women beating breast j y gcancer, survivorship is a very important aspect of management that should be considered.

• Considerable data exists demonstrating theConsiderable data exists demonstrating the psychosocial and quality of life benefits of breast reconstruction following mastectomy

psychological benefits

lf tself esteem

sexuality and body image

Introduction

• In spite of these well known benefits, breast p ,reconstruction rates in Canada are still some of the lowest in the developed world.

Europe >40%Europe >40%

USA 20%

Canada <10%

• Most of the barriers are related to perceived pcontraindications to breast reconstruction.

Case Report

• 54 yo femaley

• Mammographic abnormality

• Work-up reveals clinically T2 N0 M0 invasive lobular carcinoma of the right breast.

Hi t d Ph i l• History and Physical

past medical history

assessment of risk of recurrence

surgical safety assessmentsurgical safety assessment

Staged Process

• Initial assessment

• Complete workup

• Patient education

• Discussion

Complications

Timing

Prophylactic mastectomy

Balancing proceduresBalancing procedures

• Procedure Selection

Surgical Options

• Partial Mastectomy + Radiation

• Mastectomy

• Mastectomy with Reconstruction

Indication for Mastectomy

• Large tumor, small breast (5 cm)

• Multifocal tumor

• Contraindication for Radiation Tx

• Positive margin following partial mastectomy

• Increased lifetime risk (BRCA positive, 25%, high risk screening)

• Patient preferencePatient preference

Why Reconstruction?

Quality of Lifey

A patient’s sense of well being which includes the perception of physical, psychological and spiritual functioningspiritual functioning.

It is one thing to go through the diagnosis of breast cancer, but to be reminded of it for the rest of your life can affect every aspect of it.

Survivorship.

Patient Expectation

• Level of expectation needs to be addressed l i th di i b t b tearly in the discussion about breast

reconstruction.

• Not a cosmetic procedure

GOALS

• to make the breast appear balanced clothed

• to permanently regain the breast mound contour

t i th i f t di• to give the convenience of not needing an external prosthesis

• psychological and quality of life benefits

Patient and Procedure Selection

• Patient Characteristicssmoking, arterial disease, history of

clotting disorder, pulmonary disease, cardiac disease, steroid use and immunosuppression, and diabetes.

body habitus, breast size, donor site availability.

• Disease Characteristicstumor size, nodal status, pathological

features • Treatment Plan

Neoadjuvant chemotherapy, Radiation

Contraindications for Reconstruction

• Non resectable local chest wall disease• Non-resectable local chest wall disease

• Rapidly progressive systemic disease

• Patients who have serious co-morbidity

• Patients who are psychologically unsuitablep y g y

• Complete breast reconstruction including the nipple areola reconstruction will require on average 3 3 separate surgical proceduresaverage 3.3 separate surgical procedures and can be up to a year long process.

Timing of Reconstruction

• Immediate • DelayedImmediate

Avoid scar formation

Technical/Aesthetic

Delayed

Healing

Adjuvant Therapy

Radiation sEconomical

Avoid lengthy 2nd OR

Psychological Benefits

?Outcomes

Radiation vs.

2 staged technique

Timing of Reconstruction

• The most important point to consider is the delay of adjuvant therapies such as systemic and radiation therapy.

• 8 12 weeks• 8 – 12 weeks

• Assess for increase risk for complications.

• Evidence to suggest reconstruction does not increase risk of recurrence or mortality.

Skin-Sparing Mastectomy Flap Complications After Breast Reconstruction: Review of Incidence, Management, and Outcome

Annals of Plastic Surgery: Mar 2003 - Vol 50(3) pp 249-255

37 patients underwent SSM and breast reconstruction. SSM flap complications occurred in nine patients (24.3%) and included mild (n = 2), moderate (n = 5), and severe (n = 2) skin loss, resulting in four cases of dehiscence, five reoperations, and no delay in postoperative adjuvant therapy.

Breast cancer recurrence after immediate reconstruction:

patterns and significance .

Retrospective chart review of patients who had undergone immediate breast reconstruction at M. D. Anderson Cancer Center between June 1, 1988, and December 31, 1998.

During this 10-year period, a local recurrence of cancer was found to have developed in 39 of 1694 patients. (2.3 %)

(1) immediate breast reconstruction (although potentially, it can conceal chest wall recurrence) does not seem to delay the detection of chest wall recurrence;

(2) even if a chest wall recurrence develops, it is highly associated with metastatic disease, and the survival rate is

t lik l t h b i fl d b li d t ti Thnot likely to have been influenced by earlier detection. These data support the continued use of immediate breast reconstruction without fear of concealing a recurrence or influencing the oncologic outcome.

Plast Reconstr Surg. 2003 Feb;111(2):712-20;

Skin-sparing mastectomy and immediate breast reconstruction: A prospective

cohort study for the treatment of advanced stages of breast carcinoma

Annals of Surg Onc 2002 Vol 9 (5)

67 consecutive patients underwent SSM with67 consecutive patients underwent SSM with immediate reconstruction and were prospectively observed. Postoperative adjuvant therapy was not significantly delayed (median interval, 32 days). With a median length of follow-up of 49.2 months, local recurrence was present in only one patient (4%)recurrence was present in only one patient (4%), with successful local salvage treatment, and distant metastasis was present in four patients (16%).

Contralateral Breast

• Decision to complete prophylactic• Decision to complete prophylactic mastectomy should be based on oncological reasons, not reconstructive reason.

