TRAM flap breast reconstruction after radiation treatment

Outcomes of Immediate versus Delayed Autologous Reconstruction with Postmastectomy Radiation: A Meta-Analysis

BACKGROUND

Postmastectomy autologous breast reconstruction can be immediate or delayed. The safety of performing immediate breast reconstruction (IBR) and the impact of radiation on the newly reconstructed breast is not yet validated.

METHODS

A PubMed, Embase, and Google scholar search was conducted from inception to September 17, 2023. The authors included comparative studies that assessed complications or aesthetic outcomes of IBR versus delayed breast reconstruction (DBR) in the setting of postmastectomy radiotherapy (PMRT).

RESULTS

The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy, whereas 699 had DBR. Mean follow-up time and age for both groups were comparable ( P > 0.1). None of the complications-revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing-were significantly different across groups ( P > 0.1). IBR was found to have a higher risk of flap fibrosis (OR, 28.18; 95% CI, 5.15 to 154.12; P = 0.0001; I2 = 44%) and skin flap necrosis (OR, 6.12; 95% CI, 2.71 to 13.82; P < 0.0001; I2 = 27%) but a lower risk of partial flap failure (OR, 0.18; 95% CI, 0.06 to 0.58; P = 0.004; I2 = 0%) when compared with DBR. Results of fat necrosis should be interpreted with caution. Patient-reported and objective aesthetic outcomes were mostly comparable between groups.

CONCLUSIONS

IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires.

Microsurgical breast reconstruction in the United States: a narrative review of the current state

Background and Objective

Breast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons.

Methods

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers.

Key Content and Findings

In this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications.

Conclusions

While implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.

Surgical Management of Locoregional Recurrence in Breast Cancer

Locoregional recurrences from breast cancer represent a heterogeneous group of disease that poses a therapeutic challenge and needs a multidisciplinary team management. The incidence of local recurrence after breast conservation surgery ranges from 10 to 22% and 5-15% after mastectomy at 10-year follow-up. Management of locoregional recurrence depends on tumor biology, stage at presentation, and prior local and systemic therapy. With improvements in diagnostic, pathological, and surgical techniques, radiation and systemic therapy approach, outcomes in these patients have improved. In this review, we discuss the risk factors, prognostic factors, surgical and reconstruction options, re-irradiation, and role of systemic therapy to define a reasonable treatment approach without compromising oncologic safety and achieve good cosmetic and survival outcomes.

Optimise not compromise: The importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery

Modern breast cancer care is a complex multidisciplinary undertaking in which the integrated function of multiple constituent parts is critical, and where changes to one therapeutic component may profoundly influence the delivery and outcomes of another. Oncoplastic and reconstructive breast surgery has evolved in the era of longer survival rates for women with breast cancer and aims to enhance oncological and cosmetic outcomes. However, concurrently there has been an expansion in the indications for post-mastectomy radiation therapy (Abdulkarim et al., 2011; Early Breast Cancer Trialists' Collaborative Group (EBCTCG), 2014; Poortmans et al., 2015; Wang et al., 2011), the recognition of several biologically distinct breast cancer subtypes (Perou et al., 2000; Sørlie et al., 2001, 2003; Cheang et al., 2008, 2009; Sotiriou et al., 2003; Millar et al., 2011; Blows et al., 2010; Schnitt, 2010; Haque et al., 2012; Dai et al., 2015) and the development of recommendations for prophylactic surgery for high-risk women, including BRCA-mutation carriers (James et al., 2006; Domchek et al., 2010). Primary systemic therapy is increasingly utilised yet has varying efficacy depending on tumour biology (Cortazar et al., 2014). In this paper we review the evidence which informs the multidisciplinary team opinion in the era of oncoplastic and reconstructive breast surgery. We aim to describe an optimal multidisciplinary approach which balances competing risks of multimodal therapies to optimise oncological and cosmetic outcomes.

Optimal Reconstruction Method for Large Radionecrosis Following Breast Cancer Treatment: Utility of Free Transverse Rectus Abdominis Myocutaneous Flap Using Contralateral Internal Mammary Artery as Recipient

INTRODUCTION

In extensive radionecrosis following radiotherapy for breast cancer (BC) treatment, the defect after excision can be reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap. In this study, we report outcome of free TRAM flap using contralateral internal mammary artery (IMA) as a recipient in comparison with pedicled TRAM.

