Ebook Breast cancer management for surgeons: Part 2

(BQ) Part 2 book “Breast cancer management for surgeons” has contents: Speciic autologous flap techniques, goldilocks procedure, nipple reconstruction, complications of breast surgery and their management, adjuvant endocrine therapy, adjuvant chemotherapy, hereditary breast cancer,… and other contents.

Reconstructive Surgery

Contents

Chapter 27 Immediate Reconstruction: General and Oncological

Considerations – 315

Maria João Cardoso and Giuseppe Catanuto

Chapter 28 Delayed Breast Reconstruction: General and

Oncological Considerations – 325

Zoltán Mátrai

Chapter 29 Breast Implants: Design, Safety and

Indications for Use – 355

Jana de Boniface and Inkeri Schultz

Chapter 30 Specific Implant-Based Techniques for

Breast Reconstruction – 365

Lorna J Cook and Michael Douek

Chapter 31 Specific Autologous Flap Techniques – 381

Sinikka Suominen and Maija Kolehmainen

Chapter 32 Goldilocks Procedure – 393

Fiona MacNeill

Chapter 33 Nipple Reconstruction – 401

Valentina Lefemine and Kelvin F Gomez

Chapter 34 Complications of Breast Surgery and

Their Management – 411

Michalis Kontos and Christos Markopoulos

© Springer International Publishing AG 2018

L Wyld et al (eds.), Breast Cancer Management for Surgeons, https://doi.org/10.1007/978-3-319-56673-3_27

27.2.1 Indication for Immediate Breast Reconstructions

and Overview of Current Guidelines – 316

27.3 Surgical and Oncological Safety – 317

27.4 Integration of Adjuvant and Neoadjuvant Treatments – 318

27.4.1 Effects of Neoadjuvant Chemotherapy on IBR – 318

27.4.2 Effects of Adjuvant Chemotherapy on IBR – 318

27.4.3 Effects of Adjuvant Radiotherapy on IBR – 319

27.5 Impact of Immediate Breast Reconstruction

27.7.1 Surgical Decision in Patients with Small- and 

Medium-Sized Breast and Minimal/No Ptosis – 322

27.7.2 Surgical Decisions in Patients with Large and Ptotic Breasts – 322

27.8 Conclusions – 322

References – 322

100 years The first article was published by Czerny in 1895

and concerned the transplantation of a large lipoma to

replace a breast removed for benign disease [1] Since then,

the search for alternatives to reconstruct the breast has

con-tinued relentlessly Fat grafts from several sources were used,

but they atrophied relatively quickly, failing to provide a

durable recreation of the breast mound Fat and dermal grafts

were then used, and less shrinkage occurred but still usually

failed to achieve an adequate breast size Although there were

some isolated attempts, at the beginning of the last century,

to use muscular and musculocutaneous flaps, they were not

successful and were rapidly dismissed mainly due to the

focus on radical resection (as defended by Halstead) in this

period [2] As a result of the Halsted paradigm for breast

can-cer spread in the first half of the twentieth century,

mastecto-mies became even more radical, and interest in immediate

reconstructions declined Furthermore, it was believed that

autologous tissues could hide a local recurrence, and

there-fore attempts to reconstruct the breast were discouraged in

general [3] Although some further trials were described at

the beginning of the twentieth century, it was only during the

1960s and 1970s that breast reconstructions were considered

again in a positive light, but as delayed operations in the large

majority of the cases In 1978 however the latissimus dorsi

flap was reintroduced by Bostwick and Scheflan for one-stage

breast reconstructions [4]

The development of silicone breast implants during the

1960s gave a great boost to immediate reconstructions

Initially these were just put underneath the mastectomy flaps,

with a high rate of capsular contracture and extrusion The

two-stage reconstruction evolved rapidly to help reduce

these problems and progressively gained popularity [3 5]

Often, implants were integrated into breast reconstruction

with a latissimus dorsi flap to enhance the final volume of the

breast mound In 1984 Becker introduced a dual chamber

silicone implant that could be filled with saline in an inner

chamber in an attempt to reduce the need for a second

oper-ation and to better mould the shape of the reconstructed

breast [6]

The gradual ascendency of Fisher’s theory of breast

can-cer as a systemic disease rather than Halstead’s principle of

radical local control led to a much lesser radical approach to

cancer surgery Ultimately this led to the acceptance of

breast-conserving treatment and skin- sparing approaches to

mastectomy Along with the acceptance of skin-sparing

tech-niques, other technical developments and refinement of

ana-tomically stable implants in the 1990s and the introduction

of new devices such as acellular dermal matrices (ADMs)

and meshes for implant coverage, in the last 5–10  years,

greatly reduced the need for two-stage breast

reconstruc-tions

Autologous reconstruction with myocutaneous flaps

became an established reconstructive technique during the

1980s when Hartrampf transferred a horizontal skin island

provide substantial fatty tissue volumes while providing rewarding cosmetic results However, it required a long operating time and was associated with higher complication rates

Despite a huge number of studies, mainly retrospective, the quality of evidence supporting the use of immediate breast reconstruction versus delayed is still of a relatively low level D’Souza and colleagues performed a systematic review

to assess the effects of immediate versus delayed breast reconstructions following mastectomy for breast cancer The results of this study demonstrated that only one randomized trial was available at the time of the review A generalized inadequacy of outcome evaluation (in terms of cosmetic out-come and psychosocial well-being) was reported The authors concluded that the evidence base for immediate reconstruc-tion is presently of poor methodological quality (a single RCT with flaws and a high risk of bias) which precludes con-fident decision-making [8] This Cochrane review reports study results up until 2011 In the ensuing 5 years, the mate-rials and techniques have grown exponentially but with little application of scientific rigor In the absence of good-quality randomized data, it is vital that a critical evaluation of the current evidence, even if retrospective, is undertaken It is unlikely that randomized trials will take place due to the extreme difficulty of randomization between immediate and delayed reconstruction due to lack of surgical and patient equipoise

27.2 Indications and Contraindications for Immediate Breast Reconstruction

27.2.1 Indication for Immediate Breast Reconstructions and Overview

of Current Guidelines

International guidelines on the oncological treatment of breast cancer regarding indications and contraindications for reconstructive surgery are reviewed below, although, as men-tioned above, they are based on low-level evidence

The Physician Data Query (PDQ) is a comprehensive source of cancer information from the National Cancer Institute [9] The summaries reported in this database are comprehensive and evidence based and deal with topics that cover most of the aspects of cancer care, screening and pre-vention In the chapter for health professionals, it is stated that «for patients who opt for a total mastectomy, reconstruc-tive surgery may be performed at the time of the mastectomy (i.e., immediate reconstruction) or at some subsequent time (i.e., delayed reconstruction)» No other specific information

on the timing of the reconstruction is provided Some details

on surgical techniques (implants or flaps) are available, but

no data on the surgical or oncological safety of immediate reconstruction are reported

The National Comprehensive Cancer Network (NCCN)

guidelines provide complex decisional algorithms for the

majority of known cancers These are continuously updated

and revised to reflect new data and clinical information that

may add to or alter current clinical practice standards The

NCCN guidelines for breast cancer in chapter BINV-H 2016

[10] discuss the principles of breast reconstruction It is

clearly indicated that patients should have proper

informa-tion and that breast reconstrucinforma-tion can be performed soon

after mastectomy However, timing is not subject to clear

indications and contraindication with the exception of an

absolute contraindication for IBR in the setting of

inflamma-tory breast cancer [11]

In Europe, the European Society for Medical Oncology

(ESMO) guidelines from 2015 [12] contain general

recom-mendations for the treatment of invasive breast cancer and

are not very detailed regarding both the timings and specific

procedures for reconstructive surgery, except in favouring

autologous reconstruction in the setting of postmastectomy

radiotherapy

In the UK, two groups have been working to establish

guidelines and standards for breast reconstruction: the

Association of Breast Surgery (ABS) and the British

Association of Plastic, Reconstructive and Aesthetic Surgeons

(BAPRAS) In 2012 they produced guidelines for best

prac-tice for oncoplastic breast reconstruction [13] These

guide-lines are very specific and not only help in establishing the

indications for breast reconstruction but deal in great detail

with the technical aspects of breast reconstruction and also

with complications and outcomes

From the analysis of these guidelines, it is concluded that

immediate breast reconstruction can and should be offered

to the majority of patients in whom mastectomy is indicated

or preferred, with the exception of patients with

inflamma-tory breast cancer or in the presence of severe comorbidities

where prolongation of surgical time would increase risks

However, patients should be made aware of the possible

influence on aesthetic outcomes and morbidity if

postmas-tectomy RT is needed and consideration given to autologous

reconstruction, where outcomes may be better following flap

irradiation, in these cases [14]

27.3 Surgical and Oncological Safety

One of the most frequent questions about breast

reconstruc-tion regards safety

Immediate breast reconstruction may require more

com-plex procedures, with longer operating times, and therefore

can be associated with a higher risk of complications If

com-plications occur, extra time may be needed to recover and to

start adjuvant treatments If the start of adjuvant treatments

is delayed, would this longer interval impact on patient

out-comes in terms of both disease-free survival and overall

sur-vival?

Fisher and colleagues evaluated wound complications,

other medical complications and wound infections using

bivariate and multivariate analyses to identify predictors of outcome in two subgroups of patients from the ACS-NSQIP datasets who underwent either mastectomy and immediate reconstruction with a tissue expander (TE) or mastectomy alone [15] They confirmed that IBR using tissue expansion (TE) was not associated with a greater risk of wound (3.3%

vs 3.2%, P = 0.855), medical (1.7% vs 1.6%, P = 0.751) or overall (9.6% vs 10.0%, P = 0.430) complications The study

reported an association with a higher risk of deep wound

infections (2.0% vs 1.0%, P < 0.001) and unplanned tions (6.9% vs 6.1%, P = 0.025) A logistic regression analysis

reopera-failed to demonstrate significantly associated independent risk of wound, medical or overall complications with the addition of TE reconstruction

A further study by Jagsi and colleagues [16] extended the observation period up to the first 2 post-operative years and reported on postmastectomy complications in a sample of 14,894 women treated by mastectomy from 1998

to 2007 who underwent immediate autologous

reconstruc-tion (n  =  2637), immediate implant-based reconstrucreconstruc-tion (n = 3007) or no reconstruction within the first 2 postopera- tive years (n = 9250) Wound complications were diagnosed

in 2.3% of patients without reconstruction, 4.4% patients with implants and 9.5% patients with autologous reconstruc-

tion (P < 0.001) In conclusion, an extended period of

obser-vation revealed an increase in the complication rate in the population undergoing IBR

It has been suggested that this slightly higher tion rate associated to immediate breast reconstruction might generate delays in the administration of adjuvant treatments and as a consequence have an impact on the oncological outcomes of breast cancer patients A systematic review by Xavier Harmeling and colleagues [17] investigated the impact on immediate reconstruction in terms of delay in time to chemotherapy (TTC) Fourteen studies were included, representing 5270 patients who had received adju-vant chemotherapy, of whom 1942 had undergone IBR and

complica-3328 mastectomy only Only one study identified a cantly shorter mean TTC, four studies found a significantly delay of 6.6–16.8 days and seven studies found no significant difference In conclusion, the authors confirmed that IBR does not necessarily delay the start of adjuvant chemotherapy

signifi-to a clinically relevant extent

Hamahata and colleagues [18] confirmed a slight increase

in the time to treatment in a subgroup of patients undergoing IBR (61.0 ± 10.5 days in IBR group and 58.0 ± 12.3 days in non-IBR group) The post-operative complication rate was 10.0% in the IBR group and 6.1% in the non-IBR group These results have been confirmed by Eck and colleagues [19] who observed that patients who underwent immediate breast reconstruction did not have a delay in adjuvant treat-ment when compared to patients with no reconstruction

(41 days vs 42 days, P = 0.61) However, complicated cases

can have a small but significant impact on the adjuvant

treat-ment start date (47 days vs 41 days, P = 0.027).

