Delayed-immediate Reconstruction Research Articles

Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy.

Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.

Reconstructive Burnout after Mastectomy: Implications for Patient Selection.

The reconstructive journey after mastectomy can be a long road, with many hurdles to achieve an ideal aesthetic result. Cancer therapy, operative complications, and comorbidities impact patients physically and emotionally. This study introduces the term reconstructive burnout and aims to evaluate which factors predict and contribute to patients prematurely stopping reconstruction. The authors performed a retrospective review of patients undergoing breast reconstruction after skin-sparing mastectomy from 2014 to 2017 performed by two senior surgeons (N.T.H. and S.S.T.) at a single institution. Reconstructive burnout is defined as either no breast mound creation or completion of the breast mound without completion of all major revisions. A total of 530 patients were included, with 76.6% completing reconstruction. In patients undergoing delayed-immediate reconstruction, patients with wounds ( P = 0.004), infections ( P = 0.037), or a complication requiring operative intervention ( P < 0.001) were correlated with incomplete reconstruction; explantation of expanders was highly correlated with reconstructive burnout ( P < 0.001). Implant-based and autologous reconstruction had comparable burnout rates (17.1% versus 19.1%; P = 0.58). Logistic regression models found high body mass index, radiation therapy, any tissue expander complication, and tissue expander explantation to be significant predictors of burnout. Autologous reconstruction was the strongest predictor of completion of reconstruction in both univariable and multivariable models. Reconstructive burnout in breast reconstruction is associated with tissue expander complications, high body mass indices, and radiation therapy. Overall rates of burnout were comparable between autologous and implant-based reconstruction, with autologous reconstruction being the strongest predictor of completion of reconstruction. It is critical to tailor each patient's reconstructive journey to meet both their emotional and physical needs to avoid reconstructive burnout.

Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation.

Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

P49. DELAYED-IMMEDIATE BREAST RECONSTRUCTION IN THE ERA OF PRE-PECTORAL TISSUE EXPANDERS: AN ALGORITHMIC APPROACH

PURPOSE: Current trends toward pre-pectoral tissue expander placement and nipple sparing mastectomies have decreased the morbidity and improved the cosmetic outcomes for breast reconstruction. The authors aim to delineate an algorithm for patients undergoing autologous breast reconstruction. METHODS: A prospectively maintained patient database was queried for all patients undergoing autologous reconstruction. Factors considered in surgical decision-making for reconstruction included type of mastectomy, incision pattern, plan for radiation, pre-operative breast volume and degree of ptosis, and presence of adequate tissue for autologous reconstruction. Breast complication rates were compared between the immediate reconstruction group and the delayed-immediate reconstruction group. RESULTS: 84 patients and 131 breasts underwent autologous breast reconstruction after mastectomy. 62 breasts underwent immediate reconstruction, and 48 breasts underwent delayed-immediate reconstruction. Compared to patients undergoing immediate autologous breast reconstruction, patients undergoing delayed-immediate pre-pectoral reconstruction have a decreased major breast complication rate (32.3% vs 4.2%; p<0.001), mastectomy flap necrosis rate (32.3% vs 0%; p<0.001) and nipple-areolar complex necrosis rate (19.3% vs 0%; p<0.001). Patients with anticipated skin envelope deficiency should undergo immediate reconstruction. Patients undergoing nipple-sparing mastectomy should have delayed-immediate pre-pectoral reconstruction to take advantage of the delay phenomenon for the nipple-areolar complex. Any patients expected to receive post-operative radiation should have delayed-immediate reconstruction. Incisions on the breast should be made within the Wise pattern to preserve breast shape, cosmesis, and facilitate subsequent revision surgery. CONCLUSION: Pre-pectoral delayed-immediate breast reconstruction results in a decreased major breast complication rate. This algorithm serves as a useful guideline for decision making in autologous breast reconstruction.

Advantages of the Delayed-Immediate Microsurgical Breast Reconstruction: Extending the Choice.

