Long-term clinical outcome of immediate reconstruction after mastectomy

Is mastectomy with immediate reconstruction safe for patients undergoing neoadjuvant chemotherapy? A nationwide study from Korean Breast Cancer Society

PURPOSE

In this study, we compared the prognoses of patients who underwent mastectomy with immediate breast reconstruction (IBR) after neoadjuvant chemotherapy with those who underwent mastectomy.

METHODS

This retrospective study included 87,995 patients who were surgically treated for primary breast cancer between 2008 and 2014. We compared the three groups of patients who were divided based on the following surgeries: breast-conserving surgery (BCS), mastectomy, and mastectomy with IBR.

RESULTS

Of the 3295 patients who were treated with neoadjuvant chemotherapy, 482 patients achieved a pathological complete response (pCR) and 2813 patients did not (non-pCR). In survival analysis of the pCR patients, the 5-year Overall Survival (5 yr OS) between those who underwent mastectomy with IBR and mastectomy (P = 0.639) In the non-pCR group, 5 yr OS of the mastectomy with IBR group was 90.0%, while those of the mastectomy group was 84.4% in patients with clinical stage II (P = 0.032). In a multivariate analysis by Cox regression method revealed that the prognoses of the patients who underwent mastectomy with IBR were not different from those of patients who underwent mastectomy group in both groups (the pCR group and the non-pCR group).

CONCLUSION

In the pCR group, the prognoses of patients who underwent mastectomy with IBR were not different from those of patients who underwent mastectomy. In the non-pCR group, women in the mastectomy with IBR group had shown worse prognoses than the mastectomy group in advanced clinical stage. Appropriate operation should be determined depending on the status of individualized patients.

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

BACKGROUND

An integrated approach to skin sparing mastectomy with tissue expander placement followed by radiotherapy and delayed reconstruction was initiated in our institution in 2002. The purpose of this study was to assess the surgical outcomes of this strategy.

METHODS

Between September 2002 and August 2013, a total of 384 reconstructions had a tissue expander placed at the time of mastectomy and subsequently underwent radiotherapy. Rates and causes of tissue expander explantation before, during, and after radiotherapy, as well as tumor specific outcomes and reconstruction approaches, were collected.

RESULTS

Median follow-up after diagnosis was 5.6 (range 1.3-13.4) years. In the study cohort, 364 patients (94.8%) had stage II-III breast cancer, and 7 patients (1.8%) had locally recurrent disease. The 5-year rates of actuarial locoregional control, disease-free survival, and overall survival were 99.2, 86.1, and 92.4%, respectively. The intended delayed-immediate reconstruction was subsequently completed in 325 of 384 mastectomies (84.6% of the study cohort). Of the remaining 59 tissue expanders, 1 was explanted before radiotherapy, 1 during radiotherapy, and 7 patients (1.8%) were lost to follow-up. Fifty patients (13.0%) required tissue expander explantation after radiation and before their planned final reconstruction, primarily due to cellulitis. Nonetheless, the cumulative rate of completed reconstructions was 89.6%. The median time from placement of the tissue expander until reconstruction was 12 (interquartile range 9-15) months.

CONCLUSIONS

Tissue expander placement at skin-sparing mastectomy in patients who require radiotherapy appears to be a viable strategy for combining reconstruction and radiotherapy.

Does breast reconstruction after mastectomy for breast cancer affect overall survival? Long-term follow-up of a retrospective population-based cohort

BACKGROUND

This study compared overall and breast cancer-specific survival using long-term follow-up data among women diagnosed with invasive breast cancer undergoing mastectomy or breast reconstruction.

METHODS

Retrospective study using population-based data from Ontario Cancer Registry (1980 to 1990) including women receiving breast reconstruction within 5 years after mastectomy and controls of age- and cancer histology-matched women with mastectomy alone. We compared overall and breast cancer-specific survival using an extended Cox hazards model. Secondary analysis examined conditional survival across early, intermediate, and late follow-up.

RESULTS

Seven hundred fifty-eight matched pairs formed the cohort, with a median follow-up of 23.4 years (interquartile range, 1.1 to 33.0 years). Fewer breast reconstruction patients died overall or from breast cancer compared with controls (overall survival, 44.5 percent versus 56.7 percent, p < 0.0001; breast cancer-specific survival, 31.8 percent versus 42.6 percent, p = 0.0002, respectively). Breast reconstruction was associated with a 17 percent reduced risk of death and a 19 percent reduced risk of breast cancer death, after adjustment (overall survival hazard ratio, 0.83; 95 percent CI, 0.72 to 0.96; breast cancer-specific survival hazard ratio, 0.81; 95 percent CI, 0.68 to 0.99). Among 885 women (58 percent) surviving 20 or more years, there was no difference in risk of death from breast cancer (hazard ratio, 0.59; 95 percent CI, 0.31 to 1.10).

CONCLUSION

In a large cohort with invasive breast cancer followed over 20 years, there is no evidence that breast reconstruction is associated with worse survival outcomes compared with mastectomy alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A note from history: Landmarks in history of cancer, part 7

In the 2 and half decades reviewed (1970-1995), research established that chromosomal translocation, deletion, and DNA amplification are prerequisites to cancerogenesis and that oncogenes, tumor-suppressor genes, growth factors, and cytokines play crucial roles in the pathomechanism of cancer. Human papillomavirus, human immunodeficiency virus, herpes virus, and hepatitis B virus were identified as cancer-causing viruses. Several laboratory tests were developed for the detection of primary and recurrent cancers, and cancer prevention by screening methods was popularized. Sonography, computerized tomography, magnetic resonance imaging, positron emission tomography, excision of sentinel lymph nodes, and immunohistochemical techniques became routine procedures. Clinicopathologic staging and classification of tumors were standardized. Limited surgery, adjuvant and neoadjuvant chemoradiation, and the therapeutic use of monoclonal antibodies, tumor vaccines, and targeted chemotherapy became routine practice. The decline in cancer incidence and mortality demonstrated that cancer prevention and advancement in oncology are pivotal to success in the crusade against cancer. Above all, it was clearly established that the care of patients with cancer can be accomplished best in a multidisciplinary setting involving surgical oncologists, radiologists, radiation therapists, medical oncologists, surgical pathologists, and laboratory scientists. In conclusion, the 25 years from 1970 and 1995 are the high-water mark in clinical oncology, and this is the period when oncology turned from art to science.