In 2012 a meta-analysis from Gieni and colleagues [20] investigated local control rates after IBR. Ten articles were

Immediate Reconstruction: General and Oncological Considerations

The odds ratio (OR) for recurrence of breast cancer for

mas-tectomy with IBR as compared to masmas-tectomy alone was 0.98

(95% CI, 0.62, 1.54) This meta-analysis demonstrated no

evidence for an increased frequency of local breast cancer

recurrence with IBR compared with mastectomy alone

Another study by Eriksen and colleagues [21] confirmed

no differences in terms of local control between 300 patients

who underwent breast reconstruction compared to a second

cohort of matched patients identified from the Regional

Breast Cancer Register of the Stockholm-Gotland health-

care region treated with mastectomy alone (8.2% in the IBR

group and 9.0% in the control group or, in the regional

recurrence rate, 8.2% versus 9.7%) The authors also reported

no significant differences in the timing of adjuvant

treat-ments

Risk factors for complications were extensively

investi-gated by Fischer [22] in a large review of the ACS-NSQIP

2005–2011 dataset of patients who underwent immediate

breast reconstruction either with implants or autologous

tis-sues A «model cohort» of 12,129 patients was randomly

selected from the study cohort to derive predictors Weighted

odds ratios derived from logistic regression analysis were

used to create a composite risk score and to stratify patients

The remaining one-third of the cohort (n = 6065) was used as

the «validation cohort» to assess the accuracy of the risk

model A risk score was created with stratification of patients

into four subgroups based on their total risk score (p < 0.001):

risk categories were low (0–2, risk  =  7.14%), intermediate

(3–4, risk = 10.90%), high (5–7, risk = 16.70%) and very high

(8–9, risk = 27.02%) This score by Fisher may therefore be of

value for the identification of patients at high risk who may

be better served by avoiding or delaying breast

reconstruc-tion until the end of adjuvant treatments or until modifiable

risk factors have been recovered, i.e smoking, obesity, etc It

may also be valuable in patient counselling

To conclude, and based on the available evidence from

the literature, immediate breast reconstruction is generally

safe when surgical complications are minimized by careful

case selection, choice of procedure and consideration of the

wider cancer treatment pathway Correct selection of patients

may help to stratify those high-risk individuals more prone

to complications which may delay the time to adjuvant

treat-ment with a potential subsequent impact on outcomes

27.4 Integration of Adjuvant

and Neoadjuvant Treatments

27.4.1 Effects of Neoadjuvant Chemotherapy

on IBR

Preoperative chemotherapy is a good tool to reduce the size

of cancer that otherwise should be treated by mastectomy

However, some patients may be poor responders and still

require mastectomy after treatment This may raise concerns

neoadjuvant chemotherapy on immediate breast struction was investigated in a meta-analysis by Song and colleagues [23] who confirmed that neoadjuvant chemo-therapy did not increase the overall rate of complications after immediate breast reconstruction (odds ratio [OR]  =  0.59; 95% confidence interval [CI]  =  0.38–0.91) At the same time, no increase in hematomas and seromas was reported, and the risk of expander or implant loss was not higher among patients after neoadjuvant chemotherapy (OR  =  1.59; 95% CI  =  0.91–2.79) The large majority of patients included in this meta-analysis had an implant-based reconstruction Only two studies reported on autolo-gous tissue-based reconstructions Both studies confirmed

recon-no association between total flap loss and preoperative motherapy

che-The same conclusion was published by Abt reporting for the American College of Surgeons National Surgical Quality Improvement Program 2005–2011 databases [24] about the short-term morbidity in patients undergoing mastectomy with and without breast reconstruction This study included

a population of 19,258 patients (22.4%) treated by immediate breast reconstruction, with 820 (4.3%) receiving neoadjuvant chemotherapy (NAC) After multivariate analysis and adjust-ment for confounding factors, NAC was independently asso-ciated with a lower overall morbidity in the immediate tissue expander reconstruction subgroup (OR, 0.49; 95% CI, 0.30–0.84), confirming also the safety of NAC in this subgroup of patients

There are however also some studies reporting a higher rate of failure, specifically related to the use of expander/implants [25], but unfortunately these studies are mainly ret-rospective and don’t allow firm conclusions to be drawn.Analysis of the existent body of evidence regarding the use of NAC and subsequent immediate breast reconstruction after mastectomy concludes that there is no proof that imme-diate reconstruction should be contraindicated in patients who were submitted to NAC

27.4.2 Effects of Adjuvant Chemotherapy

on IBR

This topic is discussed above, and the evidence suggests little impact of IBR on the timing of adjuvant chemotherapy and suggests that it has no negative impact on wound healing or infection rates In fact, adjuvant chemotherapy usually only starts when wounds are completely healed There is the exception of expansion, but even there the rate of complica-tions is very low [26]

One area of continued uncertainty is the safety of mencing adjuvant chemotherapy in patients with «red breast» syndrome as a consequence of the use of acellular dermal matrices Whether this impacts on rates of implant loss and longer-term cosmesis is not yet known, and research

com-is urgently needed in thcom-is area [27]

27.4.3 Effects of Adjuvant Radiotherapy

on IBR

The indications for postmastectomy radiotherapy have

increased recently due to a demonstrated increase in overall

survival in a recent large meta-analysis This not only found

benefit in the long-established indication of more than three

nodes but also found a survival benefit for thoracic wall

irra-diation in cases with 1–3 positive axillary nodes [28]

According to the latest St Gallen consensus of 2015, the

exception to the use of RT should only be in patients with

very good tumour biology [29]

Radiotherapy has an inevitable effect on tissues and may

generate chronic inflammation of the subcutaneous tissues

resulting in long-term fibrosis, atrophy, retraction, ulcers and

telangiectasia that are usually classified using the SOMA

scale [30] These changes may compromise the results of

immediate breast reconstructions both with tissue

expand-ers/implants and autologous tissues However, radiotherapy

techniques have greatly improved in the last decade, with

better targeting, reducing skin doses and better schedules

Consequently severe reactions (ulceration and

telangiecta-sia) are much less common, but fibrosis still occurs and may

impact on reconstruction outcomes

In many countries, radiotherapy is still regarded as either

a relative or absolute contraindication for immediate breast

reconstruction due to the well-documented problems

associ-ated with this combination

In the last 5 years, several systematic reviews and meta-

analyses have clarified the effect of radiotherapy on breast

reconstruction paving the way for more confidence when

this option is considered by both the doctor and patient

A systematic review by Lam and colleagues [31] about the

effects of postmastectomy adjuvant radiotherapy on immediate

two-stage prosthetic breast reconstruction compared the

out-comes of those who had radiotherapy after placement of a

tis-sue expander and after the second surgical stage The primary

endpoint of this study was the reconstruction failure rate with

implant loss Secondary endpoints were the rate and degree of

capsular contracture and aesthetic outcomes A significantly

higher reconstruction failure rate after immediate two-stage

prosthetic breast reconstruction was reported in comparison to

patients who did not have radiotherapy Interestingly the

authors commented that their conclusions were based on a

lower level of evidence as no randomized controlled trials were

identified, and only one prospective, non-randomized,

multi-centre trial was found Despite these considerations, there is a

clear trend indicating that radiotherapy increases the failure

rate of two-stage breast reconstructions

A further systematic review by Berbers and colleagues

[14] identified five subgroups of patients according to the

timing and type of reconstructions (autologous tissue based

after RT, permanent implant after RT, autologous tissue

before RT, permanent implant after RT and overall)

The authors reported a very large variation in

complica-tion rates and in cosmetic outcome between groups A higher

complication rate and revision rate were associated with

implant-based reconstruction performed in previously

radiotherapy-treated patients Less fibrosis was reported when radiotherapy was performed first Implant failure occurred more often if applied after radiotherapy (odds ratio (OR) 3.03 [1.59–5.77]) No differences in the complication rates for autologous tissue according to the timing of radiation were demonstrated

This study follows a previous meta-analysis form Barry and colleagues [32] In keeping with other reports, patients undergoing PMRT and BR are more likely to suffer morbid-ity compared with patients not receiving PMRT (OR = 4.2; 95% CI, 2.4–7.2 [no PMRT vs PMRT]) Autologous recon-struction is associated with less morbidity in the RT setting (OR = 0.21; 95% CI, 0.1–0.4 [autologous vs implant-based]) PMRT has a generally detrimental effect on BR outcome

These results suggest that when immediate reconstruction

is undertaken in women likely to be advised to have PMRT, an autologous flap results in less morbidity when compared with implant-based reconstruction [33] ( Figs 27.1 and 27.2)

.Fig. 27.1 Right nipple-sparing mastectomy with immediate

reconstruction with latissimus dorsi and implant with post- operative radiotherapy – capsular contracture

.Fig. 27.2 Right immediate TRAM flap reconstruction with post-

operative radiotherapy

Immediate Reconstruction: General and Oncological Considerations

proceed with the reconstruction, an autologous tissue-based

intervention has a higher probability of success As an

alterna-tive, a two-stage (radiotherapy with expander inflated) or an

immediate-delayed reconstruction (in case of doubts

regard-ing the need for radiotherapy) would also be considered a

pos-sible option Delaying reconstruction should always be

discussed, but patients’ preferences should always be respected

once they are fully aware of the possible consequences

More recently acellular dermal matrices (ADMs) have

become increasingly popular in implant-based breast

reconstruction ADMs are products derived from human

or animal dermis which has been treated to remove the

cel-lular (antigenic) components ADMs provide an extra layer

of coverage and support for breast implants, particularly

over its lower lateral parts They are used in expander/

implant- based breast reconstruction after mastectomy

Radiotherapy seems to have a negative impact in

recon-struction with expander/implant and ADMs, but evidence

is of very poor quality, and some recent studies start to

sug-gest a decrease in capsular contracture with the use of

ADMs [34]

27.5 Impact of Immediate Breast

Reconstruction on Quality of Life

While the oncological aspects of breast cancer surgery have

been extensively investigated, quality of life after mastectomy

and reconstruction have received less attention although the

development of good-quality QoL instruments specific to

breast cancer outcomes has improved our understanding of

these issues considerably in the past decade

There are now a number of breast-specific QoL tools

which have been validated to varying degrees [35] Among

those which have been adequately validated, three (EORTC

QLQ BR-23, FACT-B, HBIS) focus on non-surgical

treat-ment issues; the BIBCQ does not address aesthetic concerns

after breast reconstruction, and only one, the BREAST-Q,

was specifically developed for use in patients undergoing

mastectomy and reconstruction Another tool developed on

behalf of EORTC is currently undergoing a process of

valida-tion [36]

Using these tools, QoL comparisons have been made

between mastectomy and BR versus breast conservation,

mastectomy alone versus mastectomy plus reconstruction

and skin-sparing versus non-skin-sparing techniques These

are reviewed below

Heneghan and colleagues [37] reviewed a prospectively

collected database in order to evaluate the differences in

terms of quality of life between breast-conserving surgery

and skin-sparing mastectomy followed by immediate

recon-struction Questionnaires specific for breast cancer were

employed (EORTC QLQ B23/B30, FACT-B) to assess

patient-reported QoL outcomes Interestingly both cohorts

breast reconstruction can safely be offered to patients ing mastectomy with similar outcomes to those who undergo breast-conserving surgery

requir-This observation was confirmed by a recent [16] survey from the SEER database [16] They evaluated 1450 patients (963 underwent breast-conserving surgery, 263 mastec-tomy without reconstruction and 222 mastectomy with reconstruction) They measured quality of life using the FACT-B questionnaire and two measures of patient-reported satisfaction including cosmetic outcomes: one was applied to all patients and one specifically to patients who received breast reconstruction (both derived from existing validated tools) No significant differences in well-being by surgery type were observed when comparing mas-tectomy plus no reconstruction, breast conservation, and mastectomy and immediate breast reconstruction, except that there seemed to be a greater improvement in physical well-being by the time of the follow-up survey for patients who received mastectomy with breast reconstruction Among patients receiving mastectomy with reconstruction, radiation receipt was associated with inferior scores for patients receiving implant reconstruction plus radiation therapy Autologous reconstruction cases fared better In conclusion, this study confirms that immediate breast reconstruction generates QoL scores not dissimilar from breast-conserving surgery and confirmed the positive role

of autologous reconstruction in mitigating the deleterious effects of radiotherapy

Skin-sparing mastectomies preserving more of the skin envelope and sometimes the nipple have been evaluated in the context of QoL and cosmesis [38, 39] Patient satisfaction and nipple-areola sensitivity after bilateral prophylactic mas-tectomy and immediate implant breast reconstruction have been evaluated using the BREAST-Q questionnaire [39] Interestingly, satisfaction with the (reconstructed) nipple- areolar complex was similar after skin-sparing mastectomies (SSMs) and nipple-sparing mastectomies (NSMs) Nipple- areola complex sensitivity was lower in the NSM group (mean score, 1.9; 95% confidence interval, 1.5–2.3) compared with the control group – reconstructed nipple (mean score,

4.7; 95% confidence interval, 4.6–4.9; P < 0.01).

