C L I N I C S I NP L A S T I C

S U R G E R Y

Clin Plastic Surg 34 (2007) 51–62

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Partial Mastectomy ReconstructionMoustapha Hamdi, MD, FCCPa,*, James Wolfli, MDa,b,Koenraad Van Landuyt, MD, FCCPa

- Oncologic outcome of partial mastectomyWhy do we need reconstructive

procedures in BCT?- Partial mastectomy reconstruction

Delayed reconstructionImmediate reconstruction

- Summary- References

The treatment of breast cancer is an evolvingfield. Different modalities are continuously beingdeveloped to maximize patient survival while min-imizing the treatment’s morbidity [1]. Currently,the two main options for the management of pri-mary breast cancer are total mastectomy and partialmastectomy with radiation. Although partial mas-tectomies (lumpectomy or quadrantectomy) con-serve the nipple and areola complex (NAC) andnative breast tissue, asymmetry and distortion ofthe breast can still occur. Many methods of recon-struction have been described. The early and long-term effects of radiation also contribute to thecomplexity of these cases. This article reviewsbreast-conserving therapy (BCT), reconstructionoptions, and outcomes.

Oncologic outcome of partial mastectomy

Conservative surgery followed by breast irradiationhas replaced modified radical mastectomy as thepreferred treatment for early-stage invasive breastcancer. The 5-year survival of partial mastectomywith radiation is not statistically different whencompared with mastectomy alone in patients withStage I or II breast cancer [2]. Studies have shown

0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All righplasticsurgery.theclinics.com

that women diagnosed at early stages of invasivebreast cancer have equivalent outcomes whenthey are treated with lumpectomy and radiationtherapy or modified radical mastectomy [2–4].

Partial mastectomy includes quadrantectomyand lumpectomy. In quadrantectomy, a wide exci-sion is performed, including skin and underlyingmuscle fascia. In lumpectomy, the goal is tumor ex-cision with clear surgical margins. The 5-year inci-dence of in-breast tumor recurrence was higher inlumpectomy-and-radiation patients than in quad-rantectomy-and-radiation patients (8.1% versus3.1%) [2]. The incidence of local recurrence de-pends upon the tumor margin, histology, radiationtherapy, and patient age (higher rate of recurrencein age <60). Most local recurrences occur at thesite of initial tumor excision (57%–88%) or in thesame breast quadrant (22%–28%). Duo novo ipsi-lateral breast cancer makes up about 10% to 12% ofin-breast tumor recurrences [4]. In general, duringthe first 10 years after lumpectomy with radiationthe recurrence rate is 1.4% per year. The treatmentof in-breast tumor recurrence in most patients iscompletion mastectomy [5]. A surgical dilemmain breast cancer treatment arises because, on theone hand, the surgeon needs a wider excision to

a Plastic and Reconstructive Surgery Department, Gent University Hospital, De Pintelaan 185, B-9000, Gent,Belgiumb Plastic Surgery Department, Grey Nuns Hospital, 218 Meadowlark Health Centre, 156 Street & 87 Ave.,Edmonton, AB, T5R 5W9 Canada* Corresponding author.E-mail address: moustapha.hamdi@ugent.be (M. Hamdi).

ts reserved. doi:10.1016/j.cps.2006.11.007

Hamdi et al52

provide clear margins and better local control ofdisease; but, on the other hand, the surgeon wantsto spare as much tissue as possible for defect closureand make the resulting aesthetic outcome as favor-able as possible [6].

Why do we need reconstructiveprocedures in BCT?

Approximately 10% to 30% of patients are dissatis-fied with the aesthetic result after partial mastec-tomy with radiation [7]. There are many possiblecauses of aesthetic failure. Tumor resection canproduce distortion, retraction, and noticeable vol-ume changes in the breast. Changes to the positionof the NAC can extenuate asymmetry. Radiationcan also have a profound effect on the nativebreast. Initially, radiation causes generalized breastedema and skin erythema. Long-term effects of ra-diation to the breast skin include hyperpigmenta-tion, hypopigmentation, telangiectasia, andatrophy. In the breast parenchyma, radiationcauses fibrosis and retraction. For most patients, ra-diation-induced changes plateau 1 to 3 years aftertreatment. Unfortunately, it is difficult to predictwho will develop the most severe postradiationchanges [8,9].

