Scandinavian Journal of Surgery 92: 249–256, 2003

IMMEDIATE BREAST RECONSTRUCTION T. Jahkola1, 2, S. Asko-Seljavaara2, K. von Smitten1 1 2

Breast Surgery Unit, Maria Hospital, Helsinki University Hospital, Helsinki, Finland Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland

ABSTRACT

Immediate breast reconstruction (IBR) in conjunction with mastectomy for cancer or high risk of breast cancer is safe from an oncological point of view. The cosmetic outcome can be excellent, especially when performing mastectomy by sparing the skin of the breast and reconstructing the breast mound with autogenous tissue. The majority of women at their working age are willing to have their breast reconstructed. Patients with newly diagnosed cancer undergoing major surgery need extra support compared with those undergoing late reconstructions. Immediate reconstructions with one operation, one hospital stay and one sick leave are economically favourable by diminishing the demand of delayed reconstructions. Preference in patient selection for IBR should be in patients with good prognoses like those with diffuse noninvasive cancer and those with a considerable risk to develop breast cancer. Women with axillary-node negative invasive cancer and women with late local recurrences in a breast earlier conservatively treated are also suitable for IBR. If needed, oncological treatments can be given after IBR, although radiotherapy after pure implant reconstructions is not recommended. In order to give all eligible patients an equal opportunity to have IBR, treatment of breast patients should be centralised to hospitals with a team comprising breast cancer surgeons, pathologists, radiologists, and plastic surgeons. Key words: Immediate breast reconstruction; autogenous tissue; implant; free flap

INTRODUCTION The majority of breast cancer patients can be treated with breast-conserving surgery followed by postoperative radiotherapy. However, about 40 % of patients undergo mastectomy because of tumour multifocality, too large a tumour in relation to breast size or insufficient histological resection margins. Mastectomy is indicated by a high risk of recurrence especially in young patients, in patients with breast canCorrespondence: Tiina Jahkola, M.D. Breast Surgery Unit Maria Hospital P.O. Box 580, FIN - 00029 HUS, Helsinki, Finland Email: [email protected]

cer gene mutations or a strong family history, as well as in patients, for whom radiotherapy is contraindicated because of former irradiation or systemic collagen disease. The wish for breast reconstruction is strongly related to age and working status (1). A successful IBR may make it easier for the patient to cope with the loss of the breast and it is shown to associate with psychological benefit (2, 3) Because it is possible to spare skin of the breast, the aesthetic result of an IBR is usually superior to a delayed one. The advantages of IBR include one operation, one hospital stay and one sick leave. IBR is therefore cost saving compared with delayed reconstruction (4). The suggested disadvantages of IBR after mastectomy compared with mastectomy alone include possible interference with adjuvant therapy, significant

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T. Jahkola, S. Asko-Seljavaara, K. von Smitten TABLE 1 Indications for immediate breast reconstruction in conjunction with mastectomy.

1. 2. 3. 4.

Diffuse in situ cancer Inherited susceptibility for breast cancer Local recurrence after conservative surgery* Mastectomy needed because of large size or multifocality of the cancer**

** A recurrent cancer < 3 cm, not infiltrating skin or chest wall, primarily node negative, recurrence not earlier than 3 years after primary operation, no metastases. ** Preoperatively clinically and by ultrasound axillary node negative.

TABLE 2 High risk criteria for hereditary breast cancer. 1. 3 cases of breast or ovarian cancer in 1st degree relatives, one of which < 50 years of age or 2. 2 cases of breast or ovarian cancer in 1st, degree relatives, one of which < 40 years of age or 3. Breast or ovarian cancer cancer, < 30 years of age Each primary cancer of the same person is calculated separately (bilateral cancer counts as two cancers). Men are not counted in determining the degree of relationship.