Psychosocial and sexual well-being after NSM has also been studied [40] using the BREAST-Q. These results par-tially contradict the previous study Two groups of patients (with nipple preservation/without nipple preservation) belonging to a prospectively maintained database were eval-uated in multivariate linear regression analysis that con-trolled for potential confounding factors Nipple-sparing mastectomy patients reported significantly higher scores in

the psychosocial (p = 0.01) and sexual well-being (p = 0.02)

domains compared to SSM patients There was no significant difference in the BREAST-Q domains relating to physical well-being, satisfaction with the breast or satisfaction with outcomes between the NSM and SSM groups

In conclusion, quality of life after immediate breast

reconstruction can be evaluated effectively using several

vali-dated tools Modern reports confirm good results after

immediate reconstruction and outcomes comparable to

those of breast-conserving surgery Postmastectomy

radia-tion may compromise patient’s satisfacradia-tion, but this negative

impact can be diminished with the choice of autologous

reconstructions

Autologous reconstructions are more stable regarding

long-term aesthetic outcomes, while implant-based

recon-structions tend to decay in the medium to long term Patients

should be correctly informed about these results in order to

make a fully informed choice The benefits of nipple

preser-vation are less well defined with some studies reporting

advantages for nipple reconstruction after skin-sparing

mas-tectomy and other studies reporting an increase of physical

and sexual well-being with nipple preservation

27.6 Evaluating Aesthetic Outcomes

in Postmastectomy Reconstruction

It is a generalized concept that mastectomy and immediate

reconstruction have a better aesthetic outcome than

mastec-tomy with delayed reconstruction This is probably due to the

fact that usually patients submitted to immediate

reconstruc-tion have smaller and less aggressive cancers with a lesser

need for radiotherapy, and also in this subgroup are the

majority of prophylactic mastectomies

However, as in breast-conserving surgery, there is no

standardized objective way of evaluating cosmetic outcomes

[41], and in the great majority of cases, cosmetic results are

not recorded

The breast cancer conservative treatment cosmetic results

(BCCT.core) software [42] was developed for the evaluation

of breast cancer-conserving surgery, and it is not validated

for use in breast reconstruction cases However, objective

features like asymmetry and colour differences can be mined even in mastectomy and reconstruction patients

deter-There is a major need to develop objective tools that will allow us to make meaningful comparisons between tech-niques allowing the identification of factors that can have a real impact on outcomes [42]

27.7 Decision Algorithms for Postmastectomy Reconstruction Selection

This spectrum of choices and all the factors previously cussed can make the final decision about reconstruction very difficult Decision algorithms have been widely used to help

dis-to make informed selection across a range of breast cancer treatment choices with perhaps the most widely used relating

to the decision to have chemotherapy or not (e.g., Adjuvant! Online) Usually in reconstructive surgery, decision algo-rithms are based on a combination of morphological, clinical characteristics and patients’ preferences [43]

Factors used in the decision process are acquired during the first consultation after cancer diagnosis The morphologi-cal characteristics (height, weight, thoracic perimeter, breast cup size and degree of ptosis) of the patients should be recorded Breast volume and ptosis can be precisely calculated using models like the ones described by Longo [44] and Kim [45] With these factors, a simple decision algorithm can help doc-tors and patients to make more informed decisions ( Fig 3).The advantage of using decision algorithms is not only to support choices based on more objective factors but also to increase patient engagement in the decision-making process [46] Medical language is complex, and sometimes patients struggle to understand straightforward medical concepts [47] For this reason, the use of booklets, photographs and videos of diverse surgical techniques can be very helpful, if the patient feels comfortable and expresses interest to have

Assess morphology

o Large / very Large

o Moderate / Major Ptosis

Skin Reducing

Nipple to Sternal notch

< 25 cm

Nipple to Sternal notch

None Minor Moderate Major

NAC removal

NAC sparing

NAC sparing

Ptosis

.Fig. 27.3 Decision tree

regarding type of mastectomy

(skin sparing or nipple sparing)

considering volume and ptosis

Immediate Reconstruction: General and Oncological Considerations

27 27.7.1 Surgical Decision in Patients with Small- and Medium-Sized Breast

and Minimal/No Ptosis

In patients with small to medium breast volumes and minimal

to moderate ptosis, preservation of the breast skin envelope is

usually possible and may include the nipple-areolar complex if

oncologically appropriate to do so (nipple preservation is

con-traindicated in women with tumours close to the nipple, usually

defined as less than 10 mm) Reconstruction of the breast

mound may be achieved in a variety of ways depending on the

patient’s preferences and the availability or otherwise of

autolo-gous donor sites Depending on the patients’ wishes, a

contralat-eral adjustment can be performed in a single stage or as a second

stage Sub-muscular implant reconstructions are less suitable for

moderate breast size and moderate ptosis cases where the use of

an ADM may be preferable to augment the implant pocket

27.7.2 Surgical Decisions in Patients

with Large and Ptotic Breasts

In these patients, skin preservation is technically challenging,

and several approaches have been described in this situation

like the one used by Nava and colleagues [48, 49] This is a

modification of type IV skin-sparing mastectomies as

described by Carlson [50] that uses a de-epithelialized

der-mal adipose flap sutured to the pectoralis major and the

fas-cia of the serratus anterior as a component of a compound

pouch in which a permanent implant could be easily

allo-cated (dermal sling technique) The final inverted T scar

resulting from this method may be symmetrized by a wise

pattern breast reduction or mastopexy on the other side

Nipple-sparing skin-reducing mastectomy is indicated in

patients with large or medium breast volumes, but only

mod-erate ptosis When breast ptosis is significant, the ability to

safely preserve the nipple-areolar complex without necrosis

is reduced In those cases, a careful discussion with the

patients of a possible free nipple graft in the setting of no

postmastectomy radiotherapy or resection of the nipple-

areolar complex with a delayed nipple reconstruction should

be advised

27.8 Conclusions

Immediate breast reconstruction has become widely

avail-able in modern breast practice with good oncological safety,

enhanced cosmesis and quality of life and few absolute

con-traindications Radiotherapy does impact on outcomes but

should be considered as a relative, rather than an absolute,

contraindication Patients should be fully aware of the

postmastectomy radiotherapy is likely to be offered, an gous flap-based reconstruction should be the preferred option

autolo-If the patient selects an implant-based reconstruction, a stage reconstruction with an expander inflated during radio-therapy and an immediate/delayed reconstruction are also possibilities The benefits of ADMs in the radiotherapy setting are still unclear, and evidence suggests that while the risks may

two-be lower, radiotherapy is still associated with inferior outcomes.Measures of quality of life and cosmetic outcomes are fundamental to the assessment of reconstructive surgery The BREAST-Q questionnaire is a valuable and validated option which is simple to use Regarding cosmetic outcome, there is

no validated tool for the evaluation of immediate breast reconstruction results, but the use of the BCCT.core software can help to evaluate simple values like asymmetry in a stan-dard and simple way

The use of decision trees with the inclusion of the more important factors involved in surgical technique selection can help doctors and patients to make a safer and better informed choice

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9 NCI.  Breast reconstruction 2013 [updated February 2013] able from: http://www.cancer.gov/types/breast/reconstruction-fact- sheet

10 NCCN.  NCCN Guidelines for Invasive Breast Cancer Principles of breast reconstruction for invasive breast cancer; [191] 2016.

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12 Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, gers E, et  al Primary breast cancer: ESMO clinical practice guide- lines for diagnosis, treatment and follow-up Ann Oncol 2015;26(Suppl 5):v8–30.

13 Cawthorn S, Cutress RDH, Harcourt D, O’Donoghue J, Rainsbury D, Sjeppard C, et al Oncoplastic breast reconstruction: guidelines for best practice British Association of Plastic, Reconstructive and Aes- thetic Surgeons (BAPRAS); Association of Breast Surgery; 2012, pp 1–68.

14 Berbers J, van Baardwijk A, Houben R, Heuts E, Smidt M,

Keymeu-len K, et  al ‘Reconstruction: before or after postmastectomy

radiotherapy?’ A systematic review of the literature Eur J Cancer

2014;50(16):2752–62.

15 Fischer JP, Wes AM, Tuggle CT, Nelson JA, Tchou JC, Serletti JM, et al

Mastectomy with or without immediate implant reconstruction has

similar 30-day perioperative outcomes J Plast Reconstr Aesthet

Surg 2014;67(11):1515–22.

16 Jagsi R, Jiang J, Momoh AO, Alderman A, Giordano SH, Buchholz TA,

et al Complications after mastectomy and immediate breast

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2016;263(2):219–27.

17 Xavier Harmeling J, Kouwenberg CA, Bijlard E, Burger KN, Jager A,

Mureau MA. The effect of immediate breast reconstruction on the

timing of adjuvant chemotherapy: a systematic review Breast

Can-cer Res Treat 2015;153(2):241–51.

18 Hamahata A, Kubo K, Takei H, Saitou T, Hayashi Y, Matsumoto H,

et al Impact of immediate breast reconstruction on postoperative

adjuvant chemotherapy: a single center study Breast Cancer

2015;22(3):287–91.

19 Eck DL, McLaughlin SA, Terkonda SP, Rawal B, Perdikis G. Effects of

immediate reconstruction on adjuvant chemotherapy in breast

cancer patients Ann Plast Surg 2015;74(Suppl 4):S201–3.

20 Gieni M, Avram R, Dickson L, Farrokhyar F, Lovrics P, Faidi S, et al

Local breast cancer recurrence after mastectomy and immediate

breast reconstruction for invasive cancer: a meta-analysis Breast

2012;21(3):230–6.

21 Eriksen C, Frisell J, Wickman M, Lidbrink E, Krawiec K, Sandelin

K. Immediate reconstruction with implants in women with invasive

breast cancer does not affect oncological safety in a matched

cohort study Breast Cancer Res Treat 2011;127(2):439–46.

22 Fischer JP, Wes AM, Tuggle CT, Serletti JM, Wu LC. Risk analysis and

stratification of surgical morbidity after immediate breast

recon-struction J Am Coll Surg 2013;217(5):780–7.

23 Song J, Zhang X, Liu Q, Peng J, Liang X, Shen Y, et al Impact of

neo-adjuvant chemotherapy on immediate breast reconstruction: a

meta-analysis PLoS One 2014;9(5):e98225.

24 Abt NB, Flores JM, Baltodano PA, Sarhane KA, Abreu FM, Cooney

CM, et al Neoadjuvant chemotherapy and short-term morbidity in

patients undergoing mastectomy with and without breast

recon-struction JAMA Surg 2014;149(10):1068–76.

25 Dolen UC, Schmidt AC, Um GT, Sharma K, Naughton M, Zoberi I,

et al Impact of neoadjuvant and adjuvant chemotherapy on

imme-diate tissue expander breast reconstruction Ann Surg Oncol

2016;23(7):2357–66.

26 Caffo O, Cazzolli D, Scalet A, Zani B, Ambrosini G, Amichetti M, et al

Concurrent adjuvant chemotherapy and immediate breast

recon-struction with skin expanders after mastectomy for breast cancer

Breast Cancer Res Treat 2000;60(3):267–75.

27 Myckatyn TM, Cavallo JA, Sharma K, Gangopadhyay N, Dudas JR,

Roma AA, et al The impact of chemotherapy and radiation therapy

on the remodeling of acellular dermal matrices in staged, prosthetic

breast reconstruction Plast Reconstr Surg 2015;135(1):43e–57e.

28 EBCTCG, McGale P, Taylor C, Correa C, Cutter D, Duane F, et al Effect

of radiotherapy after mastectomy and axillary surgery on 10-year

recurrence and 20-year breast cancer mortality: meta- analysis of

individual patient data for 8135 women in 22 randomised trials

Lancet 2014;383(9935):2127–35.

29 Coates AS, Winer EP, Goldhirsch A, Gelber RD, Gnant M, Piccart-

Gebhart M, et al Tailoring therapies – improving the management

of early breast cancer: St Gallen international expert consensus on

the primary therapy of early breast cancer 2015 Ann Oncol

2015;26(8):1533–46.

30 Pavy JJ, Denekamp J, Letschert J, Littbrand B, Mornex F, Bernier J, et al

EORTC Late Effects Working Group Late effects toxicity scoring: the

SOMA scale Int J Radiat Oncol Biol Phys 1995;31(5):1043–7.

31 Lam TC, Hsieh F, Boyages J. The effects of postmastectomy adjuvant

radiotherapy on immediate two-stage prosthetic breast

reconstruc-tion: a systematic review Plast Reconstr Surg 2013;132(3):511–8.

32 Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta- analysis Breast Cancer Res Treat 2011;127(1):15–22.

33 Schaverien MV, Macmillan RD, McCulley SJ.  Is immediate gous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature J Plast Reconstr Aes- thet Surg 2013;66(12):1637–51.

34 Valdatta L, Cattaneo AG, Pellegatta I, Scamoni S, Minuti A, bino M. Acellular dermal matrices and radiotherapy in breast recon- struction: a systematic review and meta-analysis of the literature Plast Surg Int 2014;2014:472604.