Partial mastectomy reconstruction

Reconstruction of partial mastectomies can eitherbe delayed or immediate. In delayed reconstruc-tion, the surgeon waits until the postoperativechanges in the deformed breast stabilize (6–12months). In immediate cases, the goal is to avoidbreast deformity by performing reconstruction con-currently with the partial mastectomy.

Delayed reconstruction

Classifications of post-BCT deformitiesThe cosmetic result of BCT depends largely on thelongevity of the follow-up. Edema that occursmost commonly during the first year after surgeryand irradiation may mask some of the loss of breastvolume. Established scar tissue and progressivefibrosis will lead to different breast contour defor-mities and NAC displacement. The original loca-tion of the tumor is also a significant factor.Tumors located within the superolateral quadrantgive lateral distortion of the breast gland, or theNAC, or both. Meanwhile, tumors located centrallyor superiorly lead to retraction and upward disloca-tion of the whole breast.

Several classification schemes have been devel-oped to characterize delayed breast deformity andsuggest reconstructive options. Berrino and col-leagues’ [10] morphologic classification system un-derscores the importance of analyzing the etiologyof the deformity. In type I, the deformity resultsfrom fibrosis and scar contracture. Displacementof the NAC is often present. In type II, there is a lo-calized deficiency of tissue (skin, or parenchyma, orboth). Type III has generalized breast retractionwith normal overlying skin. This is most often sec-ondary to radiation in patients with large, ptoticbreasts. Finally, type-IV deformity results from se-vere radiotoxicity. There is significant parenchymalretraction and distortion, and the skin has dramaticradiation-induced changes. The NAC is oftendisplaced.

Clough and colleagues’ [11] classification is basedon response to reconstruction. Patients with a type-I breast deformity have a normal-appearing breastwith no deformity (Fig. 1A). However, there isasymmetry in the volume or shape between breasts.These patients were primarily treated with

Fig. 1. A 58-year-old patient presented breast asymmetry after BCT on the right breast. Resection of the tumor,which was located at the junction of superior quadrants, resulted in smaller breast with upward retraction(grade I in Clough’s classification). A contralateral breast reduction provided adequate matching procedure.(A) Preoperative view. (B) Postoperative result.

Partial Mastectomy Reconstruction 53

contralateral breast surgery (Fig. 1B). Type-II pa-tients have deformed breasts. The deformity, how-ever, is deemed correctable primarily via ipsilateralbreast surgery (Figs. 2 and 3) or flap reconstruction(Fig. 4). Type-III patients have either major defor-mity or diffuse painful fibrosis of the treated breast.These patients were treated with total mastectomyand reconstruction.

Clinical approach to patients with post-BCTdefectsFailure of the BCT is defined by of one or more ofthe following:

1. Breast deformity2. Tumor recurrence3. Postirradiation pain

Every plastic surgeon has experienced a patient’semotional stress and her disappointment after theBCT. The patient’s cosmetic expectations are usuallyhigher than during cancer treatment. In approach-ing post-BCT deformity, several points must betaken into consideration:

The choices of repair methods and techniquesavailable in operated–irradiated breasts areclearly reduced because of the reduced breastvolume and of the scar tissue.

Postradiation sequelae make any salvage proce-dure technically more difficult with an out-come that is less predictable.

Like in any reconstructive method, reoperativebreast surgery has to be more carefully plannedand executed on an individual basis. Before surgery,records of previous procedures and treatmentsshould be reviewed. The clinical evaluation shouldexamine the breast deformity with its several com-ponents. Skin deficiency may not always be obviousbut some kind of skin correction will be needed dueto skin retraction and scar tissue in almost everycase. Any postradiation skin alternations shouldbe noted since it reflects the degree of parenchymaldamage. It is difficult though to estimate the re-quired amount of skin tissue to repair the defect.Nevertheless, severe NAC distortion is a markerfor the need of a large skin component.

Before considering any treatment, relapse of dis-ease should be ruled out. A recent general and localcheckup is mandatory to determine the oncologicstatus of the patients. Pain may improve after surgi-cal correction. However, no surgical method canguarantee total pain relief. Rehabilitation programsmay be necessary to achieve better outcome.

