Simultaneous reconstructive surgery for radical mastectomy

Abstract

Breast reconstruction following radical mastectomy, if desired, is considered vital to the patient's rehabilitation and is an intrinsic part of her breast cancer treatment. Immediate reconstruction – especially immediate reconstruction using autologous tissues – has become more established since the introduction of the skin-sparing mastectomy in the early 1990s. Now, as the more current therapeutic armamentarium has been expanded to feature preoperative tumor shrinking with chemotherapy, accelerated or partial breast radiotherapy, and, in particular, the increased use of breast conservation surgery for larger tumors, immediate breast reconstruction techniques have also further evolved to address the radical mastectomy defect with newer micro-surgical techniques and autologous flap tissues, such as the IGAP, gracilis [1], and SIEA flaps, as well as improved silicone and anatomic saline implant designs [2] with post-operative adjustment capabilities designed to facilitate longer term symmetrical breast reconstruction outcomes. The increased use of postmastectomy radiation therapy in patients with early-stage breast cancer has increased the complexity of planning for immediate breast reconstruction. Studies have evaluated the outcomes of breast reconstruction performed before radiation therapy, revealing a high incidence of complications and poor aesthetic outcomes [3]. Moreover, immediate breast reconstruction can interfere with the delivery of postmastectomy radiation therapy. Multidisciplinary breast conference identification of early breast cancer patients at high risk for radiation therapy has evolved a unique and highly successful 'delayed immediate' reconstruction [4] approach that preserves the aesthetic outcomes of immediate reconstruction and avoids radiation injury to the reconstructive tissues. This is accomplished by utilizing a filled subpectoral tissue expander to temporarily preserve the breast skin envelope until the final tissue pathology is confirmed and the patient either goes on to definitive reconstruction or to radiation therapy with the expander deflated. A total of 28 high-risk early breast cancer patients have undergone the delayed immediate approach with 20 patients (71%) not ultimately requiring radiation therapy. Nineteen patients in the non-radiated group (95%) have now completed definitive reconstruction, primarily with the use of autologous tissues. The eight patients who required radiation have completed the radiation therapy and six (75%) have undergone tissue re-expansion and skin-preserving delayed reconstruction designed to be as similar in outcome to immediate reconstruction as possible. The complication rate for the initial expander placement at the time of mastectomy was 18% for all patients. Five nonradiated patients (25%) had complications in the second stage of definitive reconstruction and one patient (17%) following radiation therapy had complications in the skin-preserving delayed reconstruction. Finally, following the successful experience of the delayed immediate approach for early breast cancer patients, 17 advanced stage patients with planned postoperative radiation therapy also had the opportunity for skin-preserving tissue expansion prior to radiation therapy upon multidisciplinary approval. All the patients received neoadjuvant chemotherapy. Five of the patients (29%) had complications in the first stage of expander placement but two patients (12%) have now completed definitive reconstruction following radiation therapy with re-expansion of preserved breast skin and have experienced no complications. Immediate reconstruction minimizes incisional scars on the breast and improves overall breast contour, shape, and appearance. The improved aesthetic outcomes over delayed reconstruction, achieved as well by these diverse skin-preserving 'delayed immediate' approaches without significant incidents of complications, has convinced many breast cancer patients to view mastectomy with reconstruction as a viable and positive treatment choice.