Immediate versus delayed free TRAM breast reconstruction: an analysis of perioperative factors and complications

Transcription

1 British Journal of Plastic Surgery (22), 55, l The British Association of Plastic Surgeons doi:.54/bjps BRITISH JOURNAL OF / ~ ] PLASTIC SURGERY Immediate versus delayed free TRAM breast reconstruction: an analysis of perioperative factors and complications R. DeBono, A. Thompson* and J. H. Stevenson Departments of Plastic Surgery, and *Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, UK SUMMARY. Immediate breast reconstruction provides superior psychological benefit to the patient compared with delayed reconstruction, and has a financial advantage. Smokers undergoing immediate free TRAM breast reconstruction have a higher incidence of flap necrosis than smokers undergoing delayed free TRAM reconstruction. Whereas the differences in psychological benefit, effects of smoking and cost are well addressed in the literature, the differences in morbidity between immediate and delayed free TRAM breast reconstruction are still unknown. Knowledge of any differences would help to determine the best timing for reconstruction, and would support surgical decision making and preoperative patient advice. We present a retrospective review of 5 consecutive free TRAM breast reconstructions performed in 97 patients (89 unilateral and eight bilateral reconstructions). There were 48 immediate reconstructions and 57 delayed reconstructions. In the immediate-reconstruction group six flaps required revision of the anastomosis, and three flaps (6%) were lost. In the delayed-reconstruction group five flaps required revision of the anastomosis, and only one flap (2%) could not be salvaged. Delayed healing of the chest-wall skin flaps only occurred in immediate reconstructions (6%, P =.7) The British Association of Plastic Surgeons Keywords: immediate reconstruction, delayed reconstruction, complications, TRAM flap. Breast reconstruction after mastectomy can be performed using an implant-based technique or using only autologous tissue. Implant-based techniques are generally the simplest; however, they have various disadvantages. The breast mound is usually less natural than that obtained using autologous tissue, and there is a risk of periprosthetic infection and capsular contracture. Autologous breast reconstruction is more technically demanding and requires the appropriate expertise, t However, the results are cosmetically far superior to implant reconstruction, and nowadays free TRAM breast reconstruction has become the gold standard of autologous-tissue breast reconstruction. 2 Furthermore, analysis of the cumulative costs of implant reconstruction and autologous-tissue (TRAM) reconstruction has revealed a lower cumulative cost for the latter) Breast reconstruction can be performed immediately after mastectomy, or at a later date. Immediate breast reconstruction confers a psychological benefit to the patient. 4 Patients who undergo immediate reconstruction have less psychological distress when recalling the surgery, 5 accept their body appearance more and have the freedom to choose clothes they like to wear. 6'7 Furthermore, women who have immediate breast reconstruction are likely to accept the new breast as an integral part of their body. 8 This paper was presented at the British Association of Plastic Surgeons Winter 2 Scientific Meeting, London, UK, December 2, and at the 7th Nottingham International Breast Cancer Conference, September 2. Immediate breast reconstruction yields a better cosmetic result than delayed reconstruction. 9,~ This is because: the inframammary fold and other breast landmarks are preserved and used; the tissues that remain after the mastectomy are soft and not affected by scar tissue and contracture; the remaining breast skin easily assumes the normal breast contour once the volume is restored; and only the skin that has to be removed during the mastectomy will need to be replaced, conserving most of the normal breast skin. All these factors make the reconstructive surgery easier and improve the final aesthetic result. Moreover, immediate reconstruction also results in lower surgery-related morbidity than delayed reconstruction. 9 Due to the superior aesthetic results of immediate reconstruction, fewer revisional and contralateral procedures to improve symmetry are required. Immediate reconstruction requires a single hospitalisation and, thus, reduces the effect on social and work roles. Immediate breast reconstruction has significant financial advantages over delayed reconstruction, especially in institutions with high case loads. 2 Immediate reconstruction requires less total operating time than a two-stage delayed reconstruction; it also leads to a shorter total hospital stay by the patientj 3 The cost is also reduced by the fact that fewer revisional and contralateral adjustment procedures are required after immediate reconstruction. The costs for delayed reconstruction can be as much as 62% more than those for immediate reconstruction. 3 However, smokers have a higher rate of flap necrosis than non-smokers after immediate free TRAM breast