The choice of reconstructive methodPerforming extensive surgical manipulation of theirradiated breast must be considered with greattrepidation. High complication rates have been re-ported with attempted manipulation of the irradi-ated breast [12]. Patients who underwent eitherlocal tissue rearrangement or reduction mammo-plasty of the irradiated breast had complication

Fig. 2. A 41-year-old patient who had a BCT left with retro-areolar defect on the right breast with mild breastdeformity (Clough’s grade II). (A and B) Preoperative views. (C) Vertical scar mastopoxy consisted of careful glandplicature covered with dermal flap to enhance vascularization and skin tightening without skin undermining.Similar procedure associated with 40-g gland resection was done at the left side. (D and E) Postoperative viewsat 1 year after surgery.

Hamdi et al54

Fig. 3. A 45-year-old patient present lower-pole deformity post-BCT of the right breast (Clough’s grade II). A bi-lateral matching mammaplasty similar to the procedure described in Fig. 2 was performed. (A, B, and C) preop-erative views. (D, E, and F) postoperative results.

rates of up to 50% [13]. Complications, includingwound dehiscence, fat necrosis, skin necrosis, andnipple necrosis, may occur and the risks of suchcomplications should be discussed with the patient.In addition, the final aesthetic results of these caseswere also poor, and tended to worsen over time[12]. Therefore, attempts to correct these defects lo-cally must be limited to minor asymmetry, whichmay be solved by scar correction or Z-plastyprocedure.

The contralateral breast is usually larger andmore ptotic after partial mastectomy with radiation.When no frank deformity exists on the treatedbreast, procedures, such as reduction mammo-plasty or mastopexy performed on the nonirradi-ated breast, are excellent options to createsymmetry between breasts (see Fig. 1). Whenmild radiation sequelae are observed, a bilateralmatching procedure can be done. Nevertheless,techniques in mammaplasty should be adapted tothis specific situation. A minimal skin underminingwith a short and wide pedicle must be used (seeFigs. 2 and 3).

The use of implants to reconstruct partial mastec-tomies after radiation is potentially problematic.

The loss of tissue compliance in the irradiatedbreast makes obtaining a satisfactory result with im-plants more difficult. Secondly, capsular contrac-ture and infection rates of implant or expanderplacement in the radiated sites are very high [14].Finally, an implant obscures mammography andthus may decrease the sensitivity of recurrencesurveillance.

Breast reconstruction following partial mastec-tomy with radiation is best achieved using autolo-gous, nonirradiated flaps. Pedicled flaps, such asthe latissimus dorsi (LD) and transverse rectus ab-dominus myocutaneous (TRAM) flaps, have lowercomplication rates than the above-mentioned op-tions [13]. The key step to delayed reconstructioninvolves the excision of previous scars and releaseof parenchymal tethering. Correct flap size canthen be determined, taking into account that inthe case of musclocutaneous flaps, the muscularcomponent will atrophy. No large studies evaluatethe aesthetic results of delayed partial reconstruc-tion with flaps. In general, the shape is improved;however, this is partially negated by the donor-sitemorbidity and ‘‘plugged-in’’ appearance of the non-irradiated flap skin [12]. Location of the deformity

Partial Mastectomy Reconstruction 55

Fig. 4. A 46-year-old patient with lateral deformity after BCT on the left side characterized by skin and paren-chymal deficiency and NAC displacement. (A and B) Preoperative views. (C) The defect can be reconstructedby pedicled flap: muscle-sparing LD musculocutaneous flap. (D) Wound closure at end of surgery.

can influence the choice of flaps. Defects located atthe lateral aspect of the breast are best treated withloco-regional flaps, such as the LD musculocutane-ous or thoracodorsal artery perforator (TDAP) flap(see Fig. 4). However, the thoracodorsal vesselsmay be damaged by previous surgery or irradiationand should first be checked before raising the flap.Severe scar or postradiation sequelae may precludeharvesting such flaps. Other defects located in thesuperior, central, or inferior quadrants of the breastcan still be approached by LD or TDAP flaps. Defor-mities of the inferomedian quadrant are bettertreated with abdominal flaps (Fig. 5).