Deep inferior epigastric perforator (DIEP) reconstruction can be performed in an immediate (at time of mastectomy), delayed-immediate (immediate tissue expander followed by staged DIEP), or delayed timing following mastectomy. Avoiding flap radiation is a known benefit of the delayed-immediate approach. The purpose of this study is to evaluate patients who chose DIEP flap as the reconstructive method during initial consultation and compared characteristics of surgery in relation to their final reconstructive choice. Consecutive patients having breast reconstruction from 2017 to 2019 were divided into three groups: immediate DIEP after mastectomy (Group I); delayed-immediate DIEP with tissue expander first followed by DIEP (Group II); and patients who initially chose delayed-immediate DIEP but later decided on implants for the second stage of reconstruction (Group III). Exclusion criteria were patients that had delayed DIEP (no immediate reconstruction) or had initially chose implant-based reconstruction. The study included 59 patients. Unilateral free flaps in Group II had shorter operative times (318 minutes) compared with Group I unilateral free flaps (488 minutes) (p = 0.024). Eleven patients (30.6%) had prophylactic mastectomies in Group I compared with none in Group II (p = 0.004). Patients who had immediate tissue expansion frequently changed their mind from DIEP to implant for second stage reconstruction frequently (52.2%). Delayed-immediate DIEP reconstruction has several advantages over immediate DIEP flap including shorter free flap operative times. Patients commonly alter their preference for second stage reconstruction. A patient-centered advantage of delayed-immediate reconstruction is prolonging the time for patients to make their choice for the final reconstruction.

Abstract PO-129: Influence of triple-negative versus Luminal A breast cancer subtype on choice of autologous versus implant based delayed-immediate breast reconstruction

Abstract Background: Triple-negative and luminal A breast cancer molecular subtypes have divergent clinical and prognostic characteristics for breast cancer patients. Our study aims to compare the reconstructive choice of these two groups from the time they receive a tissue expander to the time they complete autologous or implant-based breast reconstruction. Methods: 255 patients who underwent delayed-immediate breast reconstruction with tissue expander placement from 2013 to 2017 diagnosed with either TN (n = 73) or luminal A (n = 182) invasive breast cancer subtype seen by two surgeons at a single institution were identified. Preference of autologous and implant- based reconstruction was analyzed, along with tissue expander (TE) complications, race, age, BMI, smoking, adjuvant therapy, and comorbidities. Results: There was a significant difference in the choice of implant- or autologous-based reconstruction among these two groups (p &amp;lt; 0.05). A greater proportion of luminal A patients underwent implant-based reconstruction (63.47%) and a greater proportion of TN patients underwent autologous-based reconstruction (53.13%). With regard to TE outcomes, there was no significant difference between the two groups with regard to duration of TE placement by reconstructive type, or TE surgical complications. Significantly more TN patients underwent radiation therapy (p &amp;lt; 0.01) and neoadjuvant chemotherapy (p &amp;lt; 0.0001) than luminal A patients. BMI, comorbidities, radiation therapy and overall TE complications were identified as predictive factors of patients electing for autologous reconstruction over implants. Conclusion: TN breast cancer patients mostly chose autologous-based reconstruction, while luminal A patients chose implant-based reconstruction. Both patient groups carried their tissue expanders for similar duration with similar complication profile. Radiation therapy is likely a major factor in the decision for the type of delayed-immediate reconstruction among this population. Citation Format: Joshua Amaya, Ryan M. Dickey, Kaitlin Jones, Sumeet S. Teotia, Nicholas T. Haddock. Influence of triple-negative versus Luminal A breast cancer subtype on choice of autologous versus implant based delayed-immediate breast reconstruction [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-129.

Influence of Triple-Negative versus Luminal A Breast Cancer Subtype on Choice of Autologous versus Implant-Based Delayed-Immediate Breast Reconstruction.