METHODS

We reviewed cases of chest wall radionecrosis following BC treatment during the past 8 years. Radionecrosis involving full-thickness soft tissue with defect sizes greater than 10 × 10 cm were included. We compared the outcomes of patients who underwent reconstruction with either pedicled TRAM flaps or free TRAM flaps. We used IMA as a recipient for free TRAM flap, whereas we used contralateral superior epigastric artery-based flap for pedicled TRAM.

RESULTS

A total of 14 BC patients underwent chest wall reconstruction due to radionecrosis: 7 received pedicled TRAM flaps, 5 received free TRAM flaps, and 2 were excluded because of the small defect size. The pedicled and free TRAM groups were similar in patient demographics and defect size. However, distal flap loss rate was significantly higher in the pedicled TRAM group compared with the free TRAM group (P = 0.028). There was no difference in abdominal hernia incidence between the 2 groups (P = 0.100).

CONCLUSIONS

Wide chest wall defects caused by radionecrosis following BC treatment can be successfully reconstructed with a free TRAM flap that uses a contralateral IMA as a recipient. The free TRAM flap demonstrates a lower rate of distal flap loss than the pedicled TRAM flap, hence reduces the risk of severe morbidity.

Patient determinants as independent risk factors for postoperative complications of breast reconstruction

BACKGROUND

Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling.

METHODS

We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications.

RESULTS

Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially.

CONCLUSIONS

Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.

Radiotherapy and breast reconstruction: oncology, cosmesis and complications

Breast reconstruction plays a highly important role in the management of patients with breast cancer, from a psycho-social and sexual stand-point. Given that immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiotherapy, the need to balance cosmesis in reconstruction with the oncologic needs of breast cancer patients is no more evident than in the discussion of radiotherapy. Radiotherapy is essential adjuvant therapy in the treatment of breast cancer, with the use of adjuvant radiotherapy widely shown to reduce local recurrence after both partial and total mastectomy and shown to prolong both disease-free and overall survival in patients with nodal disease. In the setting of breast reconstruction, the effects of radiotherapy are potentially two-fold, with consideration required of the impact of breast reconstruction on the administration of and the initiation of radiotherapy, as well as the effects of radiotherapy on operative complications and cosmetic outcome following immediate breast reconstruction. The current editorial piece aims to analyze this balance, contrasting both autologous and implant-based reconstruction. The literature is still evolving as to the relative role of autologous vs. alloplastic reconstruction in the setting of radiotherapy, and the more recent introduction of acellular dermal matrix and other compounds further complicate the evidence. Fat grafting and evolving techniques in breast reconstruction will herald new discussions on this front.

A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal?

PURPOSE

The specific aim of this study was to conduct a systematic review of the literature to assess outcomes data on complications and aesthetic results associated with autologous tissue-based breast reconstruction performed before or after chest wall irradiation.

METHODS

Studies from a PubMed search that met predetermined inclusion criteria were identified. Complications of interest included partial or total flap loss, fat necrosis, thrombosis, infection, seroma, hematoma, delayed wound healing, and flap fibrosis/contracture. Pooled complication rates were calculated.

RESULTS

A total of 20 articles were included in the study for autologous reconstruction. These primary articles were selected after screening 897 publications, with six studies presenting data on pre-reconstruction radiation, nine studies presenting data on post-reconstruction radiation, and five studies presenting data on both patient groups. Comparison of pooled complication rates between flaps irradiated before or after reconstruction were statistically similar, including total flap loss (1 vs. 4 %), wound healing complications (10 vs. 14 %), infection (4 vs. 6 %), hematoma (2 vs. 1 %), seroma (4 vs. 4 %), and fat necrosis (10 vs. 13 %). The pooled rate of flap contracture and fibrosis was 27 % in flap reconstructions exposed to radiotherapy. Statistical evaluation of aesthetic outcomes was impossible as a result of variability in assessment and reporting methods.

CONCLUSIONS

Review of the current literature suggests similar rates of complications and success rates in autologous breast reconstruction patients exposed to pre- or post-reconstruction radiation. Immediate autologous reconstruction should be considered as a viable option even in patients who are likely to require postmastectomy radiotherapy.