When the deformity after partial mastectomywith radiation is severe, the best option is comple-tion mastectomy and autologous reconstruction(see Fig. 4). In these cases the aesthetic outcomecan be expected to be similar to that with delayedreconstruction for the irradiated mastectomypatient.

The approach to post-BCT defects is summarizedin Box 1.

Immediate reconstruction

The authors prefer to perform immediate recon-struction whenever it is indicated and feasible be-cause operations on irradiated breasts have highcomplication rates and frequently poor aesthetic re-sults. During immediate reconstruction, the breast

can be manipulated before radiation. This poten-tially decreases complications and improves theoutcome.

Clinical approach to patients withimmediate partial breast reconstructionBreast-conserving surgery for cancer, associated withpostoperative radiotherapy, has been proven to besafe as compared with total mastectomy for tumorsup to 3 cm in diameter [2–4]. Larger tumors are stilltreated with mastectomy as a first choice. However,introducing more efficient protocols of neoadjuvantchemotherapy may allow a more conservative localapproach to advanced tumors. The combination ofa quadrantectomy with an immediate partial breastreconstruction has been considered a decisive stagein the evolution of breast cancer surgery. This com-bination, so-called ‘‘oncoplastic surgery,’’ allowsa wider resection of the tumor with safe margins.Moreover, good aesthetic results can be achieved be-cause of the advantage of immediate reconstructionwith supple, malleable nonirradiated tissue. How-ever, immediate partial reconstruction should be de-layed if the surgeon is uncertain about the marginsor tumor extension (eg, tumors with a large in situcomponent) despite the preoperative radiologic as-sessment. A delayed immediate reconstruction canstill be performed within a few days after the defini-tive margins become known.

Hamdi et al56

Fig. 5. A 47-year-old patient presented for correction of post-BCT deformity on the medial quadrant of leftbreast and right prophylactic mastectomy with immediate reconstruction. The microanatomoses were doneto the internal mammary vessels in both sides. (A and B) Preoperative views. (C) Bilateral SIEA flap is planned.Superficial inferior epigastric vessels are shown with surgical retractors. (D) One SIEA flap harvesting. (E and F)Results at 2 years show good breast symmetry.

Box 2 summarizes the specific issues that shouldpreoperatively be addressed with both patient andthe oncologic surgeon.

The choice of the reconstructive methodTo determine which reconstructive option is bestfor the patient, the size and location of the expectedtumor resection and the ratio of breast volume toresection volume must be appreciated.

Bilateral rearrangement breast tissue A large na-tive breast has historically been a moderate contra-indication for BCT, due to increased rates ofradiotoxicity, as the large breast requires higherdoses of radiation therapy to reach a therapeuticrange. Many surgeons have suggested incorporatinga reduction-mammoplasty–type procedure duringtumor resection. Benefits include a more aestheticpostoperative breast, a concealed tumor resectionincision within the reduction pattern, and smallerradiation doses due to decreased breast size.

Box 1: General guidelines for delayedreconstruction of partial mastectomy

Ensure careful patient evaluation locally andgenerally.Be aware that approach is technically more dif-ficult with less aesthetic outcome comparedwith the immediate approach.Avoid extensive manipulation of the irradiatedtissue.Use autogenous tissue to fill the defect.Usually treat lateral, superior or inferior de-fects with thoracodorsal-based pedicled flapsif available.Abdominal-based flaps are usually the besttreatment for medial defects.In the case of severe breast deformity, com-plete the mastectomy with thick skin flap andconsider total breast reconstruction with flaps.

Partial Mastectomy Reconstruction 57

The pattern can be rotated laterally or medially tofit the location of the tumor. The choice of the ped-icle is related to the tumor location (Table 1). Goodknowledge of the blood supply of the breast is es-sential to design different potential pedicles to carrythe NAC or to reconstruct the defect.

Tumors involving the lower pole are the most eas-ily treated because this region is removed duringmost reduction techniques (Fig. 6). Other regionsof tumor excision, not normally removed withreductions, can also be reconstructed using a combi-nation of breast reduction and creation of a glandularflap to fill the oncologic defect [7,15–17]. A similarmammaplasty technique is performed on the contra-lateral breast to match the size and shape of the tu-mor-affected breast. However, it is preferred to endup with a tumor-affected breast 10% larger thanthe contralateral remodeled breast because someshrinking and volume changes of the reconstructedbreast due to irradiation should be expected.