Triple-negative (TN) and luminal A breast cancer molecular subtypes have divergent clinical and prognostic characteristics for breast cancer patients. Our study aims to compare the reconstructive choice of these two groups from the time they receive a tissue expander (TE) to the time they complete autologous or implant-based breast reconstruction. A total of 255 patients who underwent delayed-immediate breast reconstruction with TE placement from 2013 to 2017 diagnosed with either TN (n = 73) or luminal A (n = 182) invasive breast cancer subtype seen by two surgeons at a single institution were identified. Preference of autologous and implant-based reconstruction was analyzed, along with TE complications, race, age, body mass index (BMI), smoking, adjuvant therapy, and comorbidities. There was a significant difference in the choice of implant- or autologous-based reconstruction among these two groups (p < 0.05). A greater proportion of luminal A patients underwent implant-based reconstruction (63.47%) and a greater proportion of TN patients underwent autologous-based reconstruction (53.13%). With regard to TE outcomes, there was no significant difference between the two groups with regard to duration of TE placement by reconstructive type or TE surgical complications. Significantly, more TN patients underwent radiation therapy (p < 0.01) and neoadjuvant chemotherapy (p < 0.0001) than luminal A patients. BMI, comorbidities, radiation therapy, and overall TE complications were identified as predictive factors of patients electing for autologous reconstruction over implants. TN breast cancer patients mostly chose autologous-based reconstruction, while luminal A patients chose implant-based reconstruction. Both patient groups carried their TEs for similar duration with similar complication profile. Radiation therapy is likely a major factor in the decision for the type of delayed-immediate reconstruction among this population.

Abstract 75: Advantages Of The Delayed-Immediate Microsurgical Breast Reconstruction: Extending The Choice

Purpose: Deep inferior epigastric perforator (DIEP) reconstruction can be performed in an immediate, delayed-immediate (immediate tissue expander followed by staged DIEP), or delayed timing following mastectomy. Several advantages of delayed-immediate reconstruction have been previously described which include avoiding radiation of the flap. The interval between the tissue expander placement and DIEP flap may grant patients additional time to choose between autologous and implant reconstruction. The purpose of this study is to evaluate patients undergoing immediate or delayed-immediate DIEP reconstruction. Methods: Consecutive patients undergoing breast reconstruction from 2017-2019 by a single surgeon were divided into three groups: immediate DIEP after mastectomy (Group I); delayed-immediate DIEP (Group II); and patients who initially chose delayed-immediate DIEP but later decided on implants for the second stage of reconstruction (Group III). Exclusion criteria were patients that had delayed DIEP (no immediate reconstruction) or had implant reconstruction (direct to implant or two-stage reconstruction with implants as the initial choice). Predictive variables were age, body mass index (BMI), comorbidities, radiotherapy, neoadjuvant or adjuvant chemotherapy, plane of tissue expander (prepectoral or subpectoral) and type of mastectomy. Outcome variables included flap loss, seroma, hematoma, surgical site infection (SSI), wound dehiscence, delayed wound healing, operative times and takeback. Results: The study included 50 patients: 29 patients in Group I, 11 patients in Group II, and 10 patients in Group III. Unilateral free flaps in Group II had shorter operative times (318 minutes) compared to Group I unilateral free flaps (528 minutes) (p=.02). Average operative time for bilateral flaps was also longer in Group I (550 minutes) compared to Group II (488 minutes) (p=.2). There was no flap loss in Group I or Group II. Nine patients (31%) had prophylactic mastectomies in Group I compared to zero patients in Group II (p=.04). Patients who had immediate tissue expansion as a first stage changed their mind from DIEP to implant for second stage at a rate of 48% (10/21). No difference was found for age (50.7 years Group II versus 46.4 years Group III, p=.4), BMI (31.3 kg/m2 Group II versus 33.8 kg/m2 Group III, p=.3), or radiation (46% Group II versus 40% Group III, p=.9). Conclusion: Delayed-immediate DIEP reconstruction has several advantages over immediate DIEP flap including shorter free flap operative times. Patients changed their preference of second stage reconstruction from autologous to implant 48% of the time after immediate tissue expander placement. A patient-centered advantage of delayed-immediate reconstruction is extending the time window patients have to make their decision regarding their final reconstruction after the malignancy has been treated.

Variables associated with length of stay in patients undergoing mastectomy and delayed-immediate breast reconstruction with tissue expander.

Delayed-immediate reconstruction with the placement of tissue expanders at the time of mastectomy is a common approach to breast reconstruction. The purpose of this study was to identify variables associated with increased LOS in patients that underwent bilateral or unilateral mastectomy with tissue expander placement. Bilateral procedure, a diagnosis of anxiety or depression, and age>55years were independently associated with increased LOS. More recent year of surgery and Friday surgery were associated with decreased LOS.