35 Chen CM, Cano SJ, Klassen AF, King T, McCarthy C, Cordeiro PG, et al Measuring quality of life in oncologic breast surgery: a systematic review of patient-reported outcome measures Breast J 2010;16(6):587–97.

36 Winters ZE, Balta V, Thomson HJ, Brandberg Y, Oberguggenberger

A, Sinove Y, et al Phase III development of the European tion for Research and Treatment of Cancer Quality of Life Question- naire module for women undergoing breast reconstruction Br J Surg 2014;101(4):371–82.

37 Heneghan HM, Prichard RS, Lyons R, Regan PJ, Kelly JL, Malone C,

et al Quality of life after immediate breast reconstruction and sparing mastectomy  – a comparison with patients undergoing breast conserving surgery Eur J Surg Oncol 2011;37(11): 937–43.

38 Nava MB, Rocco N, Catanuto G.  Conservative mastectomies: an overview Gland Surg 2015;4(6):463–6.

39 van Verschuer VM, Mureau MA, Gopie JP, Vos EL, Verhoef C, Menke- Pluijmers MB, et al Patient satisfaction and nipple-areola sensitivity after bilateral prophylactic mastectomy and immediate implant breast reconstruction in a high breast cancer risk population: nip- ple-sparing mastectomy versus skin-sparing mastectomy Ann Plast Surg 2016;77(2):145–52.

40 Wei CH, Scott AM, Price AN, Miller HC, Klassen AF, Jhanwar SM, et al Psychosocial and sexual well-being following nipple-sparing mas- tectomy and reconstruction Breast J 2016;22(1):10–7.

41 Cardoso MJ, Cardoso JS, Vrieling C, Macmillan D, Rainsbury D, Heil J,

et al Recommendations for the aesthetic evaluation of breast cer conservative treatment Breast Cancer Res Treat 2012;135(3): 629–37.

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et al Turning subjective into objective: the BCCT.Core software for evaluation of cosmetic results in breast cancer conservative treat- ment Breast 2007;16(5):456–61.

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F. The BREAST-V: a unifying predictive formula for volume ment in small, medium, and large breasts Plast Reconstr Surg 2013;132(1):1e–7e.

45 Kim MS, Reece GP, Beahm EK, Miller MJ, Atkinson EN, Markey

MK. Objective assessment of aesthetic outcomes of breast cancer treatment: measuring ptosis from clinical photographs Comput Biol Med 2007;37(1):49–59.

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47 Krumholz HM. Informed consent to promote patient-centered care JAMA 2010;303(12):1190–1.

48 Nava MB, Ottolenghi J, Pennati A, Spano A, Bruno N, Catanuto G,

et al Skin/nipple sparing mastectomies and implant-based breast reconstruction in patients with large and ptotic breast: oncological and reconstructive results Breast 2012;21(3):267–71.

49 della Rovere GQ, Nava M, Bonomi R, Catanuto G, Benson JR.  Skin- reducing mastectomy with breast reconstruction and sub- pectoral implants J Plast Reconstr Aesthet Surg 2008;61(11):1303–8.

50 Losken A, Carlson GW, Bostwick J 3rd, Jones GE, Culbertson JH, Schoemann M. Trends in unilateral breast reconstruction and man- agement of the contralateral breast: the Emory experience Plast Reconstr Surg 2002;110(1):89–97.

Immediate Reconstruction: General and Oncological Considerations

© Springer International Publishing AG 2018

L Wyld et al (eds.), Breast Cancer Management for Surgeons, https://doi.org/10.1007/978-3-319-56673-3_28

Delayed Breast Reconstruction:

General and Oncological

Considerations

Zoltán Mátrai

28.1 Introduction – 326

28.2 Indications and Special Considerations for 

Delayed Breast Reconstruction – 327

28.2.1 Oncological Considerations for Delayed-Immediate

and Delayed Breast Reconstruction – 327

28.2.2 Patient-Related Factors – 330

28.3 Practical Considerations in Delayed Breast

Reconstruction – 335

28.3.1 Technical Assessment – 335

28.3.2 Delayed Breast Reconstruction Techniques

for Partial Mastectomy Defects – 345

28.3.3 Delayed Breast Reconstruction Techniques

for Total Mastectomy Defects – 345

28.3.4 Autologous Flaps in Delayed Breast Reconstruction – 346

28.4 Outcomes of Delayed Breast Reconstructions – 349

28.4.1 Information Given to Women Before Their Breast Surgery – 349

28.4.2 Types of Breast Reconstruction Techniques – 349

28.4.3 Types of Contralateral and Secondary Reconstructive

Procedures – 349

28.4.4 Complication Rates for DBR – 349

28.4.5 Pain Management in the First 24 h After Surgery – 350

28.4.6 Access to Postoperative Psychological Support – 351

28.4.7 Long-Term Clinical and Patient Satisfaction Results

of Delayed Breast Reconstructions – 351

References – 352

28.1 Introduction

Reconstructive surgery techniques provide a range of safe

methods to recreate the breast mound and restore the skin

envelope following mastectomy and also for the restoration

of symmetry [1 2] Breast reconstruction (BR) should

opti-mally result in a soft natural looking and feeling breast which

retains its properties over time [1] Breast reconstruction is a

critical step for many women to restore their body image and

improve self-esteem and quality of life after breast cancer

surgery [3 4] The importance and popularity of BR have

increased substantially in the last three decades due to an

increased range of techniques, wider availability of

appropri-ate surgical skills, improved oncological management and

higher patient expectations [1] In fact, modern

multidisci-plinary breast care integrates optimal oncological care with

support of the psychological and aesthetic needs of women

with breast cancer, and reconstructive surgery is now a core

component of multidisciplinary cancer care Women should

be offered access to the full range of procedures in this new

era of oncoplastic breast surgery [1 3]

Oncoplastic breast surgery covers a wide range of

proce-dures to maintain or improve the cosmetic outcome of

sur-gery while maintaining optimal oncological outcomes and

includes reconstruction after mastectomy (immediate or

delayed), wide excision plus volume replacement or

displace-ment to restore the defect and correction of asymmetry

between the breasts [1 2] According to the guidelines of the

UK Association of Breast Surgeons (ABS), all patients, for

whom mastectomy is a treatment option, should have the

opportunity to receive advice on BR [5] Breast

reconstruc-tion can be performed either at the time of the primary

oper-ation (oncoplastic volume displacement/replacement or

immediate BR) or later as a separate surgical procedure

(delayed breast reconstruction (DBR)) [1 3] Traditionally

general surgeons performed the majority of breast cancer

surgeries, and reconstructions were delayed procedures done

mostly by plastic surgeons [1] Modern oncoplastic breast

surgery is increasingly being performed by breast surgeons or

oncoplastic breast surgeons who are able to combine

onco-logical and reconstructive plastic surgical techniques [1] In

2002, the National Institute for Health and Clinical Excellence

(NICE) in the United Kingdom (UK) published guidelines on

improving breast cancer outcomes and recommended that

«reconstruction should be available to all women with breast

cancer at the initial surgical operation» [2 6 7] According to

the Fourth Annual Report of the National Mastectomy and

Breast Reconstruction Audit (NMBRA) in the UK during an

audit period between 1 January 2008 and 31 March 2009,

16,485 patients underwent mastectomy [8] Of these women

21% received a concurrent immediate breast reconstruction

(IBR) and 10.5% underwent DBR. If BR is not offered, the

reasons should be recorded [2 5]

Providing adequate information about oncoplastic

sur-gery from the outset is important to avoid discouraging

patient interest and uptake [2] and should include discussion

of not only the available techniques but the timing of such surgery [1–3] Depending on the timing of reconstruction, numerous non-randomized studies have reported differ-ences in the type of surgery, the psychological benefits, aes-thetics and complication rates [3] In the Third NMBRA, the most common type of procedure for women undergoing IBR was implant-only or tissue expander-based reconstruction (36.8%) versus DBR where the most common technique was autologous flap based (58.5%) [2]

Although high-level evidence is not available to explore differences between BR types in terms of quality of life or patient safety, there are significant differences in terms of the reconstructive techniques between IBR and DBR, which reflects the basic difference of the initial status of the breast skin, soft tissue and volume loss to be restored [3 9]

Nipple-sparing mastectomy (NSM), areola-sparing tectomy (ASM) and skin-sparing mastectomy (SSM) are increasing popular, as evidence of their oncological safety grows and commercial products to facilitate BR are being developed continually, such as acellular dermal matrices (ADM), shaped and textured implants and expanders and lipomodelling equipment Consequently IBR and DBR tech-niques have an increased range of indications and usually provide a good to excellent aesthetic result with a low mor-bidity to an increasing number of women [9 10]

mas-Despite the advantages of IBR, DBR will always be needed

in certain cases [11] Immediate reconstruction may be tively contraindicated in some women with high-risk cancers for oncological reasons (e.g the likely need for radiotherapy (RT)), and the procedure is not available in all cancer centres [11] Other reasons include patients’ preference for delayed reconstructive surgery or a delayed decision to undergo such surgery once the cancer treatments are complete and they are psychologically ready to face a new challenge [11] Although DBR is technically more challenging than IBR, good results can be achieved [11]

rela-A number of special issues should be considered with regard to DBR [3] Compared to IBR, delayed reconstruction

is generally expected to recover a worse initial situation, characterized by previously irradiated poor-quality residual skin in limited amounts, an excessive loss of soft tissue and volume, extensive scar tissue, incisional scars running sub-optimally, blood vessels meant to supply flaps located in fibrotic surrounding tissue, partial or complete lack of aes-thetic subunits such as the inframammary fold (IMF) and/or lateral mammary fold or nipple-areola complex (NAC) [3 9

11] It should be highlighted that patients choosing DBR have substantially more time to consider the surgical options, seek advice from plastic and/or breast surgeons and evaluate the various reconstructive techniques available once onco-logical treatment has been completed, which is potentially advantageous compared to women in the IBR setting who are often struggling with the burden of the initial cancer diagnosis [3 9 11] However DBR patients may also suffer psychologically These women have completed complex oncological therapies and experienced a period of living

remnant and may have struggled with external prosthetics

for a while [3] Some studies have identified these factors as

leading to decreased self-esteem and body image, causing

depression and anxiety [3 12]

Planning BR has become more complex due to the

increasing use of RT in early-stage breast cancer [9] Some

surgeons advocate use of a temporary tissue expander to

pre-serve the breast skin envelope if RT is indicated or expected

[9] In 2002 Steven J. Kronowitz from the University of Texas

M.  D Anderson Cancer Center implemented a two-stage

approach, the delayed-immediate breast reconstruction

(D-IBR) [13] This revolutionary staged approach was able to

bridge the time frame of oncological uncertainty, between

the primary surgery and the final pathological report while

preserving the skin envelope, IMF and breast shape

maxi-mizing the chance for an improved aesthetic outcome

A staged multiple-step approach is often implemented in

cases of planned DBR, including symmetrization surgery,

minor revision surgeries, NAC reconstruction and areola

tat-tooing [9] ( Fig. 28.1)

According to Kronowitz the decision of when to perform

BR remains controversial and will often depend on

individ-ual circumstances in addition to the need for adjuvant RT

[9] In planning BR, effective oncological treatment is

con-sidered the top priority, and the aesthetic goals of

reconstruc-tion are subordinate to this [3]

28.2 Indications and Special Considerations

for Delayed Breast Reconstruction

Breast reconstruction may be an option for any breast cancer

patient undergoing surgery [1 5 14] and who is physically

and mentally suitable without compromising definitive

oncological therapy or likely to be at high risk of surgical

morbidity or mortality [14] Even stage IV disease is not a

contraindication for BR if the patient’s predicted life

expec-tancy is relatively long, and surgery will not delay or prevent

life-prolonging systemic treatments MDT involvement in

such cases is mandatory [5] Patients should be provided

with appropriate sources of both written and verbal

informa-tion, detailing the risks and benefits of different types of BR

[14] The assessment should take into account all of the

onco-logical and reconstructive factors, in light of the individual

circumstances and preferences of each patient, irrespective of

whether the optimal reconstructive method is available

locally or not [14] Oncological principles must not be

com-promised and should always be prioritized [14]

When DBR is considered, the results of a full clinical

assessment and staging should be available for assessment

[1] Maintaining close communication between plastic or

oncoplastic surgeons and other team members is essential

[14] For each patient a plan of the reconstructive procedure

must be drawn up The plan defines the expected staged

(multiple-step) approach, the risk of morbidity, estimated

therapies [14] MDT members should agree on the offered DBR options, and the patient should be fully involved in the decision-making process [5 14]