Breast reconstruction following prophylactic or therapeutic mastectomy for breast cancer: Recommendations from an evidence-based provincial guideline

The side effects of mastectomy can be significant. Breast reconstruction may alleviate some distress; however, there are currently no provincial recommendations regarding the integration of reconstruction with breast cancer therapy. The purpose of the present article is to provide evidence-based strategies for the management of patients who are candidates for reconstruction. A systematic review of meta-analyses, guidelines, clinical trials and comparative studies published between 1980 and 2013 was conducted using the PubMed and EMBASE databases. Reference lists of publications were manually searched for additional literature. The National Guidelines Clearinghouse and SAGE directory, as well as guideline developers' websites, were also searched. Recommendations were developed based on the available evidence. Reconstruction consultation should be made available for patients undergoing mastectomy. Tumour characteristics, cancer therapy, patient comorbidities, body habitus and smoking history may affect reconstruction outcomes. Although immediate reconstruction should be considered whenever possible, delayed reconstruction is acceptable when immediate is not available or appropriate. The integration of reconstruction and postmastectomy radiotherapy should be addressed in a multidisciplinary setting. The decision as to which type of procedure to perform (autologous or alloplastic with or without acellular dermal matrices) should be left to the discretion of the surgeons and the patient after providing counselling. Skin-sparing mastectomy is safe and appropriate. Nipple-sparing is generally not recommended for patients with malignancy, but could be considered for carefully selected patients. Immediate reconstruction requires resources to coordinate operating room time between the general and plastic surgeons, to provide supplies including acellular dermal matrices, and to develop the infrastructure needed to facilitate multidisciplinary discussions.

Bilateral reduction mammoplasty following breast cancer: A case-control study

Purpose

Many women undergo a bilateral reduction mammoplasty after lumpectomy and radiation for breast cancer due to breast hypertrophy. The outcomes of these patients, focusing on complications and the need for additional surgery, are reviewed.

Methods

A matched case-control study with patients serving as their own control (treated breast cancer breasts were ‘cases’, healthy breasts were ‘controls’) was performed. Patients were identified through hospital records between 1980 and 2007. Patients treated by lumpectomy and radiation with subsequent bilateral reduction surgery were included. Data regarding demographics, medical history, and peri- and postoperative complications were collected. Measured outcomes included hematoma or seroma, delayed wound healing, infection, nipple-areolar complex problems, scarring, asymmetry and the need for further surgery. Continuous variables are reported as mean ± SD, and categorical variables are reported as proportions.

Results

Of the nine patients included in the study, delayed wound healing occurred in 22% of cases. Wound infections occurred in 66.7% of cases, with 22.2% experiencing a second wound infection. One patient experienced partial nipple-areolar complex loss on the radiated breast. There was abnormal scarring in 33.3% of radiated breasts. Postoperative asymmetry occurred in 77.8% of patients. Additional surgery was performed on three patients (33.3%).

Conclusions

Results of the present study suggest that women with a history of breast cancer treated by lumpectomy and radiation experience higher occurrence of postoperative complications on the radiated breast following bilateral breast reduction. Patients must be informed of these potential risks and require careful postoperative follow-up. An appropriately powered, prospective, multicentred study is required to draw definitive conclusions.

Bilateral reduction mammoplasty following breast cancer: A case-control study

PURPOSE

Many women undergo a bilateral reduction mammoplasty after lumpectomy and radiation for breast cancer due to breast hypertrophy. The outcomes of these patients, focusing on complications and the need for additional surgery, are reviewed.

METHODS

A matched case-control study with patients serving as their own control (treated breast cancer breasts were 'cases', healthy breasts were 'controls') was performed. Patients were identified through hospital records between 1980 and 2007. Patients treated by lumpectomy and radiation with subsequent bilateral reduction surgery were included. Data regarding demographics, medical history, and peri- and postoperative complications were collected. Measured outcomes included hematoma or seroma, delayed wound healing, infection, nipple-areolar complex problems, scarring, asymmetry and the need for further surgery. Continuous variables are reported as mean ± SD, and categorical variables are reported as proportions.

RESULTS

Of the nine patients included in the study, delayed wound healing occurred in 22% of cases. Wound infections occurred in 66.7% of cases, with 22.2% experiencing a second wound infection. One patient experienced partial nipple-areolar complex loss on the radiated breast. There was abnormal scarring in 33.3% of radiated breasts. Postoperative asymmetry occurred in 77.8% of patients. Additional surgery was performed on three patients (33.3%).

