Prophylactic Mastectomy & Reconstructive Implications
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1 Prophylactic Mastectomy & Reconstructive Implications Minas T Chrysopoulo, MD PRMA Center For Advanced Breast Reconstruction
2 Prophylactic Mastectomy Surgical removal of one or both breasts to reduce the risk of developing breast cancer 90% risk reduction in high risk patients Hartmann (New Engl J Med, 1999): Moderate-Risk Group (FH) 89% reduction in breast cancer occurrences 100% reduction in breast cancer deaths High-Risk Group (strong FH, genetic component) 90% reduction in breast cancer occurrences 81% to 94% reduction in breast cancer deaths
3 Candidates Personal breast cancer history Genetic susceptibility eg BRCA, Li-Fraumeni, Cowden s Strong family history mother, sister, daughter, <50 yrs LCIS increased risk of invasive disease Chest XRT before <30 yrs Breast changes widespread calcifications, dense breasts, multiple biopsies
4 Prophylactic Mastectomy Rates Rising trend in CPM Institutional & national Tuttle, et al (J Clin Oncol, 2007) stage I-III 4.2% 11.0%, Young patient age, white race, lobular histology, and previous cancer diagnosis Tuttle, et al (J Clin Oncol, 2009) DCIS 6.4% 18.4%, Young age, white race, recent year of diagnosis, LCIS
5 Prophylactic Mastectomy Rates Rising trend in CPM Sorbero, et al (Ann Surg Oncol, 2009) Stage 0 III, U Pittsburgh Pre-op MRI doubled rate (4.7% vs 9.2%) King, et al (J Clin Oncol, 2011) Stage 0 III, Sloan-Kettering 6.7% 24.2%, % of pts = BRCA or mantle XRT Independent predictors: white race, immediate breast reconstruction, FH, MRI at diagnosis, age <50 yrs, noninvasive histology, failed attempt at breast conversation
6 Prophylactic Mastectomy Rates Rising trend in BPM No current breast cancer diagnosis 9% 17% of candidates Angelina Jolie effect Majority of patients seek immediate breast reconstruction
7 Patient Factors Frost, et al (JAMA, 2000) 639 cancer-free women, , Mayo Clinic High risk vs moderate risk Retrospective, study-specific questionnaire Reasons for choosing BPM 98% >1 reason Family history (93% vs 60%) Physician advice Nodular breasts Worrisome biopsies Psychological/emotional concerns
8 Patient Factors Outcomes Mean 14.5 yrs post-op 70% satisfied/very satisfied with results 19% dissatisfied/very dissatisfied 67% would have the surgery again Strongest correlation with high satisfaction: perceived improved body appearance (r= 0.49; P<.001) improved self-esteem (r= 0.38; P<.001) limited impact on sexual relationships (r= 0.32; P<.001) lower level of stress in life (r= 0.27; P<.001) Dissatisfaction associated with: physician advice as primary reason for surgery
9 Patient Factors Frequency of psychological and social outcomes:
10 Prophylactic Mastectomy Options Mastectomy Parenchyma NAC Skin envelope Total / Simple Removed Removed Removed Skin-sparing (SSM) Removed Removed Preserved Nipple-sparing (NSM) Removed Preserved Preserved Proven oncologic safety Lymph node surgery (incl. SLNB x ) not indicated Keys to cosmesis if reconstruction planned: limited incisions skin envelope preservation coordinated team approach
11 Variable Scarring Total SSM NSM (subcutaneous)
12 Prophylactic Mastectomy Risks Immediate risks of surgery skin flap/nac necrosis Loss of sensation Inability to breastfeed Breast cancer
13 Reconstructive Goals What do patients want? age family status activity natural vs enhanced Short time to completion Low complication rates immediate long-term Longevity of reconstruction
14 Reconstruction Timing Immediate same time as SSM / NSM Delayed any time after mastectomy Immediate reconstruction usually far preferable psycho-social impact cosmesis # of procedures Typically 2 procedures