28.2.1 Oncological Considerations for Delayed-Immediate and Delayed Breast Reconstruction

If DBR is considered, full clinical assessment and staging are mandatory [14] Preoperative unrecognized locoregional recurrences can result in major difficulties, for example, if there is a need to perform an axillary lymphadenectomy shortly after microsurgery in the axilla The first step of DBR

is complete excision of the scar tissue [9] Tissue excised from the former cancer site should be sent for histopathol-ogy If the tissue is suspicious for malignancy, it should be investigated intraoperatively by frozen section before pro-ceeding, and if a recurrence is identified, the tumour must be removed radically, and BR may need to be delayed and replaced by salvage surgery which may require use of flaps (see 7 Chap 22, Surgery for Recurrent Disease)

For D-IBR, the probability of adjuvant treatment cially RT) is an important factor in decision-making [14] RT may exert a harmful effect on the reconstructed breast par-ticularly following implant-based procedures [1 14, 15] The metal ports of some tissue expanders may interfere with RT dosage and dose distribution [14] The surgery to exchange the expander to the permanent implant may be performed prior to or after completion of the RT; however, expander to implant change prior to RT is associated with a higher rate of capsular contracture, malposition, poor cosmesis and implant exposure [9 15] ( Fig. 28.2, Table 28.1)

(espe-The timing of DBR, or a staged expander to implant exchange in case of a D-IBR, is recommended at the earliest 1–3 months after the completion of the adjuvant chemother-apy or 3–6 months after RT [9] An important consideration

in DBR is that of concern that IBR may result in delayed adjuvant systemic therapy if there are complications; how-ever, data suggests this effect is minimal ( Fig. 28.3) [17]

The effect of adjuvant RT following autologous flap reconstruction is controversial [18] When postmastectomy

RT is indicated, autologous tissue reconstruction is either delayed until the end of the RT or D-IBR could be performed followed by flap transposition [18] ( Fig. 28.4) Some expe-rienced breast cancer teams have implemented protocols in which IBRs are followed by RT without significantly affecting breast volume after deep inferior epigastric perforator (DIEP) flap reconstruction [18] Women requiring postoperative RT should not be discouraged from undergoing immediate DIEP flap reconstruction, but RT is generally preferred to precede the flap transfer, because of the reported decreased aesthetic end result [18]

Tissue expansion of previously irradiated skin can result

in a significantly increased risk of capsular contracture,

.Fig. 28.1 a, b 45-year-old patent had a skin-sparing mastectomy

and SLNB with a D-IBR using a tissue expander c Five months after

the primary operation, a textured, anatomic shaped 600 cm 3 silicone

implant was placed to the right side and a textured, round, moderate

plus profile 200 cm 3 implant with a mastopexy was performed for

sym-metrisation on the left side d, e Additionally the reconstruction of the

nipple and tattooing was completed

.Fig. 28.2 a 51-year-old patient had a right BCS and SLNB in

2011 and subsequent radiotherapy BRCA2 mutation subsequently

identified In 2013 a second primary tumour in the left breast was

diagnosed b SSM of the right side and SSM and SLNB on the left side

and D-IBR using tissue expanders were performed On the right side

the differences in colour, texture and elasticity of the former irradiated

major pectoral muscle can be seen c, d After the partial expansion on

the right side, a Baker IV capsular contracture occurred, causing the

impression of the thoracic wall e Six months later the fibrotic breast

skin remnant was excised, the expander was explored and removed and the soft tissue was reconstructed with an LDmc flap and place-

ment of a tissue expander f Three months later a symmetrization was

done by using a textured anatomic-shaped 545 cm 3 silicone implant

on both sides g Nipple reconstruction and tattooing were performed

c

d

implant malposition, poor cosmesis, implant exposure and

failed BR and is therefore relatively contraindicated [9 18]

In these cases autologous tissue reconstruction is the

pre-ferred method [18]

There is some controversy to whether autologous IBR

with adjuvant RT is associated with acceptable complication

and cosmetic outcomes The meta-analysis of Schaverien and colleagues (no randomized controlled trials met the inclusion criteria only observational studies were analysed) regarding outcomes of autologous IBR with postoperative RT compared with no RT, as well as with autologous DBR following post-mastectomy RT, revealed no significant differences in total prevalence of complications or revisional surgery and a sum-mary measure for fat necrosis favouring the group without

RT (OR 2.82, 95% CI 1.35–5.92, p = 0.006) [19] Most of the studies comparing IBR and postoperative RT with DBR fol-lowing adjuvant RT reported satisfactory outcomes following IBR. There was no significant difference in overall incidence

of complications and fat necrosis (OR 0.63, 95% CI 0.29–1.38,

p = 0.25) and a summary measure for revisional surgery (OR

0.15, 95% CI 0.05–0.48, p = 0.001) favouring the DBR group

This meta-analysis reported satisfactory outcomes and a similar incidence of complications for autologous IBR and adjuvant RT when compared with no RT or delayed recon-struction following RT, although the proportion that required revisional surgery was higher for immediate than DBR. The authors highlighted that these findings are limited by the paucity of high-quality data in the published literature, and until better data is available, the findings of this review sug-gest that autologous IBR should at least be considered when adjuvant chest wall RT is anticipated [19] ( Table 28.2).According to the consensus statement of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer in 2015 for patients whose breast cancer was diagnosed during pregnancy, IBR in the first instance and D-IBR with a submuscularly placed tissue expander can

be considered [20]

IBR is contraindicated in conjunction with mastectomy for inflammatory breast cancer (IBC) because of the high recurrence rate, aggressive nature of the disease and the need for adjuvant RT without any potential delay [18] Skin- sparing mastectomy has not yet been proven to be safe in IBC.  According to the National Comprehensive Cancer Network (version 2.2016) guidelines, DBR can be recom-mended to women with IBC who have undergone a modified radical mastectomy [18]

28.2.2 Patient-Related Factors

Patient-related factors play an important role in the timing and choice of reconstructive technique These factors include per-formance status, comorbidities, body mass index (BMI), ASA score, drug and smoking history, psychological suitability, occupation, daily activities and lifestyle, pre-existing shoulder

or musculoskeletal problems, patients’ expectations and choice, goals, attitudes to risk and the likely impact of recovery time on family [14] The psychological status of the patient should be assessed preoperatively [14] If additional risks exist, they should be clearly stated when consenting the patient [14].According to the current evidence-based clinical practice guideline, breast reconstruction with expanders and implants,

of the American Society of Plastic Surgeons, smoking

Clements and Kronowitz, 2012

Cheng and Saint-Cyr, 2012

Joanna Nguyen et al., 2011

Israeli and Feingold, 2011

.Table 28.1 Forest plot of 20 studies by Valdatta et al [16 ]

The authors reported the complications occurring in

ADM-assisted immediate implant breast reconstruction, with or

without radiotherapy Odds ratios and confidence intervals at

95% are plotted The black diamond at the bottom is the pooled

odds ratio, and it is CI 95% It completely falls to the left of 1.0 [ 16 ]

g

.Fig. 28.2 (continued)

increases the risk of postoperative wound complications and

implant loss in patients undergoing postmastectomy

expander/implant BR [21] The overall complication rates

were 2.2–3.07 times higher among smokers than non-

smokers Smokers were 2.9 times more likely than non-

smokers to develop wound necrosis (p = 0.003) and 5.9 times

more likely to experience reconstruction failure (p = 0.001).

Evidence shows that obesity increases the risk of

postop-erative complications in patients undergoing

postmastec-tomy expander/implant BR [21] BMI >30 was significantly

associated with postoperative wound infections and

expander/implant failures Wound infections among patients

with immediate expander/implant reconstructions were 3.3

times higher among patients with a BMI of 25–30 (p = 0.002)

and 18.5 times higher among those with a BMI >30 when

compared to patients with a BMI <25 (p < 0.001) The risk of

implant loss was 3 times higher for those with a BMI of 25–30

(odds ratio 3.1 [95% CI 1.0–9.3]; p = 0.043) and almost 6

times higher for those with a BMI >30 when compared to those with a BMI of <25 (odds ratio 5.9 [95% CI 1.2–29.5];

p = 0.032) Several studies found a statistically significant link

between obesity and an increased risk of mastectomy skin flap necrosis, fat necrosis, wound dehiscence, infection, seroma, hematoma and implant extrusion Obese patients were almost twice as likely as patients of a normal weight to develop an expander/implant complication (odds ratio 1.8

[95% CI 1.1–3.0]; p = 0.02).

Evidence suggests that patients with a preoperative breast cup size of C or larger may be at an increased risk for postop-erative complication with immediate expander/implant BRs compared to those with a preoperative breast cup size of A or

B [21] A preoperative breast cup size larger than C remained a statistically significant risk factor for infection Patients with a breast cup size of D or DD were nearly three times more likely than patients with smaller breasts to experience an infection

(odds ratio 2.89 [95% CI 1.59–5.26]; p < 0.001) A  retrospective

Mean = 31.47

SD = 9.593

n = 43

30 20 10

120 100 80 60

40 20 0

80 60

40 Time (day)

24.8±4.5 15.0±9.8 14.9±7.2

49.4±5.2 47.8±9.2

23.1±3.0 7.1±3.6 7.7±3.7

0.743 0.133

<0.0001

<0.0001

<0.0001

(a, b>c) (a, b>c) (a, b>c) 44.2±12.4 24.6±5.5

Body mass index

Age (yr)

IBR + mastectomy only group (c) (n = 572)

Without wound complications IBR

group (a) (n = 9)

mastectomy only group (b) (n = 14)

With wound complications

p-value

.Fig. 28.3 Effect of immediate reconstruction on chemotherapy

timing a Time interval to chemotherapy in women who have or have

not undergone chemotherapy b Comparison of complication rates

in women undergoing reconstructive surgery with/without wound

complications and the impact on chemotherapy timing (Values are

presented as mean ± SD IBR immediate breast reconstruction, SD

standard deviation) (Reproduced from Lee et al [ 17 ] with permission

from The Journal of Breast Cancer)

.Fig. 28.4 a, b The 38-year-old patient was operated in 2007 on

the right breast with BCS and SLNB and adjuvant RT. In 2008 she had

cancer on the left side treated with BCS and SLNB and RT. BRCA testing

was negative In 2013 bilateral mastectomy and reSLNB on the right

side was performed due to a rpT1cpN0(sn) recurrent NOS cancer c–e

In 2014 bilateral muscle-sparing TRAM reconstruction was performed after flap delay

a

comparative study observed a greater rate of skin necrosis in

breasts larger than 600  g (> C cup) compared with breasts

smaller than 600 g (A or B cup) (19% vs 1.8%, respectively,

p < 0.001) [22] This may relate to tension in the wound close

and on the flaps of heavier implants to some degree

According to evidence, among patients with expander/

implant BRs, diabetes is not a significant risk factor for

post-operative complications, including implant failure,

pulmo-nary embolism, seroma, necrosis, mastectomy flap necrosis,

wound dehiscence, infection and capsular contracture or

reconstructive failure, defined as the premature removal of

expander or implant [21]

The review of Fisher and colleagues aimed to characterize

factors associated with postoperative complications following

breast reconstruction using the National Surgical Quality

Improvement Program (ACS-NSQIP) database from 2005–

2010 [22] The database included either implant-based

reconstruction (immediate, delayed and tissue expander) or

autologous reconstruction (pedicled transverse rectus

abdominus myocutaneous (TRAM), free TRAM and mus dorsi flap with or without implant) During the study period, 16,063 breast reconstructions were performed Autologous reconstructions were performed in 20.7% of patients and implant based in 79.3% The incidence of major surgical complications was 8.4%, and the incidence of medical and wound complications was 1.6% and 3.5%, respectively Independent risk factors for major surgical complications included immediate and autologous reconstructions, obesity, smoking, previous percutaneous cardiac surgery, recent weight loss, bleeding disorder, recent surgery, ASA ≥3, intraoperative transfusion and prolonged operative times Risk factors for medical complications included autologous reconstruction, obesity, tumour involving CNS, bleeding disorders, recent sur-gery, ASA ≥3, intraoperative transfusion and prolonged opera-tive times Key identifiable risk factors associated with both surgical and medical morbidity included autologous breast reconstruction, obesity, ASA ≥3, bleeding disorders and pro-longed operative time ( Table 28.3)

.Table 28.2 Complications of autologous breast reconstruction with or without postoperative radiotherapy according to the

meta-analysis by Schaverien et al a Forest plot of prevalence of complications b Forest plot of prevalence of fat necrosis c Forest plot of

prevalence of revisional surgery

Reprinted from Schaverien et al [ 19 ] with permission from Elsevier

78 25 36 34 19

89 51 78 39 10

274 149 371 78 57

b Fat necrosis

Study or Subgroup

Total events

Test for overall effect: Z = 2.75 (P = 0.006)