CONCLUSIONS

Results of the present study suggest that women with a history of breast cancer treated by lumpectomy and radiation experience higher occurrence of postoperative complications on the radiated breast following bilateral breast reduction. Patients must be informed of these potential risks and require careful postoperative follow-up. An appropriately powered, prospective, multicentred study is required to draw definitive conclusions.

Long-term evaluation of postmastectomy breast reconstruction

BACKGROUND

Reconstructing a breast mound constitutes the basis of breast reconstruction. The breast can be reconstructed using autologous tissue, implants or a combination thereof. The number of women wishing a breast reconstruction has increased, but evaluation of the results is lacking. The current study examined the long-term results from three methods of breast reconstruction to assess the subjective and the objective outcome.

PATIENTS AND METHODS

Patients undergoing first-time post mastectomy reconstruction, selected from the cohort of Danish women in the Central and North Region of Denmark, were evaluated. We included 363 women, reconstructed in 1990-2005. Data was collected from patient charts, a study specific questionnaire (to be found online at http://www.informahealthcare.com/doi/abs/10.3109/0284186X.2011.584554 ) and a clinical follow-up visit. The questionnaire included questions regarding demographic background and evaluation of the reconstructed breast and donor site. The clinical follow-up visit included an examination of the overall result and donor site.

RESULTS

The questionnaire was answered by 263 women, of whom 137 had an implant, 26 had a latissimus dorsi musculocutaneus flap and 100 had a pedicled transverse rectus abdominis musculocutaneus flap. Women reconstructed with autologous tissue were significantly more pleased with the result of the breast reconstruction than women reconstructed with an implant. After a median of seven years, neither the patient's age nor the length of time since the reconstruction significantly affected the patients' opinion of the overall result. There was no difference in the incidences of minor complications among the different reconstructive methods. BMI, smoking and radiation therapy influenced the risk of complications. Objective evaluation of the 180 women participating in the follow-up visit was in agreement with data from the questionnaire.

CONCLUSION

The type of reconstruction had a significant long-term influence on patient satisfaction and the objective result. Women reconstructed with autologous tissue were significantly more pleased, and the objective outcome was assessed as superior.

Postmastectomy breast reconstruction after previous lumpectomy and radiation therapy: analysis of complications and satisfaction

BACKGROUND

Lumpectomy and radiation therapy (breast conservation therapy [BCT]) are common treatments for early-stage breast cancer. However, many of these patients will require a subsequent salvage mastectomy and reconstruction after a locoregional recurrence. This study examines whether prior BCT leads to higher rates of complications and dissatisfaction with subsequent mastectomy and breast reconstruction.

METHODS

All women undergoing initial breast reconstruction at an academic institution were identified (1999-2006). Women who had undergone prior BCT were compared with women without prior BCT. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered. Rates of complications, as well as general and aesthetic satisfaction, were compared between the 2 groups. Multiple logistic regression was used to analyze the effects of prior BCT, age, comorbidities, reconstruction type, and time between radiation and reconstruction.

RESULTS

Overall, 532 women underwent 802 reconstructions, of whom 113 women (137 reconstructions) had prior BCT. Prior BCT did not correlate with higher complication rates (odds ratio [OR] = 1.09, P = 0.690), or lower general or aesthetic satisfaction (OR = 0.84, P = 0.559; OR = 0.91, P = 0.723, respectively); however, there was an increased rate of mastectomy skin flap loss (12.4% vs. 6.8%, P = 0.024). Increasing age was the most significant risk factor for complications and dissatisfaction.

CONCLUSION

Radiation in the setting of BCT did not increase overall rates of complications or dissatisfaction with subsequent breast reconstruction in our patient population. These patients, however, had a higher incidence of mastectomy skin flap loss. These findings are important for preoperative counseling and intraoperative planning in patients with prior lumpectomy and radiation.