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.

THE APPLICATION OF FULL-SCALE 3D ANTHROPOMETRIC DIGITAL MODEL SYSTEM ON BREAST RECONSTRUCTION OF PLASTIC SURGERIES

A full-scale 3D anthropometric digital model system is a set of technology that combined with 3D digital imaging system, computer 3D image processing system, reverse engineering and Computer-Aided Design. The purpose of this studied is to make a full size solid breast model by using the 1:1 anthropometric digital model technique to assist breast reconstruction plastic surgery colon the same size of symmetrical breast of the patient. The full-sized simulating breast model created in this studied not only can assist plastic surgeons by making more symmetric breasts on the other side during the reconstruction of the breast surgeries, but also can go into a process of analyzing if the two sides of the breasts are symmetrical. This studied is used the 3D optics scanner to scan on patients' breasts to obtain the breast 3D image data and then used reverse engineering technique and CAD software to simulate and to analyze the 3D image model of the reconstruction breasts. If this type of solid model is needed during the medical treatment, it can apply 3D digital data into a Rapid Prototyping machine to make the full-sized solid model. Doctors can using this solid model go into a process of evaluation and planning before the surgeries and consider being an important reference on breast reconstruction surgeries so that it can reduce patients' inconvenience and promote the medical treatment qualities.

Impact of neoadjuvant chemotherapy on breast reconstruction

BACKGROUND

With advances in oncologic treatment, cosmesis after mastectomy has assumed a pivotal role in patient and provider decision making. Multiple studies have confirmed the safety of both chemotherapy before breast surgery and immediate reconstruction. Little has been written about the effect of neoadjuvant chemotherapy on decisions about reconstruction.

METHODS

The authors identified 665 patients with stage I through III breast cancer who received chemotherapy and underwent mastectomy at Dana-Farber/Brigham & Women's Cancer Center from 1997 to 2007. By using multivariate logistic regression, reconstruction rates were compared between patients who received neoadjuvant chemotherapy (n = 180) and patients who underwent mastectomy before chemotherapy (n = 485). The rate of postoperative complications after mastectomy was determined for patients who received neoadjuvant chemotherapy compared with those who did not.

RESULTS

Reconstruction was performed immediately in 44% of patients who did not receive neoadjuvant chemotherapy but in only 23% of those who did. Twenty-one percent of neoadjuvant chemotherapy recipients and 14% of adjuvant-only chemotherapy recipients underwent delayed reconstruction. After controlling for age, receipt of radiotherapy, and disease stage, neoadjuvant recipients were less likely to undergo immediate reconstruction (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.37, 0.87) but were no more likely to undergo delayed reconstruction (OR, 1.29; 95% CI, 0.75, 2.20). Surgical complications occurred in 30% of neoadjuvant chemotherapy recipients and in 31% of adjuvant chemotherapy recipients.

CONCLUSIONS

The current results suggest that patients who receive neoadjuvant chemotherapy are less likely to undergo immediate reconstruction and are no more likely to undergo delayed reconstruction than patients who undergo surgery before they receive chemotherapy.

Application of Screening Principles to the Reconstructed Breast

A significant number of women choose mastectomy for the treatment of early and locally advanced breast cancer. Advances in reconstruction techniques and greater awareness of options have led to an increased use of immediate breast reconstruction, which has resulted in uncertainty for the management of surveillance for local recurrence. In this article, we review mastectomy and reconstruction trends and how these techniques affect the frequency and location of local recurrence. The data on surveillance imaging of the reconstructed breast are extremely limited. However, by assessing the potential role for imaging in this setting and applying the principles of screening, we have identified that there is a potential theoretic advantage of surveillance imaging in a very small subset of women: those with autologous tissue reconstructions and moderate to high risk of recurrence. A prospective registry study of surveillance imaging in this target population would be the appropriate way to determine its benefit and its impact on survival outcomes. In this review article, we will detail the reasons that should allow clinicians to forego routine surveillance imaging in the majority of women who undergo mastectomy and reconstruction.

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.

Delayed breast reconstruction with implants after invasive breast cancer does not impair prognosis

We investigated if delayed breast implant reconstruction after breast cancer impairs prognosis. Using data from the Danish Breast Cancer Cooperative Group register, we identified all women <70 years who underwent breast reconstruction with implants after mastectomy after invasive breast cancer during 1978 to 1992, on average 2.2 years (range, 3 days-9.4 years) after mastectomy. The reconstructed women were closely matched to breast cancer patients without reconstruction on age and calendar time of diagnosis, tumor size, regional lymph node involvement, and adjuvant radiation therapy. Overall, 580 reconstructed women and 1158 individually matched controls were followed-up for disease-free survival within the first 10 years and for overall survival for an average of 20.1 year (range, 12.8-27.5 years). Disease-free survival was significantly improved hazard ratio 0.78; 95% confidence interval 0.64-0.95 and overall survival was nonsignificantly improved (hazard ratio, 0.90; 95% confidence interval 0.76-1.06) among the breast reconstructed women. This is likely because of differences in socioeconomic and health factors.

A Prospective Assessment of Surgical Risk Factors in 400 Cases of Skin-Sparing Mastectomy and Immediate Breast Reconstruction with Implants to Establish Selection Criteria

BACKGROUND

Although attempts have been made to identify the risk factors leading to complications after combined skin-sparing mastectomy and immediate prosthetic breast reconstruction, hardly any criteria are available to preoperatively distinguish patients in whom such an eventful postoperative course may be expected. Therefore, the authors wanted to establish which factors increase the risk of surgical complications to such a level as to adjust their indications for immediate breast reconstruction after skin-sparing mastectomy.