Heterogeneity: Tau 2 = 0.47; Chi 2 = 12.63, df = 5 (P = 0.03); I 2 = 60%

25 36 30 34

22 43 0 9

149 371 30 78

25 22 30

28 8 0

149 46 0

Study or Subgroup Pre-recon radiotherapy Events Total Post-recon radiotherapy Events Total Weight M-H, Fixed, 95% Cl Odds Ratio M-H, Fixed, 95% Cl Odds Ratio

Odds Ratio M-H, Fixed, 95% Cl

Odds Ratio M-H, Fixed, 95% Cl

Odds Ratio M-H, Fixed, 95% Cl

Pre-recon radiotherapy Events

Post-recon radiotherapy Events

Study or Subgroup Pre-recon radiotherapy Events Total Post-recon radiotherapy Events Total Weight M-H, Fixed, 95% Cl Odds Ratio

43 101 15 38 108

9 20 11 17 6

35 78 25 34

0.01 0.1 1 10 100 Favours pre-recon DXT Favours post-recon DXT

0.01 0.1 1 10 100 Favours pre-recon dxt Favours post-recon dxt

43 15 11 70 108

4 8 2 14 3

35 25 13 32 19

15 43 70

3 2 9

.Table 28.3 Patient-related factors associated with major postoperative surgical complications in breast reconstruction according to

the reviewed database (16,063 cases) of the National Surgical Quality Improvement Program (ACSNSQIP)

No complication Major surgical complication P-value

Major surgical complications were defined as a deep

wound infection, graft or prosthetic loss or an unplanned

return to the operating room within 30 days ( Table 28.4)

In case of failure of a previous reconstruction (complete

failure or need for later substantial revision), DBR, using

autologous flaps or reimplantation, may be necessary [24]

Indications for DBR include symptomatic capsular

contrac-ture, asymmetry, implant extrusion and exposure and

previ-ous partial or total flap loss

28.3 Practical Considerations in Delayed

Breast Reconstruction

28.3.1 Technical Assessment

Undoubtedly one of the skills of the oncoplastic surgeon is

their ability to judge what will give a good aesthetic outcome

for a particular woman, best fulfilling her wishes for the

shape and volume of the new breast and how this relates to

her body size and shape before surgery For some women her

contralateral current breast shape and size may not be her

ideal, and many women wish for augmentation, reduction or

correction of ptosis

The assessment of other objective factors forms the next

step in the assessment process: the records from previous

surgery, length and position of scars, estimation of the weight

and volume of resected tissue and skin [14] The lack of an

adequate skin envelope is a key consideration in DBR

( Fig. 28.5), and, in general, more skin and tissue volume are required from the flap that will be used for the recon-struction compared to IBR [11] Finding enough skin to per-form an adequate BR is usually not problematic if the patient

is suitable for an abdominal pedicled or free flap (transverse rectus abdominis myocutaneous (TRAM) or DIEP flap) reconstruction, but it may pose an obstacle if the patient has

a low BMI [11] The surgeon needs to consider this tively and plan the BR so that sufficient skin will be available The surgeon should assess the texture and elasticity of the skin especially following RT [14] Sun-damaged skin, chronic steroid consumption, heavy smoking or tattoos on the poten-tial donor areas should be taken into consideration [11]

preopera-The presence of scar tissue makes DBR complicated [11] Scar tissue must be completely released so that the mastectomy flaps can expand to their original dimensions, only then may the missing tissue be accurately and successfully replaced [11].The previously irradiated chest wall poses special surgical problems since chronic radiation damage leads to progressive fibrosis [9 11] Damaged, fibrotic tissues surrounding an autologous flap are less likely to blend into the tissues of the

BR as well as they would without RT [11] Radiation- damaged skin often needs to be discarded, and thus more skin may be required from the flap [11] The quality of the aesthetic result that may be obtained in a patient who has had previous RT is therefore lower than that in a nonirradiated patient If ade-quate information is provided such that patients have realistic expectations of the cosmetic end results, then disappoint-ment may be avoided [11]

The estimation or objective measurement of breast volume

using MR volumetry is very helpful in planning reconstruction,

as well as the classification of the degree of breast ptosis Ideally

the volume of the resected breast should have been recorded at

the time of mastectomy which is very helpful There are

numer-ous technologies available to permit calculation of breast

volume, some based on MRI, 3D photography or on measured breast parameters Simple in- clinic methods, such as use of a series of sizers or surgeon judgement, may be helpful but are less accurate and dependent on experience The excised volume after BCS should be known from the pathological report but may be an underestimate as baseline breast size may have dif-fered and subsequent radiotherapy may have caused further volume loss The mean volume and size of the skin surface of the different autologous flaps have to be known for adequate planning of an autologous BR [11, 15, 25, 26] ( Table 28.5)

To create a reconstructive plan, the surgeon should sion the final shape and volume of the reconstructed and contralateral breast which has to be harmonized with the patient’s body habitus and preferences This part of surgical planning requires ongoing consultations with the patient Generally, in case of an implant-only postmastectomy BR, the final shape and volume of the breast are basically deter-mined by the chosen implant covered by a relatively thin layer of soft tissue Consequently, the shape, width, height and projection of the implant play the most important role in sculpting the final form In implant-based postmastectomy

envi-BR the contralateral breast is the «variable factor» and may

be shaped relatively flexibly by the use of mastopexy with or without reduction and/or implant placement and/or autolo-geous fat grafting (FG) to achieve optimal symmetry [27] If the BR is autologous tissue based, than the reconstructed, breast is the one to be shaped immediately at the time of placement of the flap or at a later date At the time of plan-ning the symmetrization surgery for the contralateral breast, the surgeon should holistically consider the patient’s prefer-ence and possible risk-reduction surgery for high-risk patients, remembering the principal rule: that symmetry is optimal if the structure of both breasts is the same

Technical assessment after BCS and RT necessitates more competence in reconstructive surgery [9 28–30] The major-ity of deformities following BCS result from scar contracture, local glandular and skin deficiencies and radiation fibrosis which together lead to progressive asymmetry and deforma-tion of the breast [9] Traditional surgical excision or quadran-tectomy leaves an open cavity, and tissue discontinuity behind the scar leads to uncontrolled scar formation resulting in adhesions and tissue contracture with adjacent displacement

of the NAC causing major distortion in up to one-third of BCS cases [9] The main reason for significant breast defor-mity after conventional BCS is a large volume of resected breast parenchyma relative to breast volume The importance

of the volume deficit is easily understandable if the excised specimen is to be imagined as a sphere after a wide excision and as a cylinder after a quadrantectomy, and so the resected

volumes are easily calculated by the Cavalieri formula (4r3 π/3)

and Archimedes’ formula (Vcylinder/Vsphere = 3:2) These lations show that even in T2 tumours the average resected breast volume is 50–100 cm3 equalling 20–25% of the volume

calcu-of an average breast calcu-of 350–450 cm3 The impact of excision in different breast quadrants further strengthens the correlation

of resected volume and cosmetic failure with medial breast defects much more difficult to address [31, 32]

.Table 28.4 Significant risk factors for the development of

implant-based breast reconstruction infection and proposed

interventions [ 23 , 24 ]

Risk factor Measures of prevention

Patient-related risk factors

Age >50 years Autologous reconstruction to be

considered Smoking Advise against smoking for at least

2 weeks prior to and 2 weeks following surgery

Hypertension Ensure adequate medical

treatment and optimize blood pressure

Diabetes mellitus Optimize blood glucose level

(recommended interval: 4.4–

6.1 mmol/L (79.2–110 mg/dL)) Obesity Autologous reconstruction to be

considered Hypercholesterolaemia Encourage dietary changes and

optimize cholesterol levels with medication if necessary Low white blood cell

count

Achieve normal white blood cell count or consider autologous reconstruction

Larger breast size Autologous reconstruction to be

considered

Disease-related risk factors

Axillary lymph node

dissection

Procedure to be performed in a separate session

Mastectomy skin necrosis Wound therapy The implant

should be placed submuscularly Immediate reconstruc-

tion

Delayed and/or autologous reconstruction to be considered Bilateral surgeries Delayed and/or autologous

reconstruction to be considered

Therapy-related risk factors

Radiotherapy Autologous reconstruction to be

considered Chemotherapy Intensive follow-up to detect

infection in time Prolonged drain use Early drain removal may help

avoid infections Late expansion Early tissue expansion is associ-

ated with early drain removal

old patent had a

mastectomy and SLNB in

2013 b In 2014 an LDmc

was performed on the

left side c Six months

later the reconstruction

was completed with

the use of a textured,

round ultrahigh profile

430 cm 3 silicone implant,

and for symmetrization

a textured, round, high

profile 300 cm 3 was

placed submuscularly on

the right side d, e The

patient refused a

masto-pexy because of concerns

about additional scars

e

A prospective cohort study by Pukancsik and colleagues

aimed to determine the critical tumour-to-breast volume

ratio for each quadrant of the breast beyond which

conven-tional BCS could no longer offer acceptable cosmetic and

functional results or satisfactory quality of life for the patient

[32] Three-hundred and fifty patients with early-stage

uni-focal (T ≤ 30 mm) breast cancer were enrolled in the study

and underwent wide excision and axillary sentinel lymph

node biopsy followed by whole breast RT. Using validated assessment tools and software (Breast Cancer Treatment Outcome Scale [BCTOS], EORTC Cancer Quality of Life Questionnaire C30-BR23, the Breast Cancer Conservative Treatment – cosmetic results [BCCT.core] software), quality

of life, aesthetic and functional parameters and their changes were correlated with the percentage of breast volume excised ( Table 28.6)

.Table 28.5 Characteristics of autologous pedicled and free flaps often used in breast reconstruction [1 , 15 , 25 , 26 ]

Name of the flap Blood supply Type of flap Maximum size of

skin island length × width (cm)

Surface of skin island (cm 2 )

Thoracal flaps

Latissimus dorsi

myocutane-ous flap (LDmc)

Lateral thoracic flaps Lateral thoracic or superficial thoracic

artery

Thoraco-epigastric flap Lateral branch of superior epigastric

artery, intercostal perforator artery

Pedicled 15–22 × 8–12 120–264

Thoracodorsal artery

perforator (TAP) flap

Thoracodorsal perforator artery and vein Pedicled 16–22 × 7–11 112–242

Intercostal artery perforator

(ICAP) flap

Intercostal perforator artery Pedicled 22–26 × 6–8 132–208

Abdominal flaps

Transverse rectus abdominis

myocutaneous (TRAM) flap

Superior epigastric artery and vein for free-flap deep inferior epigastric artery

Pedicled or free 25 × 15 375

Deep inferior epigastric

perforator (DIEP) flap

Deep inferior epigastric artery and vein, cutaneous perforators

Superficial inferior epigastric

artery (SIEA flap)

Superficial inferior epigastric artery and vein

Lumbar artery perforator

(LAP) flap

Four to eight lumbar perforator a and v

emerging from the second and fourth lumbar a

Gluteal flaps

Superior gluteal artery

perforator (SGAP) flap

Inferior gluteal artery

perforator (IGAP) flap

Transverse upper gracilis and

the profunda artery

perforator (TUGPAP) flap

Ascending branch of the medial circumflex femoral a for TUG component and the profunda a perforator for PAP component

The maximum percentage breast volume resectable in

conventional BCS without resulting in unacceptable

aes-thetic and functional outcomes or a decreased quality of life

was 18–19% in the upper-outer quadrant (p  <  0.0001),

14–15% in the lower-outer quadrant (p < 0.0001), 8–9% in

the upper-inner quadrant (p  <  0.0001) and 9–10% in the

lower-inner quadrant (p < 0.0001) [32] With the help of the

calculated cut-off values for each breast quadrant, breast

sur-geons can make more objective decisions when performing

conventional BCS, oncoplastic techniques or even

mastec-tomy with immediate reconstruction

Delayed partial reconstruction aims to restore the shape

of the breast and to achieve better symmetry using volume

displacement or replacement techniques [9] To replace skin

and volume, local dermoglandular, fasciocutaneous flaps

(e.g intercostal artery perforator (ICAP) flap, thoracodorsal

artery perforator (TDAP) flap), distant pedicled (e.g LD) or

even free myocutaneous flaps (e.g transverse upper gracilis

myocutaneous (TUG) flap) or fasciocutaneous flaps are

potential options [9 11, 33, 34] ( Table 28.7) Controversy

surrounds the optimal timing for repair of a partial

mastec-tomy defect in terms of before or after adjuvant RT [9 28–

30] Mastopexy techniques are preferred for patients

presenting after BCS but before RT due to the lower

compli-cation rates compared to those who present after completing

RT as there may be a higher risk of wound complications and

nipple necrosis when operating on irradiated tissues [9]