• Balancing procedures

reduction

mastopexy

augmentation

• Timing• Timing

Prophylactic Mastectomy

• The risk of contralateral breast caner is reported in h li h b % 11%the literature anywhere between 5% to 11%.

• Factors such as young age, lobular histology and family history contribute to the increased risk.

• BRCA + patients make up approx. 5% of breast cancer patients and have a reported risk of developing contralateral breast cancer up to 60%.

Ri k d ti t t i• Risk reduction strategiessurveillancechemo preventionsurgical resection

Surgical Procedures

Autologous Vs. Prosthetic

• The aesthetic results from autologous greconstruction are superior to those of implant based reconstruction due to their versatility, their more natural appearance, consistency and durability. Autologous tissue y y gcan better withstand radiotherapy.

• However, requires prolonged OR time and significant early investment during the first year usually coinciding with adjuvantyear, usually coinciding with adjuvant therapy.

Autologous Vs. Prosthetic

• Implant based techniques require limited surgery initially but have certain limitations and are not always quick and trouble-free. These procedures allow patients some control over breast size, but the quality of the long-term result is directly related to their tolerance of breast implants.

Autologous Reconstruction

R t ti f b t d ith• Reconstruction of breast mound with patients own tissue, using skin, muscle and adipose tissue from different regions of the body.

• Pedicle vs. Free Tissue Transfer.

• Longevity and more natural appearing.

• Increased morbidity.

• Smoking• Smoking.

TRAM

• Transverse Rectus Abdominis Myocutaneous Flap.

• Most common autologous reconstruction.

• Pedicle or Free Tissue Transfer.

“T T k”• “Tummy Tuck”

• Abdominal weakness, hernia, mesh complications, wound breakdown.

Nipple sparing mastectomy with pedicle TRAM

Unilateral Delayed TRAM Reconstruction

Delayed TRAM Reconstruction

Other Donor Sites

• DIEP Flap

• Gluteal Flap

• Tensor Fascia Lata Flap

• Periiliac Flap

• Latissimus Dorsi Flap

DIEP Flap

• Modification of the TRAM reconstruction.

• Designed to avoid removal of rectus muscle and decrease abdominal wall morbidity.

• Requires microsurgical anastamosis.

Latissimus Dorsi Flap

The latissimus dorsi flap often is reserved for ppatients in whom abdominal reconstruction is contraindicated.

- infraumbilical soft tissues are limited

- previously have undergone abdominoplastypreviously have undergone abdominoplasty

- abdominal scars that may entail compromise of the rectus abdominis pedicle.

• Can be used in combination with prosthesis for added volume.for added volume.

• Useful for lumpectomy defects

Latissimus Dorsi Flap

Latissimus and Implant Reconstruction

Expander/ Implant Reconstruction

• Simple and flexible technique• Simple and flexible technique

• May not involve additional scarring

• Breast is reconstructed with local skin

• Allows insertion of larger implantsg p

• Shorter procedure

• Shorter convalescence and rehabilitation

• Does not preclude further reconstruction tioptions

• Avoids donor site morbidity

Expander/ Implant Reconstruction

• Multiple staged proceduresp g p

• Multiple hospital visits for expansion

• Added complications of implants

• Need for revisional surgery

• Lack of projection, limited ptosis

• Less likely to achieve symmetry

• Less satisfactory long-term cosmetic outcomeoutcome

• Capsular contracture particularly after adjuvant radiotherapy.

A Tissue expander-filled

B Port

C Catheter

D Syringe

E Ribs

F Pectoralis major muscle

G Serratus muscle

Nipple Reconstruction

• Focal point of breast

• Provides symmetry and form

• Takes eye away from scarring

D l i f i• Done at completion of reconstruction

• Methods

grafting, local tissue, cartilage

• TattooingTattooing

Complications

• Flap Lossp

• Fat Necrosis

• Hernia

• Implant Exposure

• Capsular Contracture/Rupture

• Mastectomy Flap Necrosis

• Infection

• Hematoma• Hematoma

• Anaesthetic complications

Bleeding/ Hematoma

Partial Flap Necrosis Hernia

Wound Infection

Mastectomy Flap Necrosis

Implant Reconstruction and Radiation

Forefront

• Microsurgeryg y

• AlloDerm

Processed cadaver dermis used as a sling. Provides coverage of inferior pole of implant when there is a deficit of soft tissueimplant when there is a deficit of soft tissue coverage.

• Alterative donor sites

• Laparoscopic harvesting of donor tissue.

Alloderm

Delayed – Immediate Reconstruction

• 2 staged procedure in which an expander is• 2 staged procedure in which an expander is placed at the time of mastectomy.

• Systemic adjuvant therapies are given during the expansion process.

• No increase in healing timeNo increase in healing time.• Radiation given with expander in place.• 2nd OR can be either

implant reconstruction dditi f L ti i fladdition of Latissimus flap

autologous reconstruction• Allows for assessment of skin flaps.

Case Report

Summary

• Pre-op planning with a multidisciplinary team p p g p ywith much patient involvement will yield the best results for the patient and the oncologist.

• Reconstruction following mastectomy is anReconstruction following mastectomy is an acceptable additive to the treatment with Stage I/II/III disease.

• Outcomes of women having undergone reconstruction are similar to nonreconstruction are similar to non-reconstructed patients, with local recurrence being equally detected and treated.

Questions?