METHODS

The authors prospectively studied the clinical relevance of six patient-related and nine procedure-related characteristics as potential risk factors for a complicated surgical outcome in 400 combined procedures in 309 patients by univariate and multivariate logistic regression analysis. Risk factors that proved significantly correlated with loss of implant by both analyses were accepted as clinical selection criteria that distinguish potential candidates with an unacceptably high risk of such loss.

RESULTS

Mild complications occurred significantly more often in patients who were older than the mean age of 43 years and in breasts that were more than average sized or operated on by a fellow in oncologic surgery. Implants were lost significantly more often in patients who were obese or smoked and in breasts that were more than average sized.

CONCLUSIONS

The clinically relevant increase of risk of implant loss should lead to reluctance to perform combined skin-sparing mastectomy and immediate prosthetic breast reconstruction in obese patients who smoke (32 percent loss) and in those with more than average sized breasts (27 percent loss).

Breast Cancer Diagnosis and Prognosis in Augmented Women

BACKGROUND

Recent years have witnessed growing concerns about the possible adverse effects of implants on breast cancer diagnosis and treatment. Numerous reports describe how implants might interfere with mammography and impair the ability to detect cancer. Several publications document the diminished sensitivity of mammography in augmented patients with palpable tumors. However, epidemiologic studies comparing stage of disease at time of diagnosis in augmented and nonaugmented women are equivocal. The purpose of this study was to review the authors' experience with a large number of breast cancer patients to determine whether implants impair early diagnosis or adversely affect prognosis.

METHODS

The authors reviewed their prospective database, which contains detailed information on 3953 nonaugmented and 129 augmented breast cancer patients. Various parameters of the two groups were compared and differences were analyzed using appropriate statistical methodology.

RESULTS

The authors' data reveal that augmented patients present with a statistically greater frequency of palpable lesions, have a slightly greater risk of invasive tumors, and have an increased likelihood of axillary lymph node metastases. Despite this, there was no statistically significant difference in stage of disease between augmented and nonaugmented patients; mean tumor size, recurrence rates, and breast cancer-specific survival were virtually identical in both groups.

CONCLUSIONS

Based on these findings, the authors conclude that despite the diminished sensitivity of mammography in women with implants, augmented and nonaugmented patients are diagnosed at a similar stage and have a comparable prognosis. While implants may impair mammography, they appear to facilitate detection of palpable breast cancers on physical examination.

Skin-Sparing Mastectomy and Immediate Breast Reconstruction by Use of Implants: An Assessment of Risk Factors for Complications and Cancer Control in 120 Patients

BACKGROUND

Combined skin-sparing mastectomy and immediate reconstruction by use of an implant is increasingly accepted as a therapy for patients with breast cancer or a hereditary risk of breast cancer. Because little and contradictory evidence regarding possible risk factors for postoperative complications is available, the authors retrospectively assessed 13 such factors. They also evaluated the oncological safety of the procedure.

METHODS

From July of 1996 through June of 2000, 174 skin-sparing mastectomies were combined with immediate breast reconstruction in 120 patients. The authors assessed the influence of five patient-related and eight breast-related characteristics on the incidence of a complicated postoperative course by univariate and multivariate analyses. Oncological safety was evaluated by observed recurrent disease and 5-year survival.

RESULTS

Severe complications were observed in 17 patients of the 120 patients (14 percent), or 19 of the 174 breasts (11 percent). The patient-related characteristics of age and being operated on unilaterally significantly increased the risk of complications. Resident plastic surgeons and previous breast-conserving therapy including radiotherapy significantly increased the risk of implant loss. The local relapse rate among patients operated on for cancer was 0.02. The actuarial 5-year survival rate among patients who underwent curative mastectomies was 0.96.

CONCLUSIONS

Combined skin-sparing mastectomy and immediate reconstruction by use of an implant is oncologically safe, but the risk of postoperative complications cannot be neglected. The authors' observations may offer guidance for adapting indication and treatment strategies for patients with breast cancer or increased hereditary risk of such cancer.

Breast Reconstruction in Older Women: Should Age Be an Exclusion Criterion?

BACKGROUND

At present, breast reconstruction is undertaken by fewer than 10 percent of breast cancer patients undergoing mastectomy. Even though the benefits are numerous, this finding is even more notable among older women. Traditionally, women older than the age of 60 have been offered implant reconstruction or no reconstruction at all in hopes of minimizing potential morbidity. This practice may be due to a number of factors including a lack of patient education and information, as well as physician/surgeon bias regarding the safety or relevance of breast reconstruction in older women.

METHODS

The authors undertook a retrospective study in which they surveyed 75 women (age range, 60 to 77 years) from two surgeons' practices who underwent various forms of breast reconstruction over the past 8 years. Type of reconstruction, recovery time, and complication rate were correlated with patient satisfaction, general health, and quality of life.

RESULTS

An 81 percent response rate was obtained, yielding an average age of 66.6 years over a 3.8-year period. The overall rate of complications requiring operative intervention was 20.5 percent. When asked whether age should be a determining factor for breast reconstruction, more than 90 percent felt that it should not be. Only 16.1 percent of patients who had a delayed reconstruction stated that the option of breast reconstruction was presented to them at the time of their diagnosis, although 100 percent felt that it should have been. A significantly poorer physical health score was found among patients who experienced a complication, and lower mental health scores correlated with women who were less satisfied with their outcome.

CONCLUSIONS

The authors believe that all types of reconstruction should be an option for women older than 60 years of age and that age as an isolated factor should not deter physicians from offering these women the option of breast reconstruction.

Oncological aspects of breast reconstruction

Breast reconstruction has become increasingly popular over the past 20 years. There is concern that it may mask locoregional recurrence or that immediate reconstruction may compromise adjuvant treatments. We review available evidence regarding its oncological safety. The literature consists almost entirely of single institution, small retrospective reviews with variable follow-up and varying conclusions. Most reviews suggest that breast reconstruction does not adversely affect disease-free or overall survival and that there is no significant delay in presentation with recurrent disease. Three retrospective series compared chemotherapy delivery after immediate breast reconstruction with controls having mastectomy alone. No delay in chemotherapy delivery or effect on dose intensity was demonstrated. Irradiation of a prosthetic implant has been shown to increase the rate of capsular contracture; irradiation of autogenous tissue reconstruction is usually well tolerated.