Breast reconstruction and adjuvant therapies

Recent developments in the management of breast cancer have increased the complexity of planning for immediate breast reconstruction. Two recent trials have demonstrated superior locoregional control, disease-free survival, and overall survival in node-positive breast cancer patients with the addition of postmastectomy radiation therapy (XRT) to mastectomy and chemotherapy. On the basis of these results, the use of postmastectomy XRT in patients with early-stage breast cancer is increasing. Unfortunately, it is difficult to predict the presence or extent of axillary lymph node involvement-a major determinant of the need for postmastectomy XRT-before mastectomy. There are two potential problems with performing an immediate breast reconstruction in a patient who will require postmastectomy XRT. First, postmastectomy XRT can adversely affect the aesthetic outcome of an immediate breast reconstruction. Second, an immediate breast reconstruction can interfere with the delivery of postmastectomy XRT. Chemotherapy before or after reconstruction does not significantly increase the occurrence of wound-healing problems and breast reconstruction does not appear to delay the initiation or resumption of chemotherapy. The increasing use of postmastectomy XRT and chemotherapy in patients with early-stage breast cancer necessitates increased communication between the medical oncologist, radiation oncologist, breast surgeon, and plastic surgeon during treatment planning for these patients.

Immediate versus delayed reconstruction following surgery for breast cancer

BACKGROUND

Breast cancer is the most prevalent cancer in women and has a lifetime incidence of one in nine in the UK. Curative treatment requires surgery, and may involve adjuvant and neo-adjuvant therapy. In many women, post-mastectomy breast reconstruction is essential to restore body image and improve quality of life. Timing of reconstruction may be immediately at the time of mastectomy or delayed until after surgery. Outcomes such as psychosocial morbidity, aesthetics and complications rates may differ between the two approaches.

OBJECTIVES

To assess the effects of immediate versus delayed reconstruction following surgery for breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group (CBCG) Specialised Register on 22 July 2010, MEDLINE from July 2008 to 26 August 2010, EMBASE from 2008 to 26 August 2010 and the WHO International Clinical Trials Registry Platform (ICTRP) on 26 August 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing immediate breast reconstruction versus delayed or no reconstruction in women in any age group and stage of breast cancer. We considered any recognised methods of reconstruction to one or both breasts undertaken at the same time as mastectomy or at any time following mastectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened papers, extracted trial details and assessed the risk of bias in the one eligible study.

MAIN RESULTS

We included only one RCT that involved that involved 64 women.We judged this study as being at a high risk of bias. Post-operative morbidity and mortality were not addressed, and secondary outcomes of patient cosmetic evaluations and psychosocial well-being post-reconstruction were inadequately reported. Based on limited data there was some, albeit unreliable, evidence that immediate reconstruction compared with delayed or no reconstruction, reduced psychiatric morbidity reported three months post-operatively.

AUTHORS' CONCLUSIONS

The current level of evidence for the effectiveness of immediate versus delayed reconstruction following surgery for breast cancer was based on a single RCT with methodological flaws and a high risk of bias, which does not allow confident decision-making about choice between these surgical options. Until high quality evidence is available, clinicians may wish to consider the recommendations of relevant guidelines and protocols. Although the limitations and ethical constraints of conducting RCTs in this field are recognised, adequately powered controlled trials with a focus on clinical and psychological outcomes are still required. Given the paucity of RCTs in this subject, in future versions of this review we will look at study designs other than RCTs specifically good quality cohort and case-controlstudies.

Reporting clinical outcomes of breast reconstruction: a systematic review

BACKGROUND

Breast reconstruction after mastectomy for cancer requires accurate evaluation to inform evidence-based participatory decision making, but the standards of outcome reporting after breast reconstruction have not previously been considered.

METHODS

We used extensive searches to identify articles reporting surgical outcomes of breast reconstruction. We extracted data using published criteria for complication reporting modified to reflect reconstructive practice. Study designs included randomized controlled trials, cohort studies, and case series. The Cochrane Risk of Bias tool was used to critically appraise all study designs. Other criteria used to assess the studies were selection and funding bias, statistical power calculations, and institutional review board approval. Wilcoxon signed rank tests were used to compare the breadth and frequency of study outcomes, and χ² tests were used to compare the number of studies in each group reporting each of the published criteria. All statistical tests were two-sided.