additional burden to patients, inappropriateness for patients with poor prognosis, high rate of complications, compromise in surgical excision of cancer, delay in diagnosis of recurrence, poor cosmetic result, psychological disadvantage to patients, and higher price (5). However, many of these questions and prejudices have been answered already in a multitude of studies and reports, some of which will be reviewed in this article. The treatment of breast cancer has been individualised during the last decades according to tumour and patient related factors and many of the present treatment policies are based on prospective controlled randomised trials. Nevertheless, to randomise women to mastectomy versus breast reconstruction seems to be an impossible task, because both patients and surgeons find the options too different. The surgical treatment of breast cancer including IBR means delicate tailoring of the treatment taking into consideration the needs of the patient, the biology, dimensions and stage of the tumour and the continuously developing oncological therapies. In this review we present current methods used in IBRs and discuss the indications, oncological safety and health economics of the procedures. PATIENT SELECTION FOR IMMEDIATE BREAST RECONSTRUCTIONS The wish for breast reconstruction is strongly related to age and working status: it is estimated that 80 % of mastectomised patients under 45 years wish to have reconstruc-

tion while in women over 65 years only 2 % are interested in this operation (1). Immediate breast reconstruction should be discussed with patients who have a cancer not suitable for breast-conserving surgery and who express their intention to ask for reconstruction in the future. Reconstructive surgery with autogenous tissue transfer is being successfully performed for locally advanced or recurrent breast cancer, which often requires pre- or postoperative oncological treatments (6, 7). Autogenous tissue tolerates radiotherapy well although the aesthetic result may be slightly compromised (8, 9). However, if oncological treatments are to be anticipated in patients with invasive breast cancer, delayed reconstruction may be a safer alternative. Less surgery means less wound healing that might cause a delay in chemotherapy or radiotherapy. Systemic metastatic disease is generally considered a contraindication of breast reconstructions. Any surgery may induce carcinoma proliferation (10). Because of limited resources, our policy has been to favour patients with good prognoses to have immediate reconstructions. These are patients, who require mastectomy because of diffuse intraductal carcinoma (ductal carcinoma in situ, DCIS) or patients with axillary node-negative invasive cancer and too large a tumour/breast ratio, multifocality, or a late local recurrence after breast conserving surgery (Table 1). Previously given radiotherapy has shown to be no obstacle for IBR (11). Prophylactic risk-reduction mastectomy with IBR is recommended only for patients with a clearly defined high risk of breast cancer, such as BRCA1 or BRCA2 mutations, Li-Fraumeni syndrome or a family history of breast cancer similar to families with gene mutations (12) ( Table 2).

METHODS OF IMMEDIATE BREAST RECONSTRUCTION Breast reconstruction may involve transfer of autogenous tissue alone, insertion of prosthesis or a combination of tissue transfer and prosthesis. The main goal of breast reconstruction is to obtain symmetry. Therefore corrective surgery of the contralateral breast is sometimes required, especially when implants are used. To achieve a predictable result, the use of expandable implants has become increasingly popular.

SKIN-SPARING MASTECTOMY Skin-sparing mastectomy introduced by Toth and Lappert (13) is the key to obtain a good cosmetic result. By leaving most of the breast skin intact, the reconstruction fills the breast envelope making it possible to maintain the natural breast mound, so difficult to achieve in delayed breast reconstructions. Another advantage with the method is that a great part of the sensation of the skin of the breast will be retained or regenerated. A step further is nipple sparing mastectomy or “envelope mastectomy” in conjunction with immediate breast reconstruction (14). However, nipple involvement is found in 58 % of mastectomy specimens and hence the best candidates for nipple conservation would be patients with small T1 tumours at 4–5 cm distance from the nipple and these women are best treated by breast conserving surgery. Thus there seems to be little indication for nipple conserving mastectomy in the treatment of