When choosing a flap, the possible limitations and

com-plications of the donor site should be taken into account, for

instance, the average length (26 cm) of an LD myocutaneous

(LDmc) flap donor scar on the back or the loss of this large

myocutaneous flap in case of a subsequent need for a total BR

[11, 33] After BR with LD flap transfer, muscle function may

be compromised, but functional deficits due to such muscle

weakness are seen with specific activities only and are

gener-ally well tolerated [11, 35] Therefore LD flap reconstruction

is relatively contraindicated in women who undertake sports

requiring increased upper body strength, including rowers,

swimmers and mountain climbers [35] A good combined

technique for DBR after BCS can be performed with local

flaps for soft tissue reconstruction and allogenic volume

replacement; however, contracture rates and the risk of

implant extrusion are significantly higher than for

conven-tional implant-based postmastectomy BR [935] ( Fig. 28.6)

The use of glandular flaps in delayed remodelling of

irra-diated breast tissue is technically challenging, and surgical

complications occur often [9] Contralateral reduction

mas-topexy is a simple and safe approach to correct asymmetry

of volume [9] (see Table 28.7) Pedicled flaps unaffected

by RT instead of glandular flaps should be employed if the

shape of the treated breast is distorted markedly to bring

undamaged well-vascularized tissue into the defect in the

breast mound [9]

In cases of extremely damaged residual breast tissue (e.g severe radiation fibrosis or severe and extensive fat necro-sis), a completion mastectomy with autologous total BR pro-vides an additional option for delayed partial-breast reconstruction [9]

Preoperative assessment of vascular anatomy for gous flaps is mandatory [14] A simple physical test is used to examine whether the motor innervation of the LD muscle is intact or serves as a reasonable proxy of vascular integrity To assess the muscle, both sides should be examined simultane-ously The examiner stands behind the patient and feels between the thumb and fingers bilaterally as the patient coughs The contractions should be compared between the two sides Doppler ultrasonography (US) and computed tomographic (CT) angiography of both donor and recipient sites provide valuable information for planning and perform-ing microsurgery [36] In free-flap BR the use of preoperative

autolo-CT angiography helps to reduce the duration of the surgical procedure and overall postoperative morbidity [36]

After marking up the midline and the footprint of the breasts, the assessment of breast morphology should include

at minimum the measurements and documentation of breast width, sternal notch to nipple distance, nipple to inframam-mary fold distance, objectives for degree of desired breast asymmetry and bra cup size

Autologous fat grafting (FG) has become a widely implemented technique for secondary breast reconstruc-tion [9 37, 38] The indications include improving con-tour, shape and volume following autologous flap reconstruction (with or without implants), implant-only reconstructions and deformity correction following breast conservation therapy [9] Fat can be harvested from the abdomen, thighs and buttocks Complications are usually rare and include fat necrosis, erythema, keloid scarring and pain Repeat FG may be necessary, mainly by patients with a history of prior RT [9] FG is a safe and effective tool for the revision of reconstruction, to improve contour, vol-ume, breast shape and symmetry It may also help in improving the quality and thickness of mastectomy flaps if very thin or radiotherapy damaged This may be done as a staged procedure before the actual reconstruction The popularity of the use of FG in BR will likely continue to increase [9] Further information on lipomodelling is cov-ered in 7 Chap 20

Assessment of the results of BR should be highly tent and objective [14] Preoperative and successive postop-erative photographs should also form part of the assessment [14] Photographs of the anterior, oblique (at 45° both sides) and lateral (both sides) views of the breasts and, when appli-cable, specific views of flap donor sites should be acquired [14] Images must be stored on a secure server with limited access and should never be used for teaching purposes or publication without the patient’s consent [14]

.Fig. 28.6 a 50-year-old patient had a wide excision in the upper-

outer quadrant of the right breast and postoperative RT resulting in

significant asymmetry between the breasts regarding breast volume,

shape and position of the NAC b–d Because of the nonexpandable

radially positioned scar and skin deficit in the affected quadrant, an

autologous soft tissue reconstruction was performed with a laterally

based ICAP flap e, f Ten months later symmetrization was performed

with a textured round high profile 450 cm 3 silicone implant on the right side and a round high profile 300 cm 3 on the left side in submus- cular position in combination with a mastopexy

Techniques for Partial Mastectomy

Defects

Delayed reconstruction after whole breast irradiation usually

necessitates the transfer of an autologous flap [9] Local or

distant, pedicled or free and fasciocutaneous or

myocutane-ous flaps can be used (see Table 28.5) Autologous FG with

percutaneous needle release of scar bands may be an option

for DBR, if the breast skin envelope is complete after BCS [9]

After partial-breast irradiation, some parts of the breast

tis-sue may not have been completely irradiated and can be used

to improve the defect by volume displacement mastopexy

techniques [9]

In cases of small breast volume (cup sizes A and B),

reconstruction before RT is often more complicated due to

the small amount of residual breast parenchyma [9 28–30]

(see Table 28.7) These patients may benefit from a

comple-tion NSM with total BR rather than BCS + RT [9] Because of

the paucity of autologous tissue options, an implant-based

BR is the method of first choice [9] Among patients who

present for DBR after RT, percutaneous needle release of scar

bands along with FG can be helpful [9]

In cases of more voluminous breasts (cup sizes C and D)

and in the presence of ptosis the partial mastectomy, defects

can be successfully repaired by displacement of the

remain-ing breast tissue usremain-ing mastopexy techniques and/or

rota-tion/advancement flaps [9 28–30] (see Table 28.7) Fat

grafting is used to fill diffuse volume loss due to RT in the

second stage of these types of DBR techniques [9] In

repair-ing BCS defects, local flaps (ICAP, TDAP, LD) for DBR are

safe to use after confirmation of negative surgical margins

[9] The inferior pedicled Wise pattern mastopexy, or its

modifications, tends to be the most versatile technique for

BR [9] Superior pedicled mastopexy techniques may be

nec-essary to deal with defects located in the lower breast

quad-rants [9] In the case of therapeutic mammoplasty and

delayed contralateral breast symmetrization, it is

recom-mended to delay the operation by 3–6 months after

comple-tion of the RT to allow resolucomple-tion of post-irradiacomple-tion oedema

and volume stabilization in the ipsilateral breast [9] Revision

of an already-reduced breast may be necessary, and using FG

in the ipsilateral breast may be helpful [9]

28.3.3 Delayed Breast Reconstruction

Techniques for Total Mastectomy

Defects

D-IBR is a potential option for patients who are at an

increased risk for needing postmastectomy RT [9] Since the

D-IBR technique ensures preservation of the skin envelope,

an implant-only reconstruction is feasible even after

post-mastectomy RT.  Therefore the use of skin replacement is

unnecessary [9] Delayed-immediate techniques with skin-

preserving mastectomy may be appropriate even for patients

mary systemic treatment and adjuvant RT are indicated resulting in favourable long-term tumour control and sur-vival In 2003 Kronovitz and colleagues implemented a mul-tidisciplinary protocol of «delayed-delayed breast reconstruction» (D-DBR) for skin-preserving delayed BR after radiotherapy in patients with LABC known preopera-tively to require RT [9 39] The purpose of this protocol was

to improve aesthetic outcomes, decrease complication rates and reduce the psychological impact associated with stan-dard non-skin-sparing DBR after RT [9] Patients with inflammatory BC and those whose skin cannot be preserved

due to negative tumour margins must not undergo skin-

preserving DBR. After the completion of neoadjuvant motherapy and downsizing or downstaging, patients underwent skin-preserving mastectomy with immediate placement of a tissue expander The expander should be par-tially deflated to allow for radiotherapy, before three- dimensional CT planning [9] Reinflation of the tissue expander can usually be done 2 weeks after completion of postmastectomy RT.  The expander can be changed to the implant or autologous deepithelialized flap approximately 3–6 months after the RT and reinflation Since by D-DBR the breast skin envelope can be preserved for subsequent DBR after radiotherapy, the technique has brought about a para-digm shift in the care of patients with LABC [9]

che-Several techniques are available which aim to enhance the outcomes of implant-based breast reconstruction These include the use of tabbed tissue expanders, autologous fat grafting and use of acellular dermal matrices (ADM) [9] ADMs are connective tissue grafts that improve the quality of soft tissue in implant-based BR [40] An ADM can incorporate into the recipient tissue with associated cellular and microvas-cular ingrowth It begins to be vascularized from surrounding tissue as early as 2 weeks post-implantation, and mature vascu-lar structures are usually present at 6 months [40, 41]

The application of expanders with suture-secure tabs helps to prevent postoperative displacement or rotation of shaped implants The lower pole of the expander can be cov-ered with the use of ADM, while the pectoralis major muscle can be used for the upper pole [9] Capsular contracture rates may be decreased by providing complete coverage of the expander with ADM and by sewing the pectoralis major muscle over it using vest-over-pants sutures [9] Intraoperative filling of the expander with saline is facilitated by the ADM technique Symmetry with the contralateral native breast is also easier to achieve which reduces the number of postop-erative visits [9] ADM that has been placed over the tissue expander allows for injection of FG into the lower mastec-tomy flap at the exchange of expander to permanent implant [9 42, 43] ADMs facilitate repositioning of a malpositioned implant and, in combination with FG, may help to correct implant rippling [9 42] ADM and FG have also decreased the need for the addition of local flaps and changed how the revision of implant-based reconstruction is approached It is also very valuable in cases where there is very thin chest wall muscle coverage, and although undoubtedly not immune

from the risks associated with RT, there is some low-level

evi-dence that suggests that ADMs may help reduce the risks of

implant reconstruction in a post-RT setting [40, 41] Moyer

and colleagues compared clinical outcomes to determine

whether ADM use altered capsular tissue architecture in

irra-diated and nonirrairra-diated breasts following matrix-assisted

expander reconstruction (number of involved patients

n = 27) [40] Mean follow-up was 28 months Grade III/IV

contractures were identified in all patients on the irradiated

side versus 75% on the nonirradiated side [40] Postirradiation

biopsy specimens were taken of the peri-implant capsule in

six patients at the time of secondary surgery Elastin content

and the total cellular infiltrate were significantly greater in

the irradiated versus nonirradiated native capsules

(p = 0.0015) Conversely, the irradiated matrix capsule was

composed of similar amounts of cellular infiltrate and

colla-gen as the nonirradiated matrix capsules and nonirradiated

native capsules Irradiated ADM showed the least amount of

alpha-smooth actin staining but a similar number of blood

vessels The authors concluded that ADMs appear to limit the

elastosis and chronic inflammation seen in irradiated implant

reconstructions and are potentially beneficial in these

patients

28.3.4 Autologous Flaps in Delayed Breast

Reconstruction

In autologous BR a patient’s own tissue is used to replace the

breast defect [3] Contraindications include previous major

surgery in the required donor tissue, hypertension, chronic

obstructive pulmonary disease, diabetes, smoking and too

high or too low BMI [3]

The LDmc flap can either be pedicled or a free flap, and it

is used alone (in women with smaller breasts) or as fat-

grafted volume-enhanced LDmc flap to maximize the

vol-ume of an autologous-only procedure or the flap may be used

to cover an implant [3 44, 45] Although the need for an

LDmc in DBR has significantly reduced due to the increasing

use of skin-preserving mastectomies and ADM, the LD

mus-cle flap (LDm) or the deepithelialized TDAP flap is still

important in DBR [9] Patients with a risk of vascularly

com-promised skin, those at a high risk of infection, or who have

undergone RT, can benefit from the use of these flaps [9]

( Fig. 28.7)

Nowadays the LDmc flap for total autologous IBR or DBR

without implants is becoming more popular again, extending

the anatomical limits of this traditional LD flap Santanelli di Pompeo and colleagues published their experiences with the use of the pedicled LDmc flap with fat grafting in total autol-ogous immediate breast reconstruction without implants (23 patients between 2010 and 2013) [44] Fat was harvested using the Coleman technique and was injected into the adi-pose layer and muscle fascia of the LD flap skin paddle The mean size of the harvested skin paddle was 19.7 × 11.04 cm (range, 18 × 10 cm to 21 × 12 cm) The mean harvested fat volume was 126 ml (range, 90–180 ml), and the mean injected fat volume was 101 ml (range, 60–150 ml) All flaps healed uneventfully, no seroma occurred at the flap donor site, and

no fat grafting-related complications were observed The authors concluded that fat transfer to achieve immediate LDmc flap volume augmentation could successfully serve as

an alternative for total autologous BR, avoiding implant- related complications

The free TRAM flap is derived from the lower abdomen and transferred to the chest wall where the blood vessels of the flap are joined to the internal mammary vessels [3] The pedicled TRAM flap requires the entire rectus abdominis muscle to be mobilized, significantly disrupting the integrity

of the abdominal wall [3] Ischaemia and flap loss may be prevented or minimized by ligating the inferior epigastric vessels 1–3  months prior to the transfer of the pedicled TRAM flap A microvascular or free TRAM flap requires a smaller proportion of the muscle (muscle-sparing TRAM flap) [3] When using free flaps in the DBR setting, it is important that consideration is given to whether the recipi-ent vessel may have been damaged by previous surgery or radiotherapy