Breast implants following mastectomy in women with early-stage breast cancer: prevalence and impact on survival

BACKGROUND

Few studies have examined the effect of breast implants after mastectomy on long-term survival in breast cancer patients, despite growing public health concern over potential long-term adverse health effects.

METHODS

We analyzed data from the Surveillance, Epidemiology and End Results Breast Implant Surveillance Study conducted in San Francisco-Oakland, in Seattle-Puget Sound, and in Iowa. This population-based, retrospective cohort included women younger than 65 years when diagnosed with early or unstaged first primary breast cancer between 1983 and 1989, treated with mastectomy. The women were followed for a median of 12.4 years (n = 4968). Breast implant usage was validated by medical record review. Cox proportional hazards models were used to estimate hazard rate ratios for survival time until death due to breast cancer or other causes for women with and without breast implants, adjusted for relevant patient and tumor characteristics.

RESULTS

Twenty percent of cases received postmastectomy breast implants, with silicone gel-filled implants comprising the most common type. Patients with implants were younger and more likely to have in situ disease than patients not receiving implants. Risks of breast cancer mortality (hazard ratio, 0.54; 95% confidence interval, 0.43-0.67) and nonbreast cancer mortality (hazard ratio, 0.59; 95% confidence interval, 0.41-0.85) were lower in patients with implants than in those patients without implants, following adjustment for age and year of diagnosis, race/ethnicity, stage, tumor grade, histology, and radiation therapy. Implant type did not appear to influence long-term survival.

CONCLUSIONS

In a large, population-representative sample, breast implants following mastectomy do not appear to confer any survival disadvantage following early-stage breast cancer in women younger than 65 years old.

Local???Regional Radiation Therapy After Breast Reconstruction: What Is the Appropriate Target Volume?

The oncologic safety and cosmetic outcome of immediate breast reconstruction in breast cancer patients requiring radiation therapy remains ill-defined. Between 1980 and 1998, 18 patients were treated at the University of Utah Medical Center with mastectomy, immediate breast reconstruction, and adjuvant radiation therapy delivered via an electron arc technique. A case-control study was performed matching reconstructed patients in a 1:2 ratio with patients undergoing mastectomy without reconstruction, using number of lymph nodes and tumor size. Median follow-up was 61 months for the reconstructed group. Five-year local-regional control, disease-free survival, and overall survival rates were 87%, 58%, and 74% respectively in the reconstructed group, versus 88%, 57%, and 67% respectively in the matched control group. Cosmesis was good/excellent in 11 of 13 living patients (85%). Significant capsular contraction occurred in 18% of prosthetic reconstruction patients, and revisional surgery was required in 24% of prosthetic reconstruction patients. Utilizing the electron arc technique, the median radiation dose to the chest wall at the midlevel of the ribs was 20% of the prescribed dose, and no patient failed deep to the implant. These results suggest that in appropriately selected patients, structures deep to the reconstruction are not at high risk for local-regional recurrence, and immediate breast reconstruction yields comparable local-regional control, disease-free survival, and overall survival rates to nonreconstructed patients, with acceptable cosmetic results.

Factors That Influence the Completion of Breast Reconstruction

Post mastectomy breast reconstruction continues to evolve in both timing and technique; however, multiple surgical procedures are usually required. The purpose of this report was to determine the number of secondary procedures required to complete the breast reconstruction and factors that influence this process. All patients who underwent breast reconstruction at Emory University Hospital between 1975 and 2000 were reviewed. The end point and inclusion criterion was completion to nipple reconstruction. Secondary procedures were determined per patient for either unilateral or bilateral reconstructions, and defined as any surgical manipulation of the reconstructed breast, contralateral breast, or donor site. The cohort was stratified by timing and method of reconstruction. Additional variables included risk factors, radiation therapy, and complications. A total of 888 patients completed the reconstructive process (738 unilateral and 150 bilateral). The average number of secondary procedures was 3.99 for unilateral, and 5.54 for bilateral. Delayed reconstructions had a higher number of secondary procedures in both groups. Transverse rectus abdominus musculocutaneous flap reconstruction tended to have more secondary procedures than implant or latissimus dorsi with or without implant reconstructions. Radiation therapy increased the number of secondary procedures in unilateral (3.9 versus 4.6, P < 0.001) and in bilateral reconstructions (5.7 versus 6.4, P = 0.032). The number of secondary procedures also increased exponentially with the number of risk factors (0-4), and patients with any complication had a higher number of secondary procedures for unilateral (4.5 versus 3.6, P < 0.001) and bilateral reconstructions (6.4 versus 4.5, P < 0.001). Secondary breast and donor site procedures were used as an outcome measure to formulate comparisons. Autologous tissue reconstruction required more secondary procedures, likely in part to donor site revisions. Delayed reconstruction, the need for radiation therapy, any complication, and more risk factors significantly increased the number of secondary procedures required to complete the reconstructive process.

Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience

Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast. All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p </= 0.001). The percentage of times a contralateral procedure was performed was highest for implant reconstructions (89 percent delayed and 57 percent immediate) and lowest for TRAM flap reconstructions (59 percent delayed and 18 percent immediate). Augmentation mammaplasty was the most common symmetry procedure for implant reconstruction (41 percent), whereas reduction was the most common procedure for autologous tissue reconstruction (57 percent). Immediate unilateral breast reconstructions were stratified into non-skin-sparing mastectomy (n = 205) and skin-sparing mastectomy (n = 500). Thirty-four percent of patients with a non-skin-sparing mastectomy defect (70 of 205) underwent a contralateral breast procedure, compared with 17 percent of patients with a skin-sparing mastectomy defect (85 of 500) (p = 0.001). The percentage of times a contralateral procedure was performed in immediate reconstruction, stratified by mastectomy and reconstruction type, was only significant for TRAM flap reconstructions (25 versus 11 percent). Trends in the management of unilateral breast cancer from delayed to immediate reconstruction and from implants to autologous tissue have reduced the incidence of contralateral symmetry procedures. Reduction mammaplasty is the most common symmetry procedure used for autologous tissue reconstruction, with augmentation predominating when implants are used. The type of mastectomy also effects the management of the opposite breast, with skin-sparing mastectomy further reducing the incidence of contralateral procedures in immediate TRAM flap reconstruction, compared with non-skin-sparing mastectomy.