2 2 British Journal of Plastic Surgery reconstruction, 4 but little is known about other differences in morbidity that may exist between immediate and delayed free TRAM breast reconstructions. Given that the surgeon shoul~ explain in detail to the patient the timing and operative options for breast reconstruction, we sought to identify differences in morbidity after immediate and delayed free TRAM breast reconstruction. Patients and methods Patients with primary breast cancer undergoing mastectomy and those who had had a mastectomy were offered free TRAM breast reconstruction. Patients were excluded from the study if they declined reconstruction, had excessive previous abdominal scarfing or preferred an alternative form of breast reconstruction. The case notes of 97 consecutive patients (99-2) who had undergone free TRAM breast reconstruction following breast-cancer treatment (95 patients) or prophylactic mastectomy (two patients) were reviewed retrospectively, and data were collected using a proforma recording preoperative factors, peroperative technical details and postoperative complications. The preoperative factors studied included the patient's age, body weight, smoking status at the time of surgery and TNM stage of the primary cancer. The reconstruction was recorded as immediate or delayed, and unilateral or bilateral. For immediate reconstructions it was noted whether a skin-sparing mastectomy was performed. The operative details studied included the TRAM flap ischaemia time and the total operating time. The recipient vessels in the axilla, the type of microvascular anastomosis and the orientation of the inset TRAM flap were recorded. Return to theatre for anastomosis re-exploration in the early postoperative period was also studied. In cases were the flap was not being perfused despite a satisfactory anastomosis, a local infusion of a thrombolytic agent was administered through a fine cannula inserted into a side branch proximal to the anastomosis. Tissue-type plasminogen activator (rt-pa) (Actilyse) was administered slowly in a mg aliquot tailored against the clinical response. The postoperative complications were divided into major and minor complications. The major complications included complete flap loss and abdominal hernia or bulge formation. The minor postoperative complications were analysed according to whether they affected the TRAM flap, the abdominal donor site or the chest-wall mastectomy flap. The minor complications for the TRAM flap included fat necrosis, partial flap loss, delayed wound healing (more than 2 weeks), wound infection (positive wound microbiological culture), and haematoma or seroma formation. The minor complications for the abdominal donor site were partial abdominal flap necrosis, wound infection (positive wound microbiological culture), delayed wound healing (more than 2 weeks), and haematoma or seroma formation. The minor complications for the chest wall included partial necrosis of the mastectomy chest-wall flap. The proportions of complications in the immediate and delayed groups were compared using a X z test with one degree of freedom and a continuity correction. The difference between the two groups was regarded as statistically significant if the P value was less than.5. Results Unilateral free TRAM breast reconstruction was performed in 89 patients, of which 44 underwent immediate reconstruction and 45 underwent delayed reconstruction. Eight further patients underwent bilateral free TRAM breast reconstruction, of which two had immediate recon2 struction and six had delayed reconstruction. A total of 5 free flaps were performed; 48 were immediate and 57 were delayed. Altogether, 95 patients underwent mastectomy for breast-cancer treatment and two patients underwent bilateral prophylactic mastectomies due to a very strong family history of breast cancer. The mean age, body weight, smoking status, flap ischaemia time and total operating time were not significantly different between the immediate and delayed groups (Table ). The distribution of the primary tumour stage based on the TNM classification was similar for the two groups, apart from a higher proportion of in-situ tumours (TisN) in the immediate group and a higher proportion of TN tumours in the delayed group (Fig. ). The variable use of donor vessels in the immediate and delayed groups is illustrated in Figure 2. The orientation of the TRAM flap was very similar in the two groups (Fig. 3). In the majority of patients in both groups the TRAM flap was orientated transversely with a 8 ~ arc of rotation. In the immediate reconstruction group (48 flaps), six flaps in six patients required anastomosis re-exploration. Three flaps showed clinical signs of thrombosis at the venous anastomosis; two were successfully treated with a local infusion of rt-pa, and the third was salvaged after Table Patient demographic data, flap ischaemia time and total operating time mean -+ s.d. age (years)* mean-+ s.d. body weight (kg)* number of smokers* mean -+ s.d. flap ischaemia time (min)* mean -+ s.d. total operating time* *P >.5. Immediate reconstructions (46patients, 48flaps) h 5 min-+66 min Delayed reconstructions (5 patients, 57flaps) 47-t-7 7_ 3 83 _ 7 7 h 48 min _ 65 min