Incorporating a reduction mammoplasty withpartial mastectomy can be a complex procedure. Re-cent literature, however, suggests that early compli-cations are similar to those with mere reduction

Table 1: Choice of pedicle related to tumorlocation

Location of the defect Choice of pedicle

Inferior, inferomedial,or inferolateral

Superior,superomedial, orsuperolateral pedicle

Superior Inferior orcentro-inferior pedicle

Superomedial Superolateral pediclewith an inferocentralcomponent to fill thedefect

Superolateral Superomedial pediclewith an inferocentralcomponent to fill thedefect

Central Inferior pedicle

Box 2: Issues that should be addressedpreoperatively with patient and oncologicsurgeon

Incision linesNipple–areola preservationEstimation of defect size after tumor resectionReconstructive method depending on breast-size/tumor-size ratioConsideration of delayed immediate recon-struction if doubt about marginsStatus of contralateral breast: no surgery ver-sus mastopexy–reduction or prophylacticmastectomy

mammoplasty. The aesthetic outcome was consid-ered good or very good in 81% of patients [16]. InSpear and colleagues’ [17] review, none of the com-plications significantly interfered with healing,radiation, chemotherapy, or the quality of the result.

Replacement of the missing part One of the rel-ative anatomic contraindications for rearrangementbreast surgery is a large tumor/breast ratio. Smallerbreasts require different methods of reconstruction.If a postoperative deformity is expected due toa large-volume tumor resection in a smaller breast,the recruitment of nonbreast tissue is required. De-pending on the location and the size of the breastdefect, different flaps can be used for partial mastec-tomy reconstruction (Fig. 7).

A small lateral defect can easily be closed witha skin rotation flap or lateral thoracic axial skinflap. However, most of these flaps become unavail-able when axillary lymph-node dissection is per-formed. In obese patients, the lateral thoracic flapcan fill large defects at the lateral aspect of the breast[18]. Lateral breast defects are usually reconstructedusing a flap based on the thoracodorsal system. TheLD musculocutaneous flap is the most commonlyused. It has excellent blood supply and providesboth muscle for filling of glandular defects andskin for cutaneous deficiencies. Donor-site compli-cations mainly include seroma and dehiscence.Flap complications are few, with partial flap lossseen in <10% of patients [19]. Unfortunately, do-nor-site morbidity consists of potentially conspicu-ous scars on the back and loss of some backmusculature function. Avoiding a scar on the backcan be achieved by harvesting the LD withouta skin paddle through the lateral breast incision.The use of an endoscope can assist in raising themuscle [20]. A deinnervated and radiated LD willundergo postoperative atrophy. To compensate forthe expected loss in muscle volume, a flap muchlarger than the defect should be harvested.

The advent of perforator flaps has enabled sur-geons to spare muscle function. A similar skin pad-dle to the classical LD musculocutaneous flap canbe raised on perforators either from the thoracodor-sal or intercostals vessels [21]. Harvesting of pedi-cled perforator flaps is feasible when theappropriate perforator is chosen and the dissectionis performed meticulously. The technique becomesmore predictable if the surgical algorithm previ-ously outlined is used to select the most appropriateflap for the particular defect [22].

The pedicled TDAP flap is ideal for partialmastectomy reconstruction (Fig. 8). Preoperatively,a Doppler locates the perforator or perforators atthe lateral border of the latissimus. Introducingthe multidetector CT scan made perforator

Hamdi et al58

Fig. 6. A 48-year-old patient presented a 15-mm invasive ductal carcinoma in the inferior pole of the left breast.The tumor was widely excised. (A and B) Preoperative views. (C) Tumor resection lines were incorporated withina breast-reduction pattern with superior pedicle. (D) Defect after the quadrantectomy. (E and F) Results afterirradiation.

mapping more precise and reliable. The dominantthoracodorsal perforator can be visualized and itslocation is marked directly on the skin [23].

Converting a TDAP perforator flap into a muscle-sparing LD flap should be performed whenever theperforators are too small or nonpulsating. DifferentLD muscle-sparing techniques, which were previ-ously described, call for locating a small segmentof LD muscle under direct visualization of the per-forators so as not to damage them when harvestingthe muscular segment [22].