RESULTS

Surgical complications following breast reconstruction in 42,146 women were evaluated in 134 studies. These included 11 (8.2%) randomized trials, 74 (55.2%) cohort studies, and 49 (36.6%) case series. Fifty-three percent of studies demonstrated a disparity between methods and results in the numbers of complications reported. Complications were defined by 87 (64.9%) studies and graded by 78 (58.2%). Details such as the duration of follow-up and risk factors for adverse outcomes were omitted from 47 (35.1%) and 58 (43.3%) studies, respectively. Overall, the studies defined fewer than 20% of the complications they reported, and the definitions were largely inconsistent.

CONCLUSIONS

The results of this systematic review suggest that outcome reporting in breast reconstruction is inconsistent and lacks methodological rigor. The development of a standardized core outcome set is recommended to improve outcome reporting in breast reconstruction.

Achieving autologous breast reconstruction for breast cancer patients in the setting of post-mastectomy radiotherapy

INTRODUCTION

Breast cancer is now associated with long-term disease-free and overall survival, and in the setting of mastectomy, long term psycho-sexual health becomes an important consideration. To this end, breast reconstruction has been shown to significantly improve quality of life for mastectomy patients. With adjuvant radiotherapy often required in the setting of breast reconstruction, it is unclear what interaction the two can have.

METHODS

A thorough literature review was undertaken to assess the impact of radiotherapy on autologous breast reconstruction, and in particular, the influence of its timing on vessel selection, post-operative complications and both oncologic and cosmetic outcomes.

RESULTS

A clear benefit was established for delaying reconstruction until after radiotherapy to improve cosmetic outcomes. Although the timing of radiotherapy administration may influence vessel selection and the nature of post-operative complications encountered, overall outcomes were not dissimilar. Likewise, oncologic outcomes have not been shown to be significantly affected by the timing of radiotherapy.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

Both immediate and delayed breast reconstruction are safe modes of treatment, however patients that are expected to require adjuvant radiotherapy may benefit from delaying reconstruction until completion of oncologic treatment.

Impact of sequencing of postmastectomy radiotherapy and breast reconstruction on timing and rate of complications and patient satisfaction

PURPOSE

There are few long-term studies of how the sequencing of postmastectomy radiotherapy (PMRT) and breast reconstruction (BR) affects the time to development of complications or patient satisfaction with BR. We therefore studied this issue.

METHODS AND MATERIALS

One hundred thirteen women who underwent BR at Beth Israel Deaconess Medical Center (Boston, MA) from 1999-2006 and also received PMRT were included. Complications requiring surgery were categorized as early (within 90 days of BR) or late. The median length of follow-up after BR was 46.5 months. Patients' general and esthetic satisfaction was assessed with a validated questionnaire.

RESULTS

Complications occurred among 32% of 57 women receiving PMRT before BR and 44% of 57 patients having BR before PMRT (p = 0.176). Early complications were more frequent in patients who had PMRT first (18%) than for those with BR first (11%) (p = 0.210); conversely, late complication rates in the two groups were 14% and 33%, respectively (p = 0.009). General satisfaction was comparable between the PMRT-first and BR-first groups (68% and 68%, respectively; p = 0.995); esthetic satisfaction rates were also similar (50% and 62%, respectively; p = 0.238).

CONCLUSIONS

The sequencing of PMRT and BR did not have a substantial impact on the total risk of complications or patients' general and esthetic satisfaction. However, early complications tended to develop in patients having PMRT first, whereas patients having BR first had a higher risk of late complications. Additional study of the effects of sequencing of PMRT on particular types of reconstructions may help devise strategies for reducing these risks.

A review of the surgical management of breast cancer: plastic reconstructive techniques and timing implications

The oncologic management of breast cancer has evolved over the past several decades from radical mastectomy to modern-day preservation of chest and breast structures. The increased rate of mastectomies over recent years made breast reconstruction an integral part of the breast cancer management. Plastic surgery now offers patients a wide variety of reconstruction options from primary closure of the skin flaps to performance of microvascular and autologous tissue transplantation. Well-coordinated partnerships between surgical oncologists, plastic surgeons, and patients address concerns of tumor control, cosmesis, and patients' wishes. The gamut of breast reconstruction options is reviewed, particularly noting state-of-the-art techniques, as well as the advantages and disadvantages of various timing modalities.