Choices and information offered to patients undergoing immediate post-mastectomy breast reconstruction: a survey of patient opinion and self-assessed outcome

For those patients who request breast reconstruction after mastectomy, the immediate procedure is becoming increasingly common. Whilst this option results in resource cost savings, and may have benefits for patients, little is known about the information offered to patients who are faced with a mastectomy/reconstruction decision. To investigate these concerns, and also to determine patients' own assessment of their outcome after immediate reconstruction, we carried out a retrospective survey of all patients who underwent an immediate breast reconstruction at this Centre over a 3-year period, utilizing a detailed study-specific questionnaire, together with two widely used health status instruments. The response rate was 92% (57 patients). Nearly all patients were found to have been offered the choice of a delayed procedure, should they wish it, but information about type and choice of prosthesis was considered by patients to be inadequate. Steps to address this have been implemented. Scores from the SF-36 Health Survey Questionnaire showed that this patient group was comparable with a normal female population for the dimensions of physical function, mental health, energy, and general health. However, social function was found to be significantly lower, and a substantial minority (46%) exhibited some anxiety as assessed by the Hospital Anxiety and Depression (HAD) Scale.

Breast implants and cancer: causation, delayed detection, and survival

Concern for many women with breast implants has been focused on three topics: cancer (both breast and other cancers), delayed detection of breast cancer, and increased breast cancer recurrence or decreased length of survival. In this study, a qualitative review of the literature on these subjects was conducted, coupled with a meta-analysis of the risk for breast cancer or other cancers (excluding that of the breast). Researchers have consistently found no persuasive evidence of a causal association between breast implants and any type of cancer. The meta-analysis results obtained by combining the epidemiology studies support the overall conclusion that breast implants do not pose any additional risk for breast cancer (relative risk, 0.72; 95% confidence interval, 0.61 to 0.85) or for other cancers (relative risk, 1.03; 95% confidence interval, 0.87 to 1.24). This analysis suggests that breast implants may confer a protective effect against breast cancer. Women with implants should be reassured by the consistency of scientific studies which have uniformly determined that, compared with women without implants, they are not at increased risk for cancer, are not diagnosed with later-stage breast malignancies, are not at increased risk for breast cancer recurrence, and do not have a decreased length of survival.

Immediate breast reconstruction with saline-filled implants: no interference with the oncologic outcome?

The possible adverse effects on cancer control due to immediate breast reconstruction have been addressed recently for both silicone-filled implants and flap reconstruction. To evaluate those possible effects after immediate breast reconstruction with saline-filled implants, 49 patients reconstructed with saline-filled breast implants at the Jules Bordet Cancer Institute were studied. Selection was only based on the possibility to find a matched patient. These patients were matched with a control group of 49 matched women with breast cancer treated in the same center by mastectomy without any type of breast reconstruction. The two groups were comparable according to age at diagnosis (within 3 years), year of diagnosis (same year), stage of the tumor, histology, and nodal status. The only difference between the two groups was that radiation therapy was applied to some of the patients who were not reconstructed (due to tumor location). The results show, in terms of local recurrences, distant metastasis, and deaths, no significant difference between the two groups, even for the irradiated patients, within a mean follow-up period of 72 months (range, 24 to 108) months.

Prophylactic surgery for women at high risk for breast cancer

Women at high risk for the development of breast cancer have several options open to them including increased cancer surveillance, prophylactic mastectomy and/or oophorectomy, and chemoprevention. We consider high-risk women to be those with known BRCA mutations or a strong family history characterized by multiple relatives with breast cancer, early age at diagnosis, and in some families, ovarian cancer. We present existing data regarding prophylactic surgery for these women. Essentially, a woman at high risk for breast cancer may choose to undergo bilateral prophylactic mastectomy, with or without reconstruction. For patients who have a known breast cancer, contralateral mastectomy is also an option. Finally, for women in families with a strong incidence of ovarian cancer, prophylactic oophorectomy can be considered.

Nonsurgical breast enlargement using an external soft-tissue expansion system

Less than 1 percent of the women interested in having larger breasts elect to have surgical augmentation mammaplasty with insertion of breast implants. The purpose of this report is to describe and test the efficacy of a nonsurgical method for breast enlargement that is based on the ability of tissues to grow when subjected to controlled distractive mechanical forces. Seventeen healthy women (aged 18 to 40 years) who were motivated to achieve breast enlargement were enrolled in a single-group study. The participants were asked to wear a brassiere-like system that applies a 20-mmHg vacuum distraction force to each breast for 10 to 12 hours/day over a 10-week period. Breast size was measured by three separate methods at regular intervals during and after treatment. Breast tissue water density and architecture were visualized before and after treatment by magnetic resonance imaging scans obtained in the same phase of the menstrual cycle. Twelve subjects completed the study; five withdrawals occurred due to protocol noncompliance. Breast size increased in all women over the 10-week treatment course and peaked at week 10 (final treatment); the average increase per woman was 98 +/- 67 percent over starting size. Partial recoil was seen in the first week after terminating treatment, with no significant further size reduction after up to 30 weeks of follow-up. The stable long-term increase in breast size was 55 percent (range, 15 to 115 percent). Magnetic resonance images showed no edema and confirmed the proportionate enlargement of both adipose and fibroglandular tissue components. A statistically significant decrease in body weight occurred during the course of the study, and scores on the self-esteem questionnaire improved significantly. All participants were very pleased with the outcome and reported that the device was comfortable to wear. No adverse events were recorded during the use of the device or after treatment. We conclude that true breast enlargement can be achieved with the daily use of an appropriately designed external expansion system. This nonsurgical and noninvasive alternative for breast enlargement is effective and well tolerated.