The DIEP flap is also created from the lower abdomen but without removing any of the rectus abdominis muscle [3 9] This flap is optimal for patients who underwent total mastec-tomy followed by RT [9] The double-DIEP (bipedicled) flap can provide good cosmesis to thin patients with much less subcutaneous fat and excess skin; in addition it can be folded

or rotated to increase the projection and width of the structed breast [9]

recon-Although traditionally gluteal artery perforator flaps (SGAP, IGAP) were considered a second-line option, but recently their popularity has been increasing [9] The flaps consist of the skin and subcutaneous tissue supplied by the inferior or superior gluteal vessels [3 9 46] The stan-dard flap used to be elliptical-shaped, but it was revised and called a «boomerang flap» The boomerang flap is more appropriate for BR, especially in patients with large

.Fig. 28.7 a, b 34-year-old patient had an SSM and axillary

lymph-adenectomy with D-IBR using tissue expander after primary systemic

chemotherapy c, d On the left side the skin coverage was very thin

with a potential for implant exposure, so an endoscopically assisted LD

muscle-only flap transposition was done through an axillary incision

eThe muscle flap was positioned and adapted with resorbable sutures

along the footprint of the breast f, g The expander was again placed fully submuscularly h Six months later the expander was changed to a

textured round high-profile 650 cm 3 silicone implant on the left side, and for symmetrization a textured round moderate-profile 275 cm 3 implant was placed in submuscular position on the right side The reconstruction

of the nipple was completed waiting for the tattooing of the NAC

c d

breast volumes Indications include new breast cancer

fol-lowing previous TRAM flap reconstruction for

contralat-eral breast cancer, BRCA gene mutation confirmed after

unilateral TRAM flap reconstruction in women

request-ing contralateral risk reducrequest-ing surgery, flap failure,

previous aesthetic abdominoplasty in the woman’s past

medical history, patients with limited abdominal neous tissue or no laxity in the abdominal musculofascial system [9]

subcuta-Reconstruction of the nipple is the last step of DBR. Several surgical techniques are available (see 7 Chap 34) Using cos-tochondral cartilage grafts in nipple reconstruction can

tains durable nipple projection [9].

28.4 Outcomes of Delayed Breast

Reconstructions

The National Mastectomy and Breast Reconstruction Audit

(NMBRA) in the UK began on 1 January 2007 [2 8] The

principal aims of the audit were to describe the provision of

BR services across England and to investigate the

determi-nants and outcomes of care for women with breast cancer

having a mastectomy with or without BR [2 8] Data were

prospectively collected by clinicians on women treated

between 1 January 2008 and 31 March 2009 in a large

num-ber of institutes where mastectomy and BR surgery are

pro-vided: all 150 NHS acute trusts in England, 114 independent

sector hospitals and 6 NHS trusts in Wales and Scotland

During the audit period, 16,485 women underwent

mastec-tomy Of these women 20.6% had a concurrent IBR, while

10.5% women underwent BDR. A questionnaire was sent to

8159 women (51.2%) 3  months after their surgery The

response rate was excellent at 85.3%

28.4.1 Information Given to Women Before

Their Breast Surgery

In the 3-month questionnaire, patients needed to indicate

how much information they received before their surgery [2

8] Overall, nine out of ten women felt that they had received

the right amount of information about their chosen type of

procedure (mastectomy, mastectomy with IBR, DBR) The

majority were satisfied with the information Patients who

underwent mastectomy only were asked how much

informa-tion they had received on BR. Only 65% felt that they had

received the right amount Furthermore, 42% felt that the

lack of information contributed to not choosing to have IBR

28.4.2 Types of Breast Reconstruction

Techniques

Most IBR patients underwent an implant-based

reconstruc-tion (with or without a flap) In contrast, the majority of DBR

patients had BR using only an autologous flap ( Table 28.8)

28.4.3 Types of Contralateral and Secondary

Reconstructive Procedures

Only 4% of women underwent contralateral

symmetriza-tion surgery, and DBR patients were more likely than IBR

patients to undergo such intervention at the time of their

operation (18% vs 11%) or to have this type of procedure

planned for a later date (27% vs 13%) [4 10] Overall, 49% had planned nipple reconstruction and 41% areolar tattoo-ing Only 1% of patients had their nipple reconstructed at the time of their BR

28.4.4 Complication Rates for DBR

Inpatient complications were defined as complications requiring specific and additional treatment and thus affect-ing the patient experience Mastectomy patients were hospi-talized for 2–5 days For patients having an IBR or DBR, the inpatient stay was typically between 4 and 7 days Following mastectomy and BR, significant adverse events were rare During the audit, the mortality rate was only 0.19% during their inpatient stay, and emergency transfer to the intensive care unit was necessary for 0.61% These rates were similar for all three surgery types Reoperation rates were higher following BR than mastectomy alone due to the additional risk of reconstruction-specific complications associated with these more complex procedures [2 8] However it is likely that the selection criteria for women having more complex surgery were biased in favour of fitter women than those undergoing mastectomy only so it is not possible to say that BR surgery is as safe as mastectomy only

Risk Profiles of the Different Surgery Types

Mastectomy site complications were the most common for all reconstruction types (10%), and the majority of these were haematoma (8.9%) Only about 5% of women undergo-ing DBR were affected by mastectomy site complications

Implant-Related Complications

Implant-related complications include displacement, tion and rupture Of the women undergoing implant-based reconstruction, 3% had an implant-related complication, regardless of the type of procedure or timing The most

.Table 28.8 Type of reconstruction techniques according to

the Third Annual Report of the National Mastectomy and Breast Reconstruction Audit, UK [ 4 ]

Type of surgery IBR (%) DBR (%)

Implant/expander only 1246 (36.8) 281 (16.2) Pedicle flap + implant/expander 735 (21.7) 438 (25.3) Pedicle flap (autologous) 932 (27.5) 446 (25.8)

common complication was infection requiring the removal

of the implant Complications requiring the implant to be

removed occurred in 8.9% of women having IBR with

implant and in 6.9% of patients having a DBR with implant

( Table 28.9)

Flap-Related Complications

Free-flap procedures were associated with the highest rate of

local complications The risk of complications was lower in

those who underwent autologous pedicle flap reconstruction

and was lowest in women who had BR with a pedicle flap and

implant [2 8] This pattern was observed in both IBR and

DBR procedures Flap re-exploration was the most common

complication, particularly for free-flap procedures The

reop-eration rate was 11.8% among patients who had a free-flap

reconstruction Rates of partial and total flap failure were

1.20% and 0.20% following pedicled flap reconstructions

For free-flap reconstructions, these rates were 2.18% and

1.98%, respectively The most frequent flap donor site

com-plications were haematoma and seroma Excluding

haema-toma or seroma, the donor-site complication rate was around

2% for each type of flap-based reconstruction

Post-discharge Complications at 3 Months After Surgery

Women were asked to report post-discharge complications associated with mastectomy and BR in the questionnaire

3 months after their surgery Readmission due to unplanned further treatment or surgery was required in 10% of mastectomy- only patients and almost 1  in 6 BR patients Post-discharge wound infection occurred in 25% of BR patients One-third of all DBR patients required aspiration or drainage of seroma Among women who had a flap recon-struction, the rates of complete and partial flap failure were 1% and 5%, respectively

28.4.5 Pain Management in the First 24 h After Surgery

Low levels (6.2%) of severe pain were reported in patients undergoing mastectomy in the first 24 h following surgery Women undergoing IBR and DBR reported higher rates than women having mastectomy only at 16.5% and 20.1%, respec-tively [2 8]

.Table 28.9 Unadjusted national complication rates stratified by type of surgery Rates given with 95% confidence intervals Third

Annual Report of the National Mastectomy and Breast Reconstruction Audit, UK [ 4 ]

Type of surgery Percentage with

mastectomy site complications (%)

Percentage with mastectomy site complications (%)

Percentage with mastectomy site complications (%)

Percentage with mastectomy site complications (%)

Percentage with mastectomy site complications (%)

Copyright © 2016, Reused with the permission of the Health and Social Care Information Centre, also known as NHS Digital All rights

reserved

28.4.6 Access to Postoperative Psychological

Support

During the audit, psychological support or counselling was

required for 30.3% of mastectomy-only patients, 27.6% of

IBR patients and 16.9% of DBR patients after their surgery

28.4.7 Long-Term Clinical and Patient

Satisfaction Results of Delayed Breast

Reconstructions

The Fourth NMBRA used both clinician- and patient-

reported data to provide information on mastectomies and

BRs performed between January 2008 and March 2009 in the

UK [8] Three-quarters of DBR patients and two-thirds of IBR

treated described the results of their surgery as excellent or

very good [8] Mastectomy-only patients were much less

sat-isfied than those who underwent reconstruction; just half of

them were very satisfied with their results [8] ( Table 28.10)

Among patients undergoing DBR, 93% were satisfied

with how they looked with clothes on, and 76% were satisfied

with how they looked unclothed Ninety-two percent of the

women reported feeling confident in a social setting; 88%

answered that they felt emotionally healthy most or all of the

time Tenderness in the breast area (4%) and arm pain (9%) most or all of the time was also reported Sixty percent of the women confirmed that they were satisfied with their sex life most or all of the time

Satisfaction with Implants

High satisfaction rates were reported by the audit among women who were reconstructed with an implant-based pro-cedure: over 85% were either satisfied or very satisfied About 50% of patients who had implant-only DBR were very satis-fied with the extent to which the implant could not be seen The proportion was slightly higher (64%) among women with concurrent pedicle flap coverage

Satisfaction with Flap Donor Site

The use of flap-based BR requires the transposition of tissue most often from the back or the abdomen [8] Only a small proportion of patients were bothered most or all of the time with the appearance of their back, while problems with activ-ities involving back and shoulder muscles were reported more frequently Autologous DBR was associated with a greater level of dissatisfaction regarding the appearance of the back than implant-based DBR.  Although the skin requirements to reconstruct the breast mound were similar

in both cases, those in whom an implant was not used

.Table 28.10 Patients’ rating of the results of their surgery and of reconstructive information provision 18 months after their breast

surgery (Fourth Annual Report of the National Mastectomy and Breast Reconstruction Audit, UK [ 10 ])

Mastectomy only Immediate breast reconstruction Delayed breast reconstruction

Patients’ rating of the results of their surgery at 18 months postoperatively

Overall, how would you describe

the results of your operation?

Patients’ rating of reconstructive information provision 18 months after their surgery

Overall, how satisfied are you with

the options you have been given

about breast reconstruction

surgery since the time of your

ably needed more tissue taken from the back, reducing their

satisfaction with the appearance of the donor site

Functional problems related to the abdominal donor site

were reported by only a small minority of women who had

TRAM, DIEP or SIEA flap-based DBR. More than 80% of

patients were satisfied with the appearance of their abdomen

and how it looked and felt 18 months after their

reconstruc-tion Around 45% of women reported themselves to be very

satisfied with how their abdomen looked and felt at 18 months

after surgery compared to before their surgery

The results of the NMBRA have highlighted that the

over-all experience of care for women undergoing mastectomy

and BR was very good These national data have

demon-strated the positive effect of BR on quality of life following

mastectomy

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© Springer International Publishing AG 2018

L Wyld et al (eds.), Breast Cancer Management for Surgeons, https://doi.org/10.1007/978-3-319-56673-3_29

Breast Implants: Design, Safety

and Indications for Use

Jana de Boniface and Inkeri Schultz

29

29.1 History of Breast Implants – 356

29.2 Implants: Design, Composition, Surface and Shape – 356

29.2.1 Tissue Expanders – 356

29.2.2 Composition – 356

29.2.3 Surface – 357

29.2.4 Shape – 357

29.3 Safety Issues and Complications – 358

29.3.1 Safety: Systemic Disease – 358

29.3.2 Safety: Incidence of Breast-Implant- Associated

Anaplastic Large Cell Lymphoma (BIA-ALCL) – 358

29.3.3 Safety: PIP Implants – 359

29.3.4 Complications – 359

29.4 Capsule Formation: A Foreign Body Response – 360

29.5 Breast Implants: Indications for Use – 362

References – 362