3 Immediate versus delayed free TRAM breast reconstruction [] Immediate 4 [] Belayed I ~ _ ~ ~ L i ["],,, TIsN TIsNI TIN TINI T2N T2NI T3N T3NI T3N2 TxN Figure l--the distribution of the primal"y turnouts (two patients underwent bilateral prophylactic mastectomies) ~ I,. 9 Immediate [] Delayed TDA TDV CSA CSV SSA SSV Figure 2.--The recipient vessels used (TDA: thoracodorsal artery; TDV: thoracodorsal vein; CSA: circumflex scapular artery; CSV: circumflex scapular vein; SSA: subscapular artery; SSV- subscapular vein). revision of the anastomosis. The other three flaps failed despite revision of the anastomosis. Four of the six patients who required anastomosis re-exploration were smokers (compared with eight smokers in the remaining 4 patients). In the delayed reconstruction group (57 flaps), five flaps in five patients required anastomosis re-exploration. Two flaps showed thrombosis at the venous anastomosis: one underwent revision of the anastomosis and the other was treated with a streptokinase infusion; both flaps were salvaged. In one flap there was a failure of the arterial anastomosis and, in spite of an rt-pa infusion and revision of the anastomosis, the flap was lost. The remaining two flaps were both salvaged after revision of the anastomosis. Two of the five patients requiring anastomosis re-exploration were smokers (compared with eight smokers in the remaining 46 patients). In unilateral reconstructions there were no significant differences between the immediate and the delayed groups in the rate of complete TRAM flap loss, abdominal hernia or abdominal bulge formation (Table 2). Analysis of the minor complications of the unilateral TRAM flap reconstructions revealed no significant differences between the two groups with regards to fat necrosis, partial flap loss, delayed wound healing, wound infection, or haematoma or seroma formation (Table 3). An analysis of the minor complications at the abdominal donor site for the unilateral reconstructions also showed no significant differences between the immediate and the delayed groups (Table 4). Analysis of the chest-wall flap complications of the unilateral reconstructions revealed that 6% of patients in the immediate group developed partial necrosis of the mastectomy flap. There were no mastectomy-flap problems in the delayed group. This difference was statistically significant (P =. t 7) (Table 5) Immediate n = 48 fsnsverse blique ertlcal Delayed n Table 2 Major complications in unilateral reconstructions Immediate Delayed some complication* 4 (9%) 5 (%) complete TRAM flap loss* 2 (4%) (2%) abdominal wall hernia* 2 (4%) 2 (4%) abdominal wall bulge* (%) 2 (4%) *P>.5. Table 3 Minor complications of the TRAM flap in unilateral reconstructions B Figure 3--(A) The TRAM flap orientations, expressed as percentages, in the immediate and the delayed groups. (B) Diagrammatic representation of the three flap orientations. Immediate Delayed some complication* 2 (27%) (24%) fat necrosis* 7 (6%) 7 (6%) partial TRAM flap loss* (2%) (2%) delayed wound healing* 3 (7%) 5 (%) wound infection* 3 (7%) (%) haematoma or seroma* 5 (%) 2 (4%) *P>.5.

4 4 British Journal of Plastic Surgery A separate analysis of the complications in cases of bilateral reconstruction is summarised in Table 6. The number of bilateral reconstructions was too small to allow reliable statistical analysis within the group or comparison with the unilateral reconstructions. Discussion Immediate breast reconstruction has become increasingly popular over the past 2 years. 9 During the past years, as a result of improvements in surgical technique and patient selection, the free TRAM flap has become increasingly reliable and popular. 9 Immediate reconstruction using the TRAM flap can be safely performed in patients requiring preoperative chemotherapy (neoadju- Table 4 Minor complications of the abdominal donor site in unilateral reconstructions Immediate Delayed some complication* abdominal flap necrosis* (2%) (%) 3 (7%) (2%) wound infection* delayed wound healing* (2%) (%) (%) I (2%) haematoma or seroma (%) (2%) *P >.5. Table 5 Minor complications of the chest-wall mastectomy flap in unilateral reconstructions Immediate Delayed partial necrosis of mastectomy flap* 7 (6%) (%) *)~ =5.73; P=.7. vant therapy), t5 The TRAM flap has also been proven to tolerate postoperative radiotherapy. 6 Furthermore, immediate free TRAM breast reconstruction has been successfully used in cases of recurrent breast cancer after wide local excision and radiotherapy. 