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breast cancer (15). In prophylactic mastectomies the nipple carries a risk of malignant transformation but being visible and palpable for follow up its conservation may be considered. RECONSTRUCTIONS WITH AUTOGENOUS TISSUE Despite surgical complexity, autogenous tissue is usually the best choice for breast reconstruction because there are no implant-related complications and the cosmetic result is usually better due to better imitation of natural ptosis with soft, warm and pendulous tissue. In addition, this type of reconstruction is not endangered by postoperative radiation (7, 8). The selection of tissue used for reconstruction depends on the amount of tissue needed, the amount of tissue available at the donor site and also the life style and wishes of the patient. Autogenous flaps currently used for IBR can be categorised to flaps from the lower abdomen, flaps from the upper back and flaps from the gluteal region. The ideal tissue needed for IBR is fat and a skin island to replace the areola. Whether muscle or fascia is raised as well, depends on individual anatomical conditions often not evident until at surgery. Fasciocutaneous flaps of the thigh and omentum have also been used for IBRs. RECTUS ABDOMINIS-MUSCLE FLAPS

Increasing knowledge of the blood supply of the skin and subcutaneous tissue by perforating vessels from the anterior rectus sheath initiated the use of rectus abdominis-musculocutaneous flaps. The island can be vertical and is then called the vertical rectus abdominis-muscle flap (VRAM), seldom if at all used for breast reconstructions (16). Usually a transverse flap consisting of the skin and subcutaneous tissue of the lower abdomen is used for breast reconstructions. It is called the transverse rectus abdominis-muscle flap (TRAM) (17). PEDICLED TRAM FLAP

Originally presented by Hartrampf (17) pedicled TRAM flap was raised as a pedicled flap based on the deep superior epigastric vessels. These flaps can be ipsi- or contra lateral, unipedicled or bipedicled, unilateral or bilateral. FREE TRAM FLAP

First described in 1979 by Holmström the free microvascular TRAM flap relies on the inferior epigastric vessels (18). The free TRAM breast reconstruction has become “the golden standard” for breast reconstructions. Microvascular TRAM is more demanding than the pedicled TRAM because of the microvascular surgery involved and the demand of readiness for emergency operations to correct vascular and bleeding problems during the initial days after surgery, occur-

Fig. 1. Skin sparing mastectomy, with level 1 axillary clearance, combined with free microvascular TRAM (DIEP) flap reconstruction is a one stage procedure in two teams. Breast surgeon performs the mastectomy and evacuation; plastic surgeon harvests the free flap in the lower abdomen. The deep inferior epigastric vessels of the flap are connected to the thoracodorsal vessels in the axilla.

ring in up to 10–15 % (19). Total flap loss is possible, rate 0.5 % in our material of free TRAM reconstructions (20). The free flap has gained popularity because it has better perfusion, making larger tissue transfers possible and diminishing the risk of fat necrosis (21). The most dreadful postoperative complications of TRAM reconstructions are donor site problems as abdominal bulging, hernia and chronic pain. These problems are considerably fewer in free TRAM reconstructions (22). The technique used in our unit has been described by Asko-Seljavaara and Nieminen (23, 20). FREE DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP (DIEP)

In the deep inferior epigastric perforator flap (DIEP) the perforating vessels through the rectus muscle are carefully dissected. The rectus muscle and sheath are preserved because the flap is composed only of skin and fat, the essential parts required for breast reconstruction (24, 25). Avoidance of muscle sacrifice minimises the risk of abdominal hernia and bulging and need of tight fascial closure and the use of mesh (26). FREE SUPERFICIAL INFERIOR EPIGASTRIC ARTERY (SIEA) FLAP

The SIEA flap is based on the superficial inferior epigastric vessels and leaves the fascia of the rectus muscle intact (27). Because the rectus muscle is not touched, the advantages are the same as for the DIEP flap. The vessels are, however, smaller and the vascular pedicle is shorter than in the DIEP flap. In many

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patients the vessels are missing or they have been cut in previous surgery. The donor area is similar to that of the TRAM flap. LATISSIMUS DORSI-MUSCULOCUTANEOUS FLAP