An analysis of breast cancer surgery after free transverse rectus abdominis myocutaneous (TRAM) flap reconstruction

BACKGROUND

Breast reconstruction is currently offered on a more routine basis to patients after mastectomy for breast cancer. This paper analyzes the outcomes of breast cancer surgery, and the results and effects of breast reconstruction using free TRAM flaps.

METHODS

A retrospective review of 75 consecutive patients who had free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after breast cancer surgery was performed. A total of 92 free TRAM flaps were performed on 75 patients in Victoria, British Columbia, from January 1992 to May 1999. Thirty-three patients (44%) underwent primary breast cancer surgery and an immediate reconstruction (7 bilateral and 27 unilateral) and 42 patients (56%) had delayed reconstruction (10 bilateral and 32 unilateral).

RESULTS

Twenty- one patients (28%) had stage 0 disease, 20 (26.7%) had stage I disease, 17 (22.7%) had stage IIA disease, 12 (15%) had stage IIB disease, and 4 (5.3%) had stage IIIA disease. In 1 patient the stage of disease was unknown. The mean patient age was 49.4 years (range 33 to 73). Of the patients undergoing immediate reconstruction 3 had postoperative chemotherapy and 1 had postoperative radiotherapy. Three patients had combined chemoradiotherapy. In none of these cases was the adjuvant therapy delayed by the reconstructive surgery. Overall mean follow-up time from cancer diagnosis was 56.8 months and from the time of TRAM flap reconstruction, 36.7 months. To date, 5 recurrences have been detected (6.6%). Mean time between reconstruction and detection of recurrence was 22.8 months. Detection of recurrence was achieved clinically and was not impaired in any of the cases by the presence of the free flap. Patient satisfaction was assessed via a telephone survey, with 93% of patients pleased with the cosmetic results of their surgery.

CONCLUSIONS

For those patients with breast cancer requiring mastectomy, free TRAM flap reconstruction is a safe, cosmetically acceptable surgical alternative that impairs neither effective breast cancer surgery nor detection of recurrent disease.

Concurrent adjuvant chemotherapy and immediate breast reconstruction with skin expanders after mastectomy for breast cancer

BACKGROUND

Immediate breast reconstruction (IBR) by means of skin expander is currently one of the most widely used methods of breast reconstruction in mastectomized patients. However, given that many breast cancer patients usually receive adjuvant chemotherapy, the adoption of IBR raises new questions concerning possible cumulative toxicity. The present study reports our experience in the use of concurrent adjuvant chemotherapy and immediate breast reconstruction with skin expander after mastectomy for breast cancer and the acute cumulative toxicity of the treatments.

METHODS

We evaluated a consecutive series of 52 breast cancer patients who have received IBR by skin expander after radical mastectomy and adjuvant chemotherapy concurrently during skin expansion between 1995 and 1998 (IBR/CT group). We identified two series of control patients treated during the same period: 51 consecutive patients undergoing radical mastectomy and IBR without adjuvant chemotherapy (IBR group) and 63 consecutive patients undergoing radical mastectomy and adjuvant chemotherapy without IBR (CT group). For each patient, we evaluated the incidence of surgical complications and chemotherapy's side effects and dose intensity.

RESULTS

The interval between surgery and the start of expander inflation was similar in IBR/CT (range 0-19, median 5 days) and IBR groups (range 0-40, median 5 days) and the timing of inflation was not influenced by chemotherapy. The overall incidence of surgical complications in patients undergoing IBR was low: seroma in eight cases, infection in one, skin necrosis in one, expander rupture in two and erythema in three. There were no statistically significant differences in the distribution of complications between the IBR/CT and IBR groups. The dose intensity of chemotherapy was similar between IBR/CT and CT groups, with a median dose intensity of 96% and 95% of the projected dose, respectively. The only statistically significant difference in terms of chemotherapy side effects (p = 0.03) was that stomatitis was more frequent and intense in the CT than in the IBR/CT group.

CONCLUSIONS

Concurrent treatment with IBR and adjuvant chemotherapy appears feasible and safe, it does not increase acute surgical complications or chemotherapy side effects, and does not require any changes in dose intensity or the timing of inflation.

Esthetic reconstruction after mastectomy for inflammatory breast cancer: is it worthwhile?

BACKGROUND

Because inflammatory breast cancer (IBC) has been viewed as a malignancy with a poor likelihood of longterm survival, few women have been offered esthetic reconstruction after mastectomy for IBC. Recent advances in multimodality therapy have improved the outcomes for women with this disease. The purpose of this review was to assess the results of esthetic breast reconstruction in the population with IBC.

STUDY DESIGN

Review of medical records at the City of Hope National Medical Center for the 10-year period ending in May 1997, revealed 23 women who underwent elective esthetic breast reconstruction after mastectomy for IBC. The records of these patients were reviewed retrospectively. Patients requiring reconstruction for large surgical chest wall defects were not included in the review.

RESULTS

Treatment for IBC included mastectomy in all patients, chemotherapy in 22, and chest wall radiation therapy in 14. Immediate reconstruction was performed at the time of mastectomy (n = 14) or was delayed (n = 9). The types of reconstruction included transverse rectus abdominis musculocutaneous flap (n = 18), latissimus dorsi flap (n = 2), or prosthetic mammary implant reconstruction (n = 3). Seven women chose to undergo additional reconstruction procedures (ie, nipple reconstruction) after their initial reconstruction. With a median followup of 44 months for survivors, 16 patients developed recurrence after reconstruction. Of these, 6 were local recurrences and 10 were distant failures. Seven patients are currently alive with no evidence of disease, 4 are currently alive with disease, and 12 have died as a result of breast cancer. The median disease-free survival after reconstruction was 19 months. The median overall survival after reconstruction for all patients was 22 months. The only negative predictor of survival was a positive surgical margin at mastectomy.