7 The introduction of the deep inferior epigastric perforator (DIEP) flap 8'9 and the recently described free paraumbilical perforator adiposal flap 2~ offer further attractive options for autologous-tissue breast reconstruction. Analysis of the total operating time for immediate and delayed breast reconstruction using the TRAM flap revealed no significant difference between the two groups. This can partly be explained by the fact that in immediate reconstructions two groups of surgeons normally operate simultaneously: whilst the mastectomy is being performed by one group, the TRAM flap is raised and kept vascularised on its pedicle by the second group. In this way, the mastectomy adds very little time to the whole operation. In a study comparing resource costs of immediate and delayed breast reconstructions, Khoo et al found that the mean resource cost of a mastectomy followed by delayed reconstruction was as much as 62% higher than that of an immediate reconstruction, t3 Our findings support these data, as they show that the operating time for an immediate reconstruction is not significantly different from that of a delayed reconstruction, and, hence, most of the mastectomy operating time incurred in a delayed reconstruction can be saved. This has clear theatre-resource implications, and avoids a second inpatient hospital stay. Comparisons of the major complications of the TRAM flap and the donor-site morbidity showed no significant differences between the two groups. A higher rate of flap loss was noted in the immediate group (6%) than in the delayed group (2%); however, this was not statistically significant. One of the three failed flaps in the immediate group was lost as a result of a failure of monitoring. These figures are in line with those of other published series. 4,9 Just over one-quarter of the patients in the immediate group were smokers at the time of surgery, whilst Table 6 Major and minor complications in cases of bilateral free TRAM breast reconstruction Immediate reconstruction (two patients, four flaps) Delayed reconstruction (six patients, 2 flaps) major complications complete unilateral TRAM flap loss abdominal wall hernia abdominal wall bulge minor complications of the TRAM flap fat necrosis partial TRAM flap loss delayed wound healing wound infection haematoma or seroma l minor complications of the abdominal donor site abdominal flap necrosis wound infection delayed wound healing haematoma or seroma minor complications of the chest-wall mastectomy flap partial necrosis of the mastectomy flap

5 Immediate versus delayed free TRAM breast reconstruction 5 two-thirds (four out of six patients) of the patients in this group requiring anastomosis re-exploration (six flaps in six patients) were smokers. A similar high incidence of smokers in the subset of patients requiring anastomosis re-exploration was seen in the delayed group. Specifically, 4% of the patients in this group that required anastomosis re-exploration (two out of five patients) were smokers, compared with 2% in the delayed group overall. These data further support the already-established detrimental effect of smoking on free TRAM flap outcome) 4 With regards to major complications of the donor site, we noted a low incidence of abdominal hernia when using the muscle-sparing TRAM flap. Mesh repair of the donor site was used more frequently in the earlier part of the series. As the series progressed, and an increasing number of muscle-sparing flaps and DIEP flaps were used, the use of mesh became mainly limited to obese patients and those undergoing bilateral reconstruction. The data from this study show a similar incidence of postoperative abdominal hernia as in other published series. The minor donor-site complications in the two groups were also comparable with other series. 4 Further data analysis of the minor complications of the TRAM flap revealed no significant differences between the two groups. The rates of fat necrosis and partial TRAM flap loss in the two groups were identical, indicating that there was no microcirculatory disadvantage in the immediate compared with the delayed group. These data are comparable with earlier studies. ~4 In this study, fat necrosis was the commonest complication of the TRAM flap. Fat necrosis of the TRAM flap has received detailed attention in the literature. 2~22 Kroll reported an incidence of fat necrosis of 2.9% in 279 breast reconstructions using the free TRAM flap. 2 Cigarette smoking is an established risk factor for fat necrosis. 2,22 In our series, only five of the 6 patients that suffered fat necrosis were smokers. This supports the theory that a combination of factors, including cigarette smoking, number of perforators, calibre of perforators and using a part of the flap across the midline, determine the likelihood of fat necrosis. 2 Therefore, all these factors should be considered during preoperative patient selection and intraoperative surgical decision making in order to reduce the risk of fat necrosis. Bilateral breast reconstruction involves two breast reconstructions in one patient, and requires bilateral harvesting of the rectus abdominis muscle; therefore, it would be expected to be associated with a two-fold increase in the incidence of major complications of the TRAM flap and donor site, and minor complications of the TRAM flap and the chest wall. The number of bilateral breast reconstructions in this series was too small to allow reliable statistical analysis. If the bilateral reconstructions are considered as one group (immediate and delayed), the incidence of complete TRAM flap loss was one out of 6 flaps (6%), which is in line with the rate of complete TRAM flap loss in patients undergoing unilateral reconstruction in this series and in other published series. 