Latissimus dorsi musculocutaneous flap (LD flap) is transposed from the back (28). This is a reliable flap and microsurgical expertise is not needed. It gives a good breast for either slim women with small breasts or overweight women, who have excess tissue in their upper back. The LD muscle tends to atrophy and sometimes the flap does not have enough volume originally. Prostheses are often used under LD flaps. Another alternative to add volume is the extended LD flap (29). In this variation of the LD flap most or all of the fat overlying the whole of the LD is used to increase the bulk of the flap so that even rather a large breast can be reconstructed without prosthesis. One of the main indications for using this flap is significant obesity; these patients are at risk of abdominal wall complications and fat necrosis when using TRAM flaps. The transposition of the LD muscle does not interfere with the movements and strength of the shoulder in ordinary women. The scar of the donor site in the back can be placed horizontally under the bra or obliquely mimicking the line of a swim suit giving a good cosmetic result. With skin sparing mastectomy there may be no need of taking skin with the flap so a LD-muscle flap can be harvested endoscopically with no scar in the back at all (30). Since change in the volume of the LD muscle due to atrophy may be difficult to estimate, the use of expandable prosthesis with LD flap is an alternative giving flexibility in volume (31). THORACODORSAL ARTERY-PERFORATOR FLAP (TAP)

The TAP flap is a recent refinement of the LD flap where a cutaneous island is raised from the latissimus dorsi area without taking muscle and the flap is based on musculocutaneous perforators from the thoracodorsal artery (32). This flap can be used for reconstruction of a small breast. LATERAL THORACODORSAL FLAP

Lateral thoracodorsal flap is a pedicled fasciocutaneous flap used only in combination with an implant with good aesthetic results. It is based on the intercostal perforators at the level of the submammary crease (33). THE SUPERIOR OR INFERIOR GLUTEAL FREE FLAP

In most female patients, there is an excess of tissue available in the gluteal area, and this tissue can be reliably transferred using microsurgical techniques (34). By using the inferior gluteal vessels one gets a longer vascular pedicle than by using the superior ones (35).

GLUTEAL PERFORATOR FREE FLAP (GAP)

Both the superior and the inferior gluteal flaps can be raised as perforator flaps, totally preserving the muscles and utilizing only the skin and fat. Especially the superior GAP flap seems to be promising (36). LATERAL TRANSVERSE FREE THIGH FLAP

This flap uses skin and fat from the upper lateral thigh based on the lateral circumflex femoral vessel blood flow into the fascia lata muscle (37). A modification of this flap is the anterolateral thigh flap, which seems to be a good choice for a type of Chinese women (38). FREE LAPAROSCOPICALLY HARVESTED OMENTAL FLAP

A pedicled omental flap was first used for breast reconstruction 40 years ago. Recently successful IBRs after skin sparing mastectomy have been performed using laparoscopically harvested free omental flaps (39, 40). CHOICE OF RECIPIENT VESSELS IN FREE FLAP BREAST RECONSTRUCTIONS

In free flap breast reconstruction the thoracodorsal artery and vein are usually used for the vascular access at the recipient site. In the axilla the circumflexa scapulae vessels are another alternative. In order to have a better exposition of these vessels at least the lower part of level 1 of the axilla is cleared. Operating on patients with invasive cancer, the axilla has to be cleared or staged with lymphatic mapping and sentinel node biopsy. When doing the immediate breast reconstruction for prophylactic reasons or in cases of pure DCIS without invasive cancer, it is desirable to avoid even a partial clearance of the axilla because of the risk of loss of skin sensitivity and arm problems. The internal mammary artery and vein or its perforators may therefore be preferred as recipient vessels (41). In free flap reconstruction especially in conjunction with prophylactic mastectomy where there is no need of any axillary exploration, this should therefore be an option. RECONSTRUCTIONS WITH IMPLANTS SIMPLE INSERTION OF AN IMPLANT

The simplest technique of immediate reconstruction is to place the prosthesis either directly in the subcutaneous space or under the pectoralis major muscle. Earlier series placing prostheses under the skin flaps after a mastectomy without skin-sparing technique encountered a high incidence of flap necroses, wound dehiscence, implant extrusions, infections and peri-implant contractures (42, 43). When simple insertion of prosthesis is used, a submuscular position is to prefer, which also yields a better cosmetic outcome (44). Implants can be placed under any tissue flaps, usually under LD-flaps, to gain more volume.