Abstract: Analysis of Clinical Outcomes, Cosmetic Results, and Patient Satisfaction Following Delayed-Immediate Breast Reconstruction

INTRODUCTION: Timing and aesthetic outcomes of post-mastectomy breast reconstruction may be affected by the need for radiotherapy treatment (RT), which is often unknown at the preoperative stage since it is determined by pathological findings from the mastectomy specimen. In delayed-immediate reconstruction,1 a tissue expander (TE) is placed directly after the mastectomy to preserve the skin envelope. If RT is not necessary, patients undergo definitive reconstruction. If RT is necessary, the TE remains and patients undergo final reconstruction after RT. We sought to compare the clinical outcomes, cosmetic results, and patient satisfaction of delayed-immediate autologous reconstruction (DIR) vs. delayed autologous reconstruction. METHODS: DIR patients were matched to delayed patients based on age (+/- 5 years), body mass index (BMI) (+/- 2.5), and unilateral or bilateral reconstruction. Retrospective chart review was conducted to collect clinical outcomes, independent reviewers scored cosmetic outcomes (skin quality/color, scar formation, symmetry, breast contour/size/position, overall aesthetic outcome), and patients scored their satisfaction using the BREAST-Q patient reported outcomes instrument. We further examined whether other factors such as smoking, obesity, and RT influenced cosmetic results. Statistical analyses were conducted in IBM SPSS Statistics 24. RESULTS: 19 DIR and 19 delayed patients were included. The mean patient age was 46.5 years (range 29–64) and the mean BMI was 29.6 (range 21.4–41.9). There were no differences in demographics between the two groups. 16 patients underwent unilateral reconstruction and 22 patients underwent bilateral reconstruction. DIR was associated with a higher infection rate (42.1% vs. 5.3%, p=0.026), and all infections involved the TE. DIR patients had significantly better breast contour/size/position than the delayed group (p=0.041). Further, compared to patients who received RT, those who did not receive RT demonstrated better cosmetic outcomes in terms of skin quality/color (p=0.001), symmetry (p=0.001), breast contour/size/position (p<0.001), and overall aesthetic outcome (p<0.001). There were no differences in patient satisfaction between the two groups. CONCLUSION: DIR could be an excellent choice for patients wanting autologous reconstruction when the need for radiation therapy remains unknown, as it demonstrated better breast contour/size/position as compared to the delayed group. However, patients should be informed about the higher risk of TE infection, which could influence the ultimate cosmetic result, and that patient satisfaction was ultimately the same for patients choosing either reconstructive strategy. Reference Citations: 1. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg 2004;113:1617–28.

A 10-Year Experience with Mastectomy and Tissue Expander Placement to Facilitate Subsequent Radiation and Reconstruction.

An integrated approach to skin sparing mastectomy with tissue expander placement followed by radiotherapy and delayed reconstruction was initiated in our institution in 2002. The purpose of this study was to assess the surgical outcomes of this strategy. Between September 2002 and August 2013, a total of 384 reconstructions had a tissue expander placed at the time of mastectomy and subsequently underwent radiotherapy. Rates and causes of tissue expander explantation before, during, and after radiotherapy, as well as tumor specific outcomes and reconstruction approaches, were collected. Median follow-up after diagnosis was 5.6 (range 1.3-13.4) years. In the study cohort, 364 patients (94.8%) had stage II-III breast cancer, and 7 patients (1.8%) had locally recurrent disease. The 5-year rates of actuarial locoregional control, disease-free survival, and overall survival were 99.2, 86.1, and 92.4%, respectively. The intended delayed-immediate reconstruction was subsequently completed in 325 of 384 mastectomies (84.6% of the study cohort). Of the remaining 59 tissue expanders, 1 was explanted before radiotherapy, 1 during radiotherapy, and 7 patients (1.8%) were lost to follow-up. Fifty patients (13.0%) required tissue expander explantation after radiation and before their planned final reconstruction, primarily due to cellulitis. Nonetheless, the cumulative rate of completed reconstructions was 89.6%. The median time from placement of the tissue expander until reconstruction was 12 (interquartile range 9-15) months. Tissue expander placement at skin-sparing mastectomy in patients who require radiotherapy appears to be a viable strategy for combining reconstruction and radiotherapy.

Prosthetic breast reconstruction: indications and update.

Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres. A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000. After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients. Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.

Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy: A survey of UK breast surgeons

Decision-making for women requiring reconstruction and post-mastectomy radiotherapy (PMRT) includes oncological safety, cosmesis, patient choice, potential delay/interference with adjuvant treatment and surgeon/oncologist preference. This study aimed to quantitatively assess surgeons' attitudes and perceptions about reconstructive options in this setting, and to ascertain if surgical volume influenced advice given. A questionnaire was sent to surgical members of the UK Association of Breast Surgery (ABS) in March–June 2014. The questionnaire elicited information on surgeon volume, reconstructive practice and drivers influencing decision-making. Response rate was 42% (148/355), representing 71% of UK breast units. Delayed breast reconstruction (DBR) was offered more commonly than immediate implant, delayed-immediate or immediate autologous reconstruction (p < 0.05). Cosmesis was thought to be equivalent between IBR and DBR by 15% of surgeons, and 26% believe IBR and DBR offer similar Health-related Quality of Life (HRQoL). Surgeon volume had no effect on reconstruction choice. Common decision-making drivers included negative effects of radiotherapy upon reconstructive and cosmetic outcome. The majority of surgeons (77%) believe the current evidence base is insufficient to guide decision-making. Despite surgeons believing that cosmesis and quality of life are not equivalent between IBR and DBR, DBR remains the commonest approach to this difficult clinical scenario. Surgeons perceive they are using a variety of newer techniques such as Delayed-Immediate Reconstruction and Acellular Dermal Matrices to try to ameliorate the effects of PMRT. This survey demonstrates that there is wide variation in reported surgical practice in this difficult setting. There is widespread acknowledgement of the lack of evidence to guide decision-making.

Delayed versus Delayed-Immediate Autologous Breast Reconstruction: A Blinded Evaluation of Aesthetic Outcomes.

BackgroundThe technique of delayed-immediate breast reconstruction includes immediate insertion of a tissue expander, post-mastectomy radiation, followed by reconstruction. The aesthetic benefits of delayed-immediate reconstruction compared to delayed reconstruction are postulated but remain unproven. The purpose of this study was to compare aesthetic outcomes in patients following delayed and delayed-immediate autologous breast reconstruction.MethodsA retrospective analysis was performed of all patients who underwent delayed or delayed-immediate autologous breast reconstruction by the senior author from 2005 to 2011. Postoperative photographs were used to evaluate aesthetic outcomes: skin quality, scar formation, superior pole contour, inferior pole contour, and overall aesthetic outcome. Ten non-biased reviewers assessed outcomes using a 5-point Likert scale. Fisher's Exact and Wilcoxon-Mann-Whitney tests were used for comparative analysis.ResultsPatient age and body mass index were similar between delayed (n=20) and delayed-immediate (n=20) cohorts (P>0.05). Skin and scar quality was rated significantly higher in the delayed-immediate cohort (3.74 vs. 3.05, P<0.001 and 3.41 vs. 2.79, P<0.001; respectively). Assessment of contour-related parameters, superior pole and inferior pole, found significantly improved outcomes in the delayed-immediate cohort (3.67 vs. 2.96, P<0.001 and 3.84 vs. 3.06, P<0.001; respectively). Delayed-immediate breast reconstruction had a significantly higher overall score compared to delayed breast reconstructions (3.84 vs. 2.94, P<0.001). Smoking and the time interval from radiation to reconstruction were found to affect aesthetic outcomes (P<0.05).ConclusionsPreservation of native mastectomy skin may allow for improved skin/scar quality, breast contour, and overall aesthetic outcomes following a delayed-immediate reconstructive algorithm as compared to delayed breast reconstruction.

Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction.

For two-stage, implant-based, delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a good option for patients who wish to avoid a traditional latissimus dorsi donor-site incision. The purpose of this study was to compare outcomes of RALDH and the traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy. A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications, and outcomes were assessed. One hundred forty-six pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed robotically during the study period (average follow-up 14.6 ± 7.3 mo). Latissimus dorsi breast reconstruction following radiation was performed in 64 patients using TOT and 12 using RALDH. Surgical complication rates were 37.5% in TOT versus 16.7% in RALDH (p = 0.31) including seroma (8.9% versus 8.3%), infection (14.1 versus 8.3%), delayed wound healing (7.8% versus 0), and capsular contracture (4.7% vs. 0). Robotic-assisted harvest of the latissimus dorsi muscle is associated with a low complication rate and reliable results for delayed reconstruction of the irradiated breast while eliminating the need for a donor-site incision.