Defining the role for autologous breast reconstruction after mastectomy: social and oncologic implications

Breast reconstruction plays a significant role in the management of breast cancer. The removal of a breast has implications for the psychologic, social, and sexual well-being of the patient, establishing the need for discussion of postmastectomy breast reconstruction with suitable patients. However, operative morbidity and the potential for diminished oncologic safety are ongoing issues of contention. A Medline literature review was performed to evaluate the interplay between the psychosocial need for breast reconstruction in patients after mastectomy and the issues surrounding its oncologic safety. Immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiation therapy (RT). Immediate breast reconstruction in the setting of chemotherapy is not associated with greater complication rates; however, there is some evidence for increased complications in the setting of adjuvant RT. Breast reconstruction has a positive effect on the psychosocial outcomes of mastectomy and is oncologically safe in the immediate and delayed settings. Ultimately, the decision-making process of whether to reconstruct, how to reconstruct, and when to reconstruct requires a multidisciplinary approach, with the patient, plastic surgeon, oncologic surgeon, medical oncologist, and radiation oncologist all contributing.

Breast cancer following augmentation mammoplasty - a review of its impact on prognosis and management

The incidence of breast cancer in women with implants is increasing and will continue to do so for the foreseeable future due to the marked increase in breast implant insertion in recent years. Undoubtedly many of these women will wish to know whether the presence of implants worsens the prognosis of their breast cancer. Furthermore, the clinical management of such patients may be difficult, as aesthetic results are likely to be a major concern for women who have already undergone cosmetic surgery to the breast. There is no consensus on surgical approach to this scenario. This article reviews the literature on the prognosis of breast cancer patients with a history of augmentation mammoplasty and examines the available data regarding their surgical treatment.

The pedicled TRAM flap in breast reconstruction

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a viable option in breast reconstruction. This article documents the history of the TRAM flap and puts in context the vascular anatomy through a discussion of the vascular zones. Options for flap delay are discussed and an algorithm is presented for patient selection. Finally, the issue of unipedicle versus bipedicle flap harvest is discussed and complications are examined.

Immediate versus delayed reconstruction

Recent developments in the management of breast cancer, including axillary sentinel lymph-node biopsy, as well as the inability to reliably detect micrometastatic disease in the axillary lymph nodes either preoperatively or intraoperatively, and the increasing use of both postmastectomy radiation therapy and neoadjuvant chemotherapy, have had a significant impact on the timing of breast reconstruction. The interplay and sequencing of these diagnostic and treatment modalities in patients with breast cancer have become important issues. This article addresses the clinical dilemma of determining the appropriate timing of breast reconstruction based on various patient-related clinical and pathological factors.

The Role of the Latissimus Dorsi Flap in Reconstruction of the Irradiated Breast

BACKGROUND

The role of the latissimus dorsi flap with a prosthesis in reconstruction of the previously irradiated breast is examined in this retrospective review of one surgeon's 10-year experience.

METHODS

Twenty-eight patients with available charts were divided into five groups: (1) 11 patients with previous breast conservation therapy and recurrence; (2) eight patients with previous mastectomy and radiation; (3) four patients with an expander that had been irradiated; (4) three patients with prior irradiation and implant reconstruction presenting for revision; and (5) two patients with breast deformity from breast conservation therapy.

RESULTS

Eighteen patients had a latissimus flap placed at the time of the expander and 10 had a latissimus flap at the time of implant placement or exchange. Average follow-up was 28.8 months (range, 1 week to 7 years). All patients had soft breasts at follow-up, with no evidence of capsular contracture. Donor-site complications included five donor-site seromas. The majority of patients (65 percent) underwent a planned two-stage reconstruction, and the majority of the revision operations were for exchanges to smaller implants. The response rate to a patient satisfaction survey was 67 percent. The average cosmetic satisfaction rating was 8.5 of 10 (with 10 being the highest). The average pain rating was 1.7 of 10 (with 10 being the worst). The overall satisfaction rating was 8.8 of 10. Fourteen of 16 patients indicated that they would undergo this procedure again.

CONCLUSIONS

Although purely autologous reconstructions may be the best choice for many irradiated breasts, it has been shown in this study that a cosmetically acceptable reconstruction with manageable risk can be performed using a prosthesis combined with a latissimus dorsi flap.