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Fig. 2. Bilateral breast reconstruction with latissimus dorsi musculocutaneous flaps on both sides and silicone prosthesis under the muscle. Skin-sparing mastectomy performed on the right breast because of diffuse DCIS and prophylactic mastectomy on the left breast.

EXPANDER-IMPLANT RECONSTRUCTIONS

In IBR with expander prosthesis there is usually excess skin after the skin sparing technique and little if any skin expansion is needed. Pectoralis major muscle may require stretching and expander technique gives flexibility in adjusting the final volume of the reconstructed breast also under tissue flaps. Originally, tissue expanders with a remote fill tube and injection port were gradually expanded and then removed from the sub pectoral space and a permanent implant was inserted in another operation (45– 48). In order to avoid the additional operation of expander removal and insertion of the permanent prosthesis, a Becker type expandable prosthesis may be used (49). Modern anatomical expandable implants with textured surface can give good cosmetic results (50, 31). Because it is very difficult to shape a ptotic and pendulous breast with this technique, a correction of the ptosis of the other breast is often required. Therefore, usually patients with small non-ptotic breasts are chosen for implant procedures. The choice of implants with IBR is thoroughly discussed in a review by Malata et al. (51). Patients undergoing bilateral prophylactic mastectomy are an ideal group for anatomic expandable implants, because in these patients it is easy to obtain symmetry and a lack of ptosis will not be a problem. These patients are often young and wish to have children and therefore a bilateral TRAM reconstruction is not a good option. RECONSTRUCTION OF MAMILLA AND AREOLA In our practice, reconstruction of the mamilla is performed with local skin flaps 3–12 months postoperatively. Tattooing of mamilla and areola takes place

Fig. 3. Skin-sparing mastectomy and free TRAM flap reconstruction of the left breast because of small invasive carcinoma with extensive intraductal component (EIC) in a young patient. Mamilla reconstructed later by local flaps and tattoo.

some weeks later. In implant reconstructions the periareolar wound can be closed with a purse-string suture and tattooed thereafter. SURGICAL AND ONCOLOGICAL ASPECTS OF SKIN-SPARING MASTECTOMY Skin-sparing mastectomy is a time-consuming operation proceeding along the level of the fascia of Scarpa aiming at radical removal of all tumour tissue as well as all breast tissue. In addition to complications in the healing of the flaps used for reconstruction, also the spared skin of the breast may suffer complications ranging from epidermolysis to infarction of skin envelope. The incidence of native skin necrosis ranges from 3.6 to 21.6 % in published reports (52– 55). Patients with large, ptotic breasts, tobacco smokers and patients with previous irradiation have an increased risk of skin necrosis. In patients with large breasts, a reasonable option is to perform a contralateral breast reduction and diminish the skin envelope of the mastectomy (13). In the past, it was feared that loco-regional recurrences would be concealed by the reconstruction leading to delayed detection, but this has not been