CONCLUSIONS

The significant emotional and esthetic benefits of breast reconstruction should be available to women with IBC. In light of the improving prognosis of IBC with current aggressive multimodality treatment, reconstructive procedures should be offered as part of comprehensive therapy.

Immediate breast reconstruction after mastectomy for cancer

AIMS

The oncological, surgical and cosmetic results, patient satisfaction and psychological morbidity of immediate breast reconstruction following mastectomy for breast cancer were evaluated.

METHODS

From 1980 to 1994, 79 immediate breast reconstructions were performed in Malmö. From 1985 immediate breast reconstruction was performed in 21% of mastectomies among patients </=65 years. The most common indication for immediate reconstruction was extensive DCIS+/-multifocal invasive growth. In 61 cases permanent implants were used and in 18 expanders. The median volume in the permanent implants was 225 ml, compared with 380 ml in cases where expanders were used.

RESULTS

Post-operative complications requiring re-operation occurred in 13%. After introduction of the expander technique, no necrosis requiring explanation has occurred. Of the patients receiving radiotherapy, 71% developed capsular contracture (10/14). Four patients developed locoregional recurrence. Three-quarters of the patients had an acceptable to very satisfactory cosmetic result. Eight per cent were judged to have a Baker III-IV contracture. Of the patients, 85% were satisfied with the softness of the reconstructed breast and 76% stated the result to be in accordance with their expectations.

CONCLUSIONS

We find immediate breast reconstruction after mastectomy a safe operation with results comparable to those after late reconstruction and without an increased risk of recurrence. Immediate reconstruction with an implant is not recommended in cases where radiotherapy may be necessary.

Technical aspects of immediate breast reconstruction--two year follow-up of 100 patients treated consecutively

We report the technical aspects of immediate breast reconstruction of the first 100 consecutive patients done at the Karolinska Hospital. Two patients had bilateral cancer. Preoperative chemotherapy had been given to five patients and postoperative chemotherapy to 13 patients. In 96 patients the indication was breast carcinoma. Mean tumour size was 13.1 mm and always less than 100.0 mm. Radiotherapy had been given preoperatively in nine patients and postoperatively in 10 patients. Mean operation time was 127 minutes, and median operating time 100 minutes. Hospital stay was five days. Breast reconstructions were performed with permanent prostheses in 22, expanders in 66, pedicled TRAM flaps in eight, and free TRAM flaps in four patients. To complete the breast reconstruction one major and 1.4 minor operations were needed. Total time to reconstruction was 461 days. The overall complication rate was 16%, with 13 local complications. Three developed haematomas, seven lost their implants, two developed partial necroses of pedicled TRAM flaps, and one developed abdominal bulging after a free TRAM flap. Patients were followed up after 2.0-5.7 years. The capsular contracture rate in the implant group was 24%.

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS?

BACKGROUND

Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients.

METHODS AND RESULTS

We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography.

CONCLUSION

We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.

Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy

BACKGROUND

Skin-sparing mastectomy, combined with immediate breast reconstruction, has become increasingly popular. However, there are no published long-term data to support its oncologic safety. Our purpose was to evaluate the long-term oncologic risk of skin-sparing mastectomy.

METHODS

The records of all patients who had undergone treatment of T1 or T2 breast cancer by mastectomy and immediate breast reconstruction, and who were followed for at least 5 years or developed recurrence of disease before that time were reviewed. Local and distant recurrence rates observed in patients treated by skin-sparing mastectomy were compared with those in patients treated by conventional, non-skin-sparing mastectomy.

RESULTS

A total of 104 patients were treated with skin-sparing mastectomies. In that group, 6.7% developed local recurrences, 12.5% developed distant metastases, 88.5% remained free of disease, and 7.7% died of their disease. Among the 27 patients who did not have skin-sparing mastectomies. 7.4% had local recurrences, 25.9% had distant metastases, 74.1% remained free of disease, and 18.5% died of disease. These recurrence rates are similar to those reported elsewhere after treatment with conventional mastectomy and without reconstruction.

CONCLUSIONS

Our findings suggest that skin-sparing mastectomy does not significantly increase the risk of local or systemic disease recurrence in patients with early breast cancer.

Controversy in breast reconstruction

We have discussed the major controversies in the reconstruction of the breast. As trends in cancer ablative surgery have shifted toward breast conservation techniques, the reconstructive choices available to the plastic surgeon have evolved. Advances in oncology, adjuvant therapy, and surgical techniques have changed the defects left following ablative surgery. Patient preferences have also changed, with a greater number of patients presenting to the reconstructive surgeon having already decided the timing and type of reconstruction they prefer. We must continually remind ourselves that the best and least controversial option is the one reached through appropriate consultation among patient, oncologist, and surgeons.

Clinical Outcome of Immediate Breast Reconstruction Using a Silicone Gel-filled Implant after Nipple-preserving Mastectomy

In order to evaluate the safety of silicone gel-filled implants for breast reconstruction in terms of cancer control, we reviewed 122 patients with postoperative state I and II breast cancer who were treated by nipple-preserving mastectomy and immediate breast reconstruction using a silicone implant, and compared them with 92 controls treated by nipple-preserving mastectomy alone. Twelve complications requiring surgical management occurred in the 122 reconstructions(9.8%). Two implants were replaced, and 10 implants were removed. These 10 cases were excluded from survival analysis. The mean Follow-up duration was 78 months in the 112 patients with breast reconstruction, and 55 months in the controls. There were no significant differences in the overall, disease-free, and locoregional disease-free survival rates between the two groups. In the reconstruction group, recurrence occurred in 14 patients. Five of them had locoregional recurrence alone, and are surviving free of disease following local resection. By the last follow-up, there was no incidence of secondary cancer at any site, including the contralateral breast cancer or connective tissue disease in the both group. Our results do not support the hypothesis of a detrimental effect of breast reconstruction using silicone gel-filled implants after mastectomy for breast cancer.

