Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned

Does Prior Breast Irradiation Increase Complications of Subsequent Reduction Surgery in Breast Cancer Patients? A systematic Review and Meta-Analysis

BACKGROUND

Reduction mammoplasty and mastopexy are potentially complicated by prior breast irradiation as part of breast conserving therapy. Associated tissue changes with therapeutic irradiation have led to surgeons deciding the risks may outweigh potential benefit for those patients. A systematic review of the existing literature was performed to explore surgical outcomes of patients undergoing delayed bilateral reduction mammoplasty or mastopexy following unilateral breast irradiation as part of breast conserving therapy.

METHODS

Medline, PubMed and EMBASE were searched from 1990 to 2023 according to PRISMA guidelines. Studies were combined by the generic inverse variance method on the natural logarithms of rate ratios (RR) using a random effect model in Review manager 5.4.1.

RESULTS

Fifteen studies reported outcomes in 188 patients who underwent breast reduction (BR) following unilateral breast conserving surgery and radiotherapy. The median age at BR was 51.5 years (range 39-60), and median time since radiotherapy was 48 months (range 11.7-86). We compared outcomes for irradiated breast (IB) versus non-irradiated breast (NIB). Pooled results showed higher rate of major complications in the IB (RR 2.52, 95%CI 0.96-6.63, p=0.06), but not statistically significant. However, rate of minor complications was significantly higher in the IB (RR 3.97 95%CI 1.86-8.50, p<0.0004). Incidence of fat necrosis as a discrete complication was 2× higher in IB (RR 2.14 95%CI 0.85-5.35, p-value 0.10) compared to the NIB, but not significant.

CONCLUSION

We found breast reduction to be safe with acceptable risk of major complications. However, the overall complication rate remains higher in IB compared to NIB.

LEVEL OF EVIDENCE III

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Safety of Reduction Mammaplasty and Mastopexy After Breast Conservation Therapy and Radiation Therapy: A Case Series

BACKGROUND

Conservative surgery and radiotherapy (CS + RT) have become the standard of care for early-stage breast cancer as an alternative to mastectomy. With the increasing rate of obesity and incidence of macromastia, surgeons increasingly encounter patients with a history of breast radiation desiring breast reduction. However, elective breast surgery after irradiation remains to be controversial due to known adverse effects of radiation, especially on wound healing, and unknown effects of lumpectomy on traditional pedicle choices. Herein, we present our experiences and outcomes of reduction mammaplasties and mastopexies in patients with breast cancer previously treated with CS + RT.

METHODS

Between 2009 and 2020, 13 patients undergoing reduction mammaplasty or mastopexy, who have previously underwent CS + RT with or without axillary surgery, were included in this study. Surgical techniques and complications, including delayed wound healing, infection, fat necrosis, and nipple-areolar necrosis, were recorded and analyzed based on the irradiated versus nonirradiated sides.

RESULTS

Of the 13 patients, delayed wound healing occurred in 7% on the irradiated side and 15% on the nonirradiated sides (P > 0.05). No significant correlation was observed between the number of complications and time of elective breast surgery from the last radiation therapy. Complications between irradiated and nonirradiated breasts did not significantly differ in both the reduction mammaplasty and mastopexy groups.

CONCLUSIONS

Reduction mammaplasty and mastopexy in patients with a history of lumpectomy and breast irradiation can be safely performed and should be considered in those experiencing macromastia or asymmetry post-CS + RT.

Influence of Tamoxifen on Different Biological Pathways in Tumorigenesis and Transformation in Adipose-Derived Stem Cells, Mammary Cells and Mammary Carcinoma Cell Lines—An In Vitro Study

Breast carcinoma is one of the most common malignant tumors in women. In cases of hormone-sensitive cells, tamoxifen as an anti-estrogenic substance is a first line medication in the adjuvant setting. The spectrum of autologous breast reconstructions ranges from fat infiltrations to complex microsurgical procedures. The influence of adipose-derived stem cells (ASC) on the tumor bed and a possibly increased recurrence rate as a result are critically discussed. In addition, there is currently no conclusive recommendation regarding tamoxifen-treated patients and autologous fat infiltrations. The aim of the present study was to investigate the effect of tamoxifen on the gene expression of a variety of genes involved in tumorigenesis, cell growth and transformation. Mammary epithelial cell line and mammary carcinoma cell lines were treated with tamoxifen in vitro as well as co-cultured with ASC. Gene expression was quantified by PCR arrays and showed increased expression in the mammary carcinoma cell lines with increasing time of treatment and concentration of tamoxifen. The data presented can be considered as an addition to the controversial discussion on the relationship between ASC and breast carcinoma cells. Further studies are needed to quantify the in vivo interaction of ASC and mammary carcinoma cells and to conclusively assess the impact of tamoxifen in reconstructive cases with fat grafting.

Treatment Algorithm of Postsurgical Fat Necrosis of the Breast—Revisited

Fat necrosis is a common complication of breast surgery, with the potential to cause both functional and aesthetic repercussions that can affect patient satisfaction. Although several fat necrosis classification systems have been proposed, fat necrosis management varies widely across institutions, requiring revisiting of existing treatment protocols. We evaluated the postoperative outcomes on 335 breasts following either breast reduction or reconstruction with deep inferior epigastric perforator (DIEP) flaps at our institution between 2016 and 2020, with particular attention to the development of fat necrosis and the need for subsequent surgical intervention. Fat necrosis was diagnosed in 36 (10.74%) breasts, of which 16 (44.4%) were surgically removed and 20 (55.5%) were conservatively managed. Time of fat necrosis diagnosis: early (≤one-month after breast surgery) or late (>1 month) was the only variable associated with surgical intervention. Fat necrosis management should be approached on a case-by-case basis. Whenever possible, conservative management with regular clinical and radiological follow-up, and patient reassurance, should be pursued even for large masses, in the absence of concomitant complications.

A Simple Technique to Correct Lumpectomy Deformities Using Free Nipple Grafting

BACKGROUND

Lumpectomy followed by radiation can lead to severe breast asymmetry. Many surgeons are hesitant to perform traditional mastopexies on irradiated breasts due to increased complication rates. An alternative approach to achieve breast symmetry is presented. This technique consists of free nipple-areola complex (NAC) grafting of the irradiated breast to a higher position and primary closure of the donor site, in an appropriate fashion without undermining, followed by a formal mastopexy of the nonradiated breast.

OBJECTIVE

To evaluate the outcomes of free NAC grafting, used as an alternative method to achieve breast symmetry, in patients who underwent lumpectomy with radiation.

METHODS

A case series of 5 patients who underwent breast revision using this technique, performed by a single surgeon from 2017 to 2019 (n = 5), is presented.

PATIENT DEMOGRAPHICS

All patients had history of lumpectomy followed by radiation therapy. The average age was 59.2 years, average BMI was 33.0. Three of 5 patients had a significant smoking history. The average time between radiation and surgery was 5.9 years.

RESULTS

The average operating time was 141.8 minutes. The average follow-up period was 5.8 months. Two (40%) of the free NAC grafts were complicated by hypopigmentation of the reconstructed NAC. No major complications were reported, and no patients required return to the operating room. All patients had successful outcomes with improved breast symmetry.

CONCLUSIONS

Free NAC grafting of irradiated breasts and contralateral mastopexy may be a reliable alternative to achieve breast symmetry, with a less invasive approach, in patients who underwent lumpectomy and radiation.

Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast

Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.