Microvascular Autologous Breast Reconstruction in the Context of Radiation Therapy

When postmastectomy radiation therapy is anticipated, delaying autologous reconstruction prevents radiation delivery issues and radiation-induced contour irregularities. Delayed-immediate autologous breast reconstruction may allow for maintenance of the breast skin envelope as compared with delayed reconstruction with the temporary insertion of a tissue expander. The authors compared perioperative complications and revision surgery rates of comparative cohorts to determine which method is preferable. Delayed-immediate reconstruction was defined as placement of a temporary tissue expander in the first stage at the time of mastectomy before flap reconstruction, which occurred following postmastectomy radiation therapy. Delayed reconstruction was categorized as mastectomy with primary closure in the first stage followed by flap reconstruction. One hundred fifty-two patients and 192 breasts met the study criteria for this retrospective review (delayed reconstruction, 118 breasts; delayed-immediate autologous breast reconstruction, 74 breasts). Patient age and body mass index were similar between groups (p>0.05). Perioperative first-stage complication rates were 8.5 percent in the delayed group and 10.8 percent in the delayed-immediate cohort (p=0.81). Total flap loss (2.5 versus 4.1 percent; p=0.68) and arterial (1.7 versus 1.4 percent; p=0.82) and venous (4.3 versus 5.4 percent; p=0.73) anastomotic revision rates were similar between the cohorts, respectively. Reoperative surgery occurred in 11.9 percent versus 9.6 percent in the delayed and delayed-immediate cohorts, respectively (p=0.69). In comparing two treatment algorithms, flap-related complication rates are comparable. First-stage surgery results in a slightly increased complication rate in the delayed-immediate cohort. Improved overall results with delayed-immediate reconstruction are implied, given significantly decreased rates of revision surgery following flap reconstruction. Therapeutic, III.

Delayed-immediate breast reconstruction - widening the indications for breast reconstruction

Introduction: In women who have a mastectomy and wish to have breast reconstruction, the best timing of breast reconstruction depends on whether radiotherapy (XRT) is needed. If there is pre-operative uncertainty about the need for XRT, patients can be offered a delayed-immediate reconstruction (DIBR). This is where after performing skin sparing mastectomy, a tissue expander or implant is placed until definitive pathology is known. If no XRT is needed, immediate reconstruction can follow, if XRT is necessary, it is performed with the implant in-situ with the hope of preserving skin.

Breast reconstruction and post-mastectomy radiation practice

PurposeThe goal of this study was to explore the perspectives and practice of radiation oncologists who treat breast cancer patients who have had breast reconstruction.MethodsIn 2010, an original electronic survey was sent to all physician members of the American Society of Radiation Oncology, National Cancer Research Institute-Breast Cancer Studies Group in the United Kingdom, Thai Society of Therapeutic Radiology and Oncology, Swiss Society of Radiation Oncology, and Turkish Radiation Oncology Society. We identified factors associated with radiation oncologists who treat breast cancer patients with reconstruction performed prior to radiation and obtained information regarding radiation management of the breast reconstruction.Results358 radiation oncologists responded, and 60% of the physicians were from the United States. While 64% of participants agree or strongly agree that breast image affects a woman’s quality of life during radiation, 57% feel that reconstruction challenges their ability to deliver effective breast radiation. Compared with other countries, treatment within the United States was associated with a high reconstruction rate (>/= 50% of mastectomy patients) prior to radiation (p < 0.05). Delayed-immediate reconstruction with a temporary tissue expander was more common in the United States than in other countries (52% vs. 23%, p = 0.01). Among physicians who treat patients with tissue expanders, the majority (60%) prefer a moderately inflated implant with 150-250 cc of fluid rather than a completely deflated (13%) or inflated expander (28%) during radiation. Among radiation oncologists who treat reconstructions, 49% never use bolus and 40% never boost a breast reconstruction. United States physicians were more likely than physicians from other countries to boost or bolus the reconstruction irrespective of the type of reconstruction seen in their clinic patients (p < 0.01).ConclusionsGreat variation in practice is evident from our study of radiation treatment for breast cancer patients with reconstruction. Further research on the impact and delivery of radiation to a reconstructed breast may validate some of the observed practices, highlight the variability in treatment practice, and help create a treatment consensus.