The authors reported the use of the lateral inter-costal artery perforator (LICAP) in partial breast re-construction within a clinical algorithm based on

the location of the defect and the availability ofthese perforators [24]. The perforators are locatedin front of the anterior border of the LD muscle.The dissection of the perforators is quite easy andquick; and it provides adequate perforator lengthto rotate the flap 180� without torsion of the perfo-rator. It is not necessary to extend the dissectioninto the costal groove.

The LICAP flap is a good alternative to the TDAPflap for lateral and inferior breast defects (Fig. 9).However, the TDAP has a longer pedicle, thus en-abling the flap to reach most of the breast (exceptfor the inferomedial quadrant). In addition, theTDAP flap has a greater arc of rotation, facilitating

TDAP FlapMS-LD muscle-skin flap

LD muscle flap

Superior Quadrants

LICAP FlapScapular flap

Lateral thoracic skin flap

Lateral Quadrants

LICAP or AICAP flapthoracoepigastirc flap

Small defect

Mastectomy +Free flap

Large defect

Medial Quadrant

Breast defect

Fig. 7. Algorithm for using flaps for partial breast reconstruction. AICAP, anterior intercostal artery perforator;LICAP, lateral intercostal artery perforator; MS-LD, muscle-sparing LD.

Partial Mastectomy Reconstruction 59

Fig. 8. A 51-year-old patient who had a 3-cm tumor in the junction of superior quadrants of the right breast. Shewas candidate for quadrantectomy with sentinel lymph-node dissection with immediate partial reconstructionwith a pedicled TDAP flap. Weight of the resected breast gland was 138 g. (A and B) Preoperative views. (C)TDAP flap markings. The perforators (circled crosses) were marked with unidirectional Doppler. (D) The flapwas based on one perforator. (E) Dissection of the perforator up to the thoracodorsal vessels through the splitLD muscle. The thoracodorsal nerve was completely preserved (blue loop). (F and G) Results at 1 year after ra-diation. (H) Donor site. The scar is hidden in the bra region.

tension-free folding or plication of the flap whenshaping the breast to achieve good breast symmetry.

Over the last 6 years, 101 pedicled perforator flapshave been used in the authors’ department at GentUniversity Hospital for breast or thoracic recon-struction. TDAP flaps were converted to muscle-sparing LD flaps in only 8% of cases. There isonly a minimal decrease in flap volume postopera-tively as opposed to the LD musculocutaneous flap,which can lose up to 30% of volume secondary tomuscle atrophy.

Muscle preservation is a sound rationale and islikely to contribute to reduced donor-site morbid-ity. Donor-site morbidity after raising a pedicle per-forator flap is reduced to an absolute minimumsince the LD muscle is left intact with functional

motor innervation. In addition, there was no sero-ma formation at the pedicled perforator flap donorsite.

Medial defects are more difficult to reconstruct.Small lower-pole defects can be reconstructed usingan epigastric rotation flap. Because this flap is basedon tissue directly below the inframammary fold(IMF), donor-site closure may distort IMF contour.More commonly, the pedicled TRAM flap is used.The superficial inferior epigastric artery (SIEA) freeflap was also described for immediate partial breastreconstruction [25]. However, stringent patient se-lection is essential when considering the harvestingof abdominal flaps either pedicled or free, since itexcludes the use of abdominal tissue for autologousreconstruction if completion mastectomy becomes

Hamdi et al60

Fig. 9. (A) 47-year-old patient with a 2-cm diameter tumor on the junction of the inferior quadrant (oval). (B)Both TDAP (indicated by TAP) and LICAP flaps were marked on the patient. Note that the LICAP flap is designedlower and more proximal toward the breast. (C) Intraoperative view. The defect was filled by surgical swab. ALICAP flap was designed with the marked perforators (circled crosses). (D) The flap was raised on intercostal per-forators without disturbing the LD vasculature. (E) Close-up view of a LICAP with two branches. (F) Defect closedwith the flap.

indicated. Therefore, in such clinical situations, theauthors prefer to complete the mastectomy and im-mediately use the abdominal flap for total breast re-construction. The authors’ first choice is the deepinferior epigastric artery perforator (DIEAP) freeflap, which produces an aesthetic donor site withlow morbidity [26]. The SIEA flap is an excellentchoice for small to moderate-size breast reconstruc-tion whenever the superficial inferior epigastric ves-sels are present.