4d9 The incidence of abdominal hernia or bulge (one out of eight patients, 2.5.%) is significantly higher than in unilateral reconstructions, and presumably reflects the bilateral harvesting of the rectus muscle. A larger series of bilateral reconstructions would be required to derive any reliable conclusions. Analysis of the complications affecting the chest-wall flaps revealed a 6% incidence of partial necrosis of the chest-wall flaps in the immediate group compared with % in the delayed group. This difference was statistically significant (P=.7). In most of the cases where this complication occurred no further surgery was required, and healing occurred with dressings only. As a result of this problem, we have modified our pattern of skin conservation during the mastectomy in immediate reconstructions: we now avoid flaps with a relatively acute angle at the tip, and excise relatively more skin from the chest wall. Furthermore, great care is taken to avoid damage to the chest-wall skin during the mastectomy. From this study, it can be concluded that immediate free TRAM breast reconstruction is not associated with a higher postoperative morbidity than delayed reconstruction, apart from the 6% risk of partial chest-wall mastectomy flap necrosis. Acknowledgements We would like to acknowledge Dr Giles Thomas, Statistics Research Support Unit, Department of Mathematics, University of Dundee, Dundee, UK, for his statistical advice, and clinical and nursing colleagues for contributing patients. References. Petit JY, Rietjens M, Ferreira MAR, Montrucoli D, Lifrange E, Martinelli P. Abdominal sequelae after pedicled TRAM flap breast reconstruction. Plast Reconstr Surg 997; 99: Kroll SS. Why autologous tissue? Clin Plast Surg 998; 25: Kroll SS, Evans GRD, Reece GP, et al. Comparison of resource costs between implant-based and TRAM flap breast reconstruction, Plast Reconstr Surg 996; 97: Schain WS, Wellisch DK, Pasnau RO, Landsverk J. The sooner the better: a study of psychological factors in women undergoing immediate versus delayed breast reconstruction. Am J Psych 985; 42: Wellisch DK, Schain WS, Noone RB, Little JW IlL Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg 985; 76: Dean C, Chetty U, Forrest APM. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet 983; : Stevens LA, McGrath MH, Druss RG, Kister S J, Gump FE, Forde KA. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg 984; 73: Rosenqvist S, Sandelin K, Wickman M. Patients' psychological and cosmetic experience after immediate breast reconstruction. Eur J Surg Oncol 996; 22: Miller MJ. Immediate breast reconstruction. Clin Plast Surg 998; 25: Kroll SS, Coffey JA Jr, Winn RJ, Schusterman MA. A comparison of factors affecting aesthetic outcomes of TRAM flap breast reconstructions. Plast Reconstr Surg 995; 96: Elliott LF, Hartrampf CR Jr. Breast reconstruction: progress in the past decade. World J Surg 99; 4: Elkowitz A, Colen S, Slavin S, Seibert J, Weinstein M, Shaw W. Various methods of breast reconstruction after mastectomy: an economic comparison. Plast Reconstr Surg 993; 92: Khoo A, Kroll SS, Reece GP, et al. A comparison of resource costs of immediate and delayed breast reconstruction. Plast Reconstr Surg 998; :

6 6 British Journal of Plastic Surgery 4. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 2; 5: Deutsch MF, Smith M, Wang B, Ainsle N, Schusterman MA. Immediate breast reconstruction with the TRAM flap after neoadjuvant therapy. Ann Plast Surg 999; 42: Zimmerman RP, Mark RJ, Kim AI, et al. Radiation tolerance of transverse rectus abdominis myocutaneous-free flaps used in immediate breast reconstruction. Am J Clin Oncol 998; 2: , Moran SL, Serletti JM, Fox I. Immediate free TRAM reconstruction in lumpectomy and radiation failure patients. Plast Reconstr Surg 2; 6: Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg 994; Harndi M, Weiler-Mithoff EM, Webster MHC. Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 5 flaps. Plast Reconstr Surg 999; 3: Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plast Reconstr Surg 2; 6: Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps, Plast Reconstr Surg 2; 6: Kroll SS, Gherardini G, Martin JE, et al. Fat necrosis in free and pedicled TRAM flaps. Plast Reconstr Surg 998; 2: The Authors Raymond DeBono MD, MSc, FRCSEd, FRCS(Gias), Specialist Registrar in Plastic Surgery J. Howard Stevenson MD, FRCSEd, Consultant Plastic Surgeon Department of Plastic Surgery Alastair Thompson MD, FRCS, Senior Lecturer and Consultant Surgeon Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD 9SY, UK. Correspondence to Mr Raymond DeBono. Paper received 8 May 2. Accepted 25 October 2, after revision.