15 Reconstruction Options Implants + biologic matrix staged (expanders) direct-to-implant ( One-Step ) Tissue back flap Latissimus dorsi abdominal flap DIEP / SIEA / TRAM buttock flap SGAP / IGAP thigh flap TUG / PAP fat grafting
16 Reconstruction Risks Inability to perform reconstruction Reconstructive failure Multiple procedures Revision surgery (implants)
17 Implant Reconstruction Most common method nationally Typically at least 2-stages (tissue expander) biologic matrix, eg: Alloderm, FlexHD cadaveric Strattice porcine expansion process expander/implant exchange ± fat grafting ± nipples Direct-to-implant Alloderm One-Step avoids expansion process 5% revision rate in best candidates
18 Implant Reconstruction Pros Short surgery Recovery One surgical site Enhancement Local surgeons Cons Ripples Capsular contracture Cold Breast animation Revision surgery
19 One or two-stage Creation of a sling Support / stability / coverage Re-define IMF / shaping Any incision lateral ± peri-areolar IMF Biologic Matrix
20 2-Stage Implant + Fat Grafting Before After
21 2-Stage Implant + Fat Grafting Before After
22 One-Step Candidates BPM patients only Nipple-sparing mastectomy No or minimal breast ptosis No previous breast / chest radiation BMI need for fat grafting? Co-morbidities Smoking
23 BPM & Alloderm One-Step Before After
24 BPM & Alloderm One-Step Before After
25 Autologous Tissue Reconstruction Pros Blood supply Natural, warm Durability Forgiving (mastectomy flaps) Donor site Cons *Technical training, team Morbidity Donor site Recovery Reimbursement Pedicled flaps Latissimus, TRAM *Microsurgery DIEP, SIEA, GAP, TUG, PAP Fat grafting
26 Perforator Flap Reconstruction DIEP SIEA GAP TUG
27 DIEP Flap Deep Inferior Epigastric Perforator Gold standard Evolution of the TRAM lower abdominal fat and skin only, NO muscle sacrifice Preferred reconstruction method if adequate tissue reliable natural donor site >500 flaps per year, <1% flap failure rate
28 DIEP & SIEA Flap
29 Candidates Previous abdominal surgery? abdominoplasty c-section NOT contraindication scars pencil doppler, CTA Comorbidities DM HTN Obesity Pro-thrombotic conditions / family history DVT Smoking
30 Multiple stages Stage 1 Reconstruction 2 microsurgeons DIEP Flap Surgery Stage 2 Revision surgery breast symmetry fat grafting nipple reconstruction abdominal contouring scar revision Stage 3 Nipple-areola micropigmentation
31 Sensory Nerve Reconstruction Sensory nerve included with flap
32 Flap Transplant to Chest
33 DIEP Donor Site Advantages Improve abdominal contour Preserve rectus innervation Unlike TRAM flap, low risk bulge/hernia (1% vs 16%) Before After
34 BPM (NSM), L DIEP, R Implant Before After
35 BPM & DIEP Flaps Before After
36 L IDC, B SSM & DIEP flaps Before After
37 R IDC, B NSM & DIEP Flaps Before After
38 Recurrent R IDC, B SSM & DIEP Flaps Before After
39 R delayed, CPM & DIEP Flaps Before After
40 Fat Grafting Very useful adjunct Enhanced Oncologic safety?
41 Conclusions Prophylactic mastectomy is on the rise Positive outcomes: High patient satisfaction Decreased emotional concern about developing breast cancer Favorable psychological and social outcomes Many reconstructive options: Immediate reconstruction offers excellent cosmetic results Specialized, coordinated team approach crucial for perforator flap procedures Evolving field stem cells
42 Thank You Minas T Chrysopoulo, MD PRMA Center For Advanced Breast Reconstruction Facebook.com/PRMAplasticsurgery Breast-Cancer-Reconstruction.blogspot.com
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