Complication related to flap irradiationPostoperative radiation therapy of any flap is a ma-jor concern. Spear and colleagues’ [27] large review

of pedicled TRAM flap reconstruction in total mas-tectomies showed no statistically significant in-crease in complications when the patient receivedpostoperative radiation, compared with no radia-tion. Tran and colleagues’ [28] examination of post-operative radiation on free TRAMs also showed noincrease in early complication rates. However, bothstudies showed a significant increase in delayed flapcontracture, pigmentation changes, and volumeloss. As these changes can dramatically lower thefinal aesthetic outcome, most surgeons delay totalmastectomy reconstruction until radiation hasbeen completed. Presently, no large, long-termoutcome studies compare immediate flap

Partial Mastectomy Reconstruction 61

reconstruction in radiated and nonradiated partialmastectomy patients. However, one would expectradiation to have less detrimental aesthetic effectson partial mastectomy patients than on total mas-tectomy patients. Theoretically, radiating both theflap and conserved breast tissue should producea more homogenous appearance than the‘‘plugged-in’’ appearance of nonirradiated flapsfollowing delayed reconstruction.

Summary

Reconstruction after partial mastectomy is an evolv-ing aspect of plastic surgery. In many centers, imme-diate reconstruction is commonly performed. Thefeeling amongst most reconstructive surgeons isthat immediate reconstruction provides superioraesthetic outcomes with fewer complications. It is,however, important to be aware of the rate of reex-cisions for positive margins by the surgeons per-forming the tumor resections. If this rate isunacceptably high, then reconstruction should bedelayed. One option is ‘‘delayed-immediate’’ recon-struction, where the reconstruction is performed af-ter final pathology clearance, but before radiation.The other option is to reconstruct the breast afterthe effects of radiation therapy have stabilized. Un-fortunately, the options for delayed reconstructionare more limited, and satisfactory results can provemore difficult to achieve. Thus, the timing andmethod of partial mastectomy reconstruction re-main controversial. However, with the increasingpopularity of partial mastectomy with radiation,the need for reconstruction will also increase.

References

[1] Winchester DP, Cox JD. Standards for diagnosisand management of invasive breast carcinoma.CA Cancer J Clin 1998;48:83–107.

[2] Veronesi U, Cascinelli N, Mariani L, et al.Twenty-year follow-up of a randomized studycomparing breast-conserving surgery with radicalmastectomy for early breast cancer. N Engl J Med2002;347:1227–32.

[3] Fisher B, Anderson S, Bryant J, et al. Twenty-yearfollow-up of a randomized trial comparing totalmastectomy, lumpectomy, and lumpectomy plusirradiation for the treatment of invasive breastcancer. N Engl J Med 2002;347:1233–41.

[4] Huston TL, Simmons RM. Locally recurrentbreast cancer after conservative therapy. Am JSurg 2005;189:229–35.

[5] Osborne MP, Borgen PI, Wong GY, et al. Salvagemastectomy for local and regional recurrence af-ter breast-conserving operation and radiationtherapy. Surg Gynecol Obstet 1992;174(3):189–94.

[6] Dillon MF, Hill AD, Quinn CM, et al. A pathologicassessment of adequate margin status in breast-conserving therapy. Ann Surg Oncol 2006;13(3):333–9.

[7] Audretsch WP. Reconstruction of the partialmastectomy defect: classification and method.In: Spear SL, Willey SC, Robb GL, et al, editors.Surgery of the breast: principles and art. Phila-delphia: Lippincott Williams & Wilkins; 2006.p. 179–216.

[8] Fehlauer F, Tribius S, Holler U, et al. Long-term ra-diation sequelae after breast-conserving therapyin women with early-stage breast cancer: an ob-servational study using the LENT-SOMA scoringsystem. Int J Radiat Oncol Biol Phys 2003;55(3):651–8.

[9] Salvin SA, Love SM, Padousky NL. Reconstruc-tion of the radiated partial mastectomy defectwith autogenous tissue. Plast Reconstr Surg1992;90(5):854–65.