Impact of Radiotherapy on Breast Reconstruction

Breast reconstruction in the face of radiotherapy poses a unique set of challenges to the plastic surgeon and thus alters the algorithm of the reconstruction. The impact of radiation changes on alloplastic and autologous breast reconstruction is unpredictable. This article reviews the pathophysiology of radiation changes and the alterations to the reconstructive process.

Radiotherapy and wound healing

Radiotherapy is an invaluable weapon when treating cancer. However, the deleterious effects of radiation, both immediate and long-term, may have a significant effect on local tissues. Problematic wound healing in radiation-damaged tissue constitutes a major problem that is frequently overlooked during the management of patients who require radiotherapy, or have had radiotherapy in the past. Poor wound healing may lead to chronic ulceration, pain, secondary infection and psychological distress and compromise the outcome of general or reconstructive surgery. We discuss the pathophysiology of poor wound healing following radiotherapy, specific problems for radiation-damaged tissue and potential treatments to improve wound healing of irradiated tissues.

New trends in breast cancer management: is the era of immediate breast reconstruction changing?

OBJECTIVE

Review of available literature on the topic of breast reconstruction and radiation is presented. Factors influencing the decision-making process in breast reconstruction are analyzed. New trends of immediate breast reconstruction are presented.

SUMMARY BACKGROUND DATA

New indications for postmastectomy radiation have caused a dramatic increase in the number of radiated patients presenting for breast reconstruction. The major studies and their impact on breast cancer management practice are analyzed. Unsatisfactory results of conventional immediate reconstruction techniques followed by radiotherapy led to a new treatment algorithm for these patients. If the need for postoperative radiation therapy is known, a delayed reconstruction should be considered. When an immediate reconstruction is still desired despite the certainty of postoperative radiotherapy, reconstructive options should be based on tissue characteristics and blood supply. Autologous tissue reconstruction options should be given a priority in an order reflecting superiority of vascularity and resistance to radiation: latissimus dorsi flap, free TRAM or pedicled TRAM without any contralateral components of tissue, pedicled TRAM/midabdominal TRAM, and perforator flap.

CONCLUSIONS

When the indications for postoperative radiotherapy are unknown, premastectomy sentinel node biopsy, delayed-immediate reconstruction, or delayed reconstruction is preferable.

A Comparison of Ipsilateral Pedicled TRAM Flap With and Without Previous Irradiation

Due to concerns for increased complications, there is reluctance to use the ipsilateral pedicled TRAM for breast reconstruction in the presence of previous chest wall irradiation. This study will assess whether the ipsilateral pedicled TRAM is a safe and effective option when the pedicle is part of the irradiation field. Consecutive cases of ipsilateral pedicled TRAM flap procedures from 1997-2003 were reviewed. Patients with and without previous irradiation were compared on several vascular indicators. There were 123 and 124 patients in the irradiated and nonirradiated groups, respectively. These groups were demographically similar, except the nonirradiated group was significantly older. The irradiated group had a significantly higher rate of minor wound problems related to mastectomy flap healing (8.9% versus 1.6%). All other flap vascular complications were equivalent. The ipsilateral pedicled TRAM flap is a safe and effective option for breast reconstruction in an irradiated field in terms of the pedicle to the flap.

TRAM flap delay: an extraperitoneal laparoscopic technique

Although the transverse rectus abdominis musculocutaneous (TRAM) flap is the gold standard in autogenous breast reconstruction, it is less reliable in patients at high risk of ischaemic compromise. A preliminary delay procedure involving ligation of the deep inferior epigastric vessels has been shown to augment flap vascularity and improve outcome in those high risk patients undergoing unipedicled TRAM flap reconstruction. Despite previous description of a transperitoneal laparoscopic technique, surgical delay generally continues to be performed as an open procedure. This may reflect apprehension over the transperitoneal approach with its attendant risk of injury to intra-abdominal organs and vessels as well as adhesion formation. In this paper we describe an extraperitoneal laparoscopic technique for TRAM flap delay. Access to the deep inferior epigastric vessels is obtained using an extraperitoneal approach similar to that used for total extraperitoneal laparoscopic inguinal hernia repair and the vessels are easily identified and ligated using a single working port. While further study is required to evaluate the safety and efficacy of this technique, we report this as an alternative to the known open procedure which may be particularly useful for bilateral TRAM flap delay with the potential for reduced operative time, postoperative pain and scarring by avoiding bilateral inguinal incisions.