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verified in practice (56). The rates of local recurrence in published series vary between 2 to 7 % depending on patient selection and follow-up times (53, 57– 60). A local recurrence after mastectomy and immediate reconstruction is a surgical treatment failure and a psychological disaster to the patient. It is also a potential risk to the patient, but not all recurrences are associated with systemic relapse (59). After mastectomy a local recurrence within the thoracic wall is prognostically more serious than a recurrence under the skin flaps (58). No differences were found in local recurrences in patients treated with IBR compared with patients treated with mastectomy alone, once the groups had been corrected for tumour size, grade and nodal status (61–63). It has been suggested that a regional recurrence after skin-sparing mastectomy is rather a function of the biology of the tumour and the stage of the disease than a consequence of the use of immediate breast reconstruction or skin-preserving mastectomy (53). SAFETY OF SILICONE PROSTHESIS There is no scientifically valid evidence to support an association between silicone implants and increased risk of autoimmune disease (64). If radiotherapy is anticipated after mastectomy, an alloplastic reconstruction is not recommended because of poor cosmetic outcome and capsular contracture formation (41, 42, 65). Good results in immediate reconstructions are to be expected when using prostheses in patients undergoing prophylactic mastectomy with IBR (66). Patients with DCIS with or without microinvasion have also been successfully treated with IBR using prosthesis (67). SAFETY OF RECONSTRUCTION WITH AUTOLOGOUS TISSUE Patient’s own tissue is superior to prosthesis in its relation to radiotherapy. Both pedicled and microvascular flaps tolerate radiotherapy but irradiation may worsen the cosmetic outcome to some degree (68–70). Immediate breast reconstruction has been shown not to delay postoperative adjuvant chemotherapy (71) and it has been performed after neoadjuvant chemotherapy (6). DONOR-SITE PROBLEMS In LD reconstructions the most frequent donor-site problem is seroma formation, being transient almost always. Its reported incidence ranges from 9–33 % (72, 73). Use of LD muscle for reconstruction leaves little functional disability to the patient. The endoscopic harvesting of LD flap minimizes visible scars and is suitable for IBR with skin sparing mastectomy if skin in the flap is not needed (30). In TRAM reconstructions the donor-site problems may be more serious. The most serious complication

is abdominal-wall hernia or annoying bulging, often combined with pain with an incidence of up to 12 % in pedicled flaps (74, 75) and 3–6 % in free TRAM flaps (20, 21). Harvesting of a free TRAM flap causes a subclinical reduction in abdominal strength, not noticed by the patients (76). Asymptomatic abdominal bulging is more common after pedicled TRAM flaps (77). The development of tissue transfers from the lower abdominal wall through DIEP flaps (25) to SIEA flaps (26) has minimized the donor-site morbidity. OWN SERIES OF IBR Our own experience and preliminary follow-up data of 201 patients treated with IBR has recently been presented (78). PSYCHOLOGICAL ASPECTS The psychological value of immediate breast reconstruction is quite well documented (79). Patients who were immediately reconstructed showed less psychiatric morbidity and emotional distress (3, 80) and they expressed high satisfaction (2). There are, however, earlier studies which have failed to confirm the assumption that reconstructive surgery of the breast has a psychologically supportive function and it seemed that the initial differences in adjustment between reconstructed and non-reconstructed patients might be minimal and disappear with time (81, 82). In our experience, IBR patients are more demanding than patients with delayed reconstructions when it comes to adjustment and understanding information given. They have to cope with a recent diagnosis of breast cancer and simultaneously concentrate on major surgery. They have no experience of life without a breast and the reconstructed breast may be a disappointment in the beginning because it is never quite the same as the original one. HEALTH ECONOMICS Breast reconstructions have seldom been addressed from the health economics point of view. A direct comparison of hospital charges in the USA have shown delayed reconstructions being 62 % more expensive than immediate reconstructions, the difference being 11042 US dollars (4). In different countries, the comparisons vary according to staff costs, practices of sick-leave compensation and mean age of retirement. IBR should be considered when a woman expresses the desire to have a reconstruction later on, if an immediate reconstruction is not offered. The health care providers should especially be interested in IBR, which requires only one operation, one hospital stay and one sick leave. The comparison of costs between implant reconstructions and autogenous tissue reconstructions has yielded controversial results (83, 84). Therefore, lead-

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ing criteria for the choice of reconstructive methods have to be based on patient related factors. In summary, IBR is an option in the surgical treatment of breast cancer. Specialised multidiciplinary departments with plastic surgeons are needed in order to tailor and optimise the treatment of breast cancer.

22.

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Received: July 16, 2003