[10] Berrino P, Campora E, Santi P. Postquadrantec-tomy breast deformities; classification and tech-niques of surgical correction. Plast ReconstrSurg 1987;79(4):567–72.

[11] Clough K, Kroll S, Audretsch W. An approach tothe repair of partial mastectomy defects. Plast Re-constr Surg 1999;104(2):409–20.

[12] Clough KB, Cuminet J, Fitoussi A, et al. Cosmeticsequelae after conservative treatment for breastcancer: classification and results of surgical cor-rection. Ann Plast Surg 1998;41(5):471–81.

[13] Kronowitz SJ, Feledy JA, Hunt KK, et al. Deter-mining the optimal approach to breast recon-struction after partial mastectomy. PlastReconstr Surg 2006;117(1):1–11.

[14] Spear SL, Onyewu C. Staged breast reconstruc-tion with saline filled implants in the irradiatedbreast: recent trends and therapeutic implica-tions. Plast Reconstr Surg 2000;105(3):930–42.

[15] Mcculley SJ, Macmillan RD. Therapeutic mam-maplasty—analysis of 50 consecutive cases. Br JPlast Surg 2005;58(7):902–7.

[16] Munhoz A, Montang E, Arruda EG, et al. Criticalanalysis of reduction mammaplasty techniquesin combination with conservation breast surgeryfor early breast cancer treatment. Plast ReconstrSurg 2006;117(4):1091–103.

[17] Spear LS, Pelletiere CV, Wolfe AJ, et al. Experi-ence with reduction mammaplasty combinedwith breast conservation therapy in the treat-ment of breast cancer. Plast Reconstr Surg2003;111(3):1102–9.

[18] Munhoz AM, Montag E, Arruda EG, et al. Therole of the lateral thoracodorsal fasciocutaneousflap in immediate conservative breast surgery re-construction. Plast Reconstr Surg 2006;117(6):1699–710.

[19] Munhoz A, Montag E, Fels KW, et al. Outcomeanalysis of breast-conservation surgery and im-mediate latissimus dorsi flap reconstruction inpatients with T1 to T2 breast cancer. Plast Re-constr Surg 2005;116(3):741–52.

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[20] Losken A, Schaefer T, Carlson GW, et al. Immedi-ate endoscopic latissimus dorsi flap: risk or ben-efit in reconstructing partial mastectomy defects.Ann Plast Surg 2004;53(1):1–5.

[21] Hamdi M, Van Landuyt K, Monstrey S, et al. Ped-icled perforator flaps in breast reconstruction:a new concept. Br J Plast Surg 2004;57(6):531–9.

[22] Hamdi M, Van Landuyt K, et al. Pedicled perfora-tor flaps. In: Spear SL, Willey SC, Robb GL, edi-tors. Surgery of the breast: principles and art.Philadelphia: Lippincott Williams & Wilkins;2006. p. 833–46.

[23] Masia J, Clavero JA, Larranaga JR, et al.Multidetector-row computed tomography inthe planning of abdominal perforator flaps.J Plast Reconstr Aesthet Surg 2006;59(6):594–9.

[24] Hamdi M, Van Landuyt K, de Frene B, et al. Theversatility of the inter-costal artery perforator

(ICAP) flaps. J Plast Reconstr Aesthet Surg2006;59(6):644–52.

[25] Rizzuto RP, Allen RJ. Reconstruction of a partialmastectomy defect with the superficial inferiorepigastric artery (SIEA) flap. J Reconstr Microsurg2004;20(6), 441–445.

[26] Hamdi M, Rebecca A. The deep inferior inferiorepigastric artery perforator flap (DIEAP) inbreast reconstruction. Seminars in Plastic Sur-gery 2006;20(2):95–102.

[27] Spear SL, Ducic I, Low M, et al. The effect of ra-diation on pedicled TRAM flap breast reconstruc-tion: outcomes and implications. Plast ReconstrSurg 2005;115(1):84–95.

[28] Tran NV, Chang DW, Gupta A, et al. Comparisonof immediate and delayed free TRAM flap breastreconstruction in patients receiving postmastec-tomy radiation therapy. Plast Reconstr Surg2001;108(1):78–82.