Delayed-Immediate Breast Reconstruction: Technical and Timing Considerations

In 2002, the author implemented a new two-stage approach, "delayed-immediate breast reconstruction," for patients who desire breast reconstruction and who are at an increased risk for conditions necessitating postmastectomy radiotherapy. There is increasing acceptance of this approach in clinical practice. This report highlights important technical and timing considerations in delayed-immediate reconstruction that help ensure the best outcomes with low rates of expander loss. Stage 1 of delayed-immediate reconstruction consists of skin-sparing mastectomy with insertion of a saline-filled tissue expander to serve as an adjustable scaffold to preserve the three-dimensional shape of the breast skin envelope. Patients who do not require postmastectomy radiation therapy undergo stage 2 (definitive breast reconstruction) within 2 weeks after stage 1 to avoid delays in the start of adjuvant chemotherapy and to preserve the ptotic shape of the preserved breast skin envelope. In patients who do require radiation, the tissue expander is deflated before the therapy to create a flat chest wall surface to permit modern three-beam radiation delivery. Beginning 2 weeks after completion of radiation therapy, the expander is reinflated to the predeflation volume. Three months after the therapy, a "skin-preserving" delayed reconstruction is performed, with removal of the expander and transfer of an autologous tissue flap. Delayed-immediate reconstruction allows patients who do not require postmastectomy radiation therapy to receive the benefits of skin-sparing mastectomy with aesthetic outcomes similar to those of immediate reconstruction. Patients who do require radiation receive a skin-preserving delayed reconstruction, while avoiding the problems that can be associated with radiation delivery after an immediate breast reconstruction.

Use of intraoperative breast cancer sentinel lymph node (SLN) assay to predict of ≥4 positive (+) lymph nodes (LN)

530 Background: Predicting which patients will have ≥4 +LN and may need radiation therapy affects immediate breast reconstruction. We hypothesized that model s to predict the likelihood of ≥4+LN may be improved by incorporation of quantitative real time RT-PCR analysis of SLN. Methods: 728 patients were enrolled in 2 prospective studies of the GeneSearch BLN Assay (Veridex LLC) for SLN metastases. 205 (28.2%) were found to have +SLN by hematoxylin-eosin staining. Of these, 115 pts (15.8%) had tumors ≤5 cm in size with &gt;4 total LN removed, forming the cohort of interest for this study. Quantitative cycle times (CT) for mammaglobin (MG) and CK19 were correlated with finding ≥4+LN on final pathology. Results: Median tumor size was 2.0 cm (range; 0.2–5.0 cm). Median number of SLN removed was 3 (range; 1–11). 18 patients (15.7%) had ≥4 +LN on final pathology. Median CT for MG was 29.1 (interquartile range (IQR): 24.7–39.0) in patients with &lt;4 +LN vs. 21.4 (IQR: 18.5–26.8) in those with ≥4 +LN, p&lt;0.001. Median CT for CK19 was 23.7 (IQR: 20.9–28.2) in patients with &lt;4 +LN vs. 19.6 (IQR: 17.8–20.7) in those with ≥4 +LN, p&lt;0.001. Tumor size ≥2cm, proportion of SLN+ &gt;50%, MG CT &lt;25.8 and CK19 &lt;20.8 were correlated with ≥4 +LN on final pathology. On multivariate analysis, tumor size, MG CT and CK19 CT were significant (see table). A simplified CPR was created with 1 point given if tumor size was ≥2cm, 1 point if MG CT &lt;25.8 and 2 points if CK19 CT&lt;20.8. Of the 24 patients (20.9%) with 0 points, only 1 (4.2%) had ≥4 +LN; of the 12 patients (10.4%) with 3 points, 8 (66.7%) had ≥4 +LN on final pathology, p&lt;0.001. Area under the receiver-operator curve was 86.2% (95% CI: 76.1%-96.2%). Conclusions: Intraoperative quantitative RT-PCR of SLN improves prediction of ≥4 +LN; further validation of this model will have clinical utility regarding the use of immediate, delayed, or delayed-immediate reconstruction approaches. [Table: see text] [Table: see text]