Immediate breast reconstruction by prosthesis: a safe technique for extensive intraductal and microinvasive carcinomas

BACKGROUND

Immediate breast reconstruction (IBR) by prosthesis is frequently proposed after mastectomy. However, due to the morbidity of this operation, especially the early implant removal rate, its indications remain controversial.

METHODS

We have performed 141 IBR by prosthesis (saline or gel-filled implant, tissue expander) in a homogeneous population of patients with extensive intraductal or microinvasive carcinoma, diagnosed after an initial local excision. This prospective study was designed to assess the feasibility and morbidity of IBR for an "ideal" population, allowing wide cutaneous preservation, without preoperative or postoperative treatment.

RESULTS

The early prosthesis removal rate (< 2 months) was 0.7%, with only 2.1% of early surgical revisions and 3% of lymphoceles. Cutaneous complications (5%) were significantly correlated with the type of incision. Cosmetic results at 1 year were good or very good in 66% of cases, similar to the percentage observed after delayed reconstruction by prosthesis.

CONCLUSIONS

In this selected population, IBR by prosthesis did not induce any additional morbidity compared with mastectomy without reconstruction. IBR by prosthesis can be systematically proposed in cases of extensive intraductal or microinvasive carcinoma.

Future prospects for reconstructive surgery in breast cancer

Reconstructive surgery has become an integral part of primary breast cancer therapy in patients requiring total mastectomy. State-of-the-art reconstructions with autogenous tissue are transverse rectus abdominis (TRAM) flap procedures. Superior aesthetic results in terms of both appearance and consistency, seem to outweigh the disadvantages of impaired abdominal wall competence and donor site scars. The "free," microvascular TRAM flap may be the way to minimize abdominal wall weakness, since only a little portion of the rectus abdominis muscle must be sacrificed. Despite all discussions, breast reconstruction using silicone (gel) implants is a safe and reliable method and will be in the future. However, not every patient may be the right candidate for silicone reconstruction. Advantages of using silicone implants include (relatively) simple technique, short operation time, and no donor site morbidity. In patients suffering from breast-conserving therapy failures, plastic surgery has to address skin and parenchymal loss in an irradiated environment. Oncoplastic surgery, such as volume shrinking or volume replacement techniques, are useful for immediate reconstruction in breast-conserving therapy.

Breast reconstruction using permanent tissue expanders

The breast is a variable organ and as such reconstructive surgeons need to use a variety of reconstructive techniques. Prosthetic reconstruction is a good technique for women who are either unsuitable for or not accepting of autogenous tissue reconstruction. We reviewed the last five years' experience at Monash Medical Centre with permanent tissue expander breast reconstruction. Forty patients underwent reconstruction of 54 breasts. Immediate reconstruction was performed in 70% with an overall average patient age of 45 years. The selection criteria, advantages, and disadvantages of this technique are discussed. Inflation of expanders took an average of 71 days and creation of breast mound (excluding nipple/areolar reconstruction) took an average of 2.3 operations. Overall aesthetic results have been judged to be good to excellent in 81%. Symmetry was more easily achieved in bilateral reconstructions. Capsular contracture rate was Baker Grade I or II in 83%. Minor complications occurred in 17% of patients. We believe that there still exists a significant number of women who are either unsuitable for or not accepting of autogenous tissue reconstruction. It is this group of women who, if well selected, can be reconstructed safely and efficiently by the use of permanent tissue expander breast prosthesis.

Immediate breast reconstruction: short-term experience in 75 consecutive cases

Immediate breast reconstructions are being done more often nowadays to avoid the stress that the patient experiences while living without a breast. In this paper, the procedure and short term outcome of 75 patients who underwent immediate breast reconstructions at the Karolinska Hospital are reported. The median age of the patients was 48 years, and most of the tumours were stage O to 2 at the time of the operation, though reconstructions were also done for patients with more advanced cancer, for psychological reasons. The approach was multidisciplinary with oncologists, general surgeons, and plastic surgeons involved. Different reconstructive methods were used, and the operations were tailor-made for each patient. Twenty one permanent prostheses, 11 expanders, 33 expander prostheses, and eight pedicled and two free transverse rectus abdominis musculocutaneous (TRAM) flaps were used for reconstruction. The opposite breast was adjusted in 43 (57%) of the patients. There were 11 postoperative complications (15%), and in only one patient (1%), could the reconstruction not be completed. There was a tendency towards more complicated reconstructive procedures over time. The demand for immediate breast reconstruction is steadily increasing from both patients and doctors.

Breast reconstruction

Breast reconstruction after mastectomy is becoming more common despite the general trend toward breast conserving therapy with lumpectomy and radiation. Reconstruction at the time of mastectomy can be done safely and eliminates the disadvantages associated with a second operation under general anesthesia. There are also some psychologic benefits to immediate reconstruction. Autologous reconstruction with flap tissue usually is preferred by the authors. In a woman with small breasts or when autologous tissue is not available, a prosthetic reconstruction is an acceptable choice. The authors prefer the use of textured saline implants in a submuscular position. Nipple and areola reconstruction is performed at least 3 months later as an outpatient procedure under local anesthesia. In 216 consecutive patients with immediate reconstruction, the patients with autologous reconstruction with transverse rectus abdominis or latissimus dorsi flaps ranked their level of symmetry as well as their level of overall satisfaction significantly higher than did the patients with prosthetic reconstruction. Similarly, the surgeons ranked the results from the autologous reconstructions higher. In the patients who underwent autologous reconstruction, 6% had necrosis of a significant portion of the flap. Prosthetic reconstructions were complicated by infections, hematomas, and chest-skin necrosis, resulting in removal of the implant in a total of 8% of the patients in this group. Thirty-four percent of the patients received adjuvant chemotherapy, and the reconstructive surgery did not result in a delay of the onset of this treatment. The authors conclude that breast reconstruction is a safe procedure with an acceptable morbidity when done either as an immediate or a delayed procedure. Patient satisfaction rates are high, particularly with autologous reconstructions.