Plastic Reconstructive Aspects after Mastectomy
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1 Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer Plastic Reconstructive Aspects after Mastectomy
2 Plastic Reconstructive Aspects after Mastectomy Version 2002: Brunnert Version : Audretsch / Blohmer / Brunnert / Dall / Fersis / Hanf / Nitz / Rezai / Scharl Version 2010: Brunnert / Thomssen
3 Definition and Considerations Oxford LoE: 3b GR: B AGO: ++ Type of reconstruction uni- / bilateral: Total breast reconstruction (BR) after MRM Immediate or delayed Total BR after SSM Considerations: Individual cancer or patient associated risk factors (LOE 1c A, AGO: ++) Patient s preference Medical and institutional qualifications Concomitant anti-angiogenesis therapy Radiotherapy planned or in medical history
4 Postmastectomy Implant Reconstruction Oxford / AGO LoE / GR Use of silicone filled breast implants (no systemic health hazards documented, no influence on DFS and detection of recurrence) 2a B + Implant reconstruction (IR) 2a B + IR without radiotherapy (RT) 2a B ++ IR following RT 2a B +/- IR prior to RT 2a B +/- IR following secondary Mx 2a B +/-
5 Postmastectomy Implant Reconstruction Considerations Cost effective Bilateral procedure can improve cosmetic result Achievement of shape and symmetry easier with permanent expander implant Oxford / AGO LoE / GR Independent of age 3b C +/- Mesh- or acellular dermis assisted prostetic subpectoral BR provides better permanent implant coverage 2b B + Lipofilling can be helpful 3b C +/- Immediate reconstruction has a higher rate of complications 2b B
6 Radiotherapy after Implant Breast Reconstruction Tallet AV Author Int J Radiat Oncol 2003 Patient satisfaction 60% acceptable Failure Complications 14% vs. 51,0% p=0,006 Observation period Pts. RT/CTR /77 Cordeiro PG n.s. p=0, /606 PRS 2004 acceptable CC (68% vs. 40%) Mc Carthy PRS % satisfied no Baker IV 40% no difference 50% 1 Baker grade up 10% 2 Baker grades up FU 23,5 mths Cordeiro PG PRS % pts. satisfied 49,3% no CC prospective 71/410 Behranwala JPRAS % free of CC after 4 years CC p<0.001 (38,6% vs. 14,1%) 2-5 years 44/92br Benedikktson K Reop. n=16 CC p= years 24/83 JPRAS 2006 free of CC after 5 years (41,7% vs. 14,5%)
7 Postmastectomy Pedicled Flap Reconstruction Reconstruction (BR) with autologous living tissue ( natural breast) TRAM, latissimus-dorsi-flap (can be performed as a muscle-sparing technique) 3b C + Delayed TRAM in risk patients 3a B + Radiotherapy: Oxford / AGO LoE / GR BR following RT 4 C + BR prior to RT 3b C +/- (dependent on quality of blood supply) Prophylaxis of DVT using low-dose heparin 2a B ++ Need of sufficient pain management 1b B +
8 Free Tissue Transfer Oxford / AGO LoE / GR Free tissue transfer 3b B + Free TRAM-flap DIEP-flap SIEA-flap 4 C +/- SGAP- / IGAP-flap Free gracilis flap (TMG) 4 C +/- Advantage: Free TRAM and DIEP are potentially muscle sparing procedures Disadvantages: Time- and personnel-consuming microsurgical procedure Intensified postoperative monitoring Higher rate of re-operations Higher total failure rate
9 Flap-Implant Combination Oxford / AGO LoE / GR Flap-implant combination 4 C + TRAM, LDF + implant IR following RT 3b C + IR prior to RT 5 D - Advantages: Improved implant coverage Suitable for radiated tissue Disadvantage: Muscle contraction (LDF) *LDF = Latissimus dorsi-flap
10 Timing of Breast Reconstruction Delayed BR 3b B ++ No interference with adjuvant procedures (CHT, RT) Disadvantage: loss of skin envelope Oxford / AGO LoE / GR Immediate BR 3b B ++ Preferential in combination with partial Mx (BCT) Obligatory: SSM Avoidance of a postmastectomy syndrome Delayed-immediate BR 3b B +/-
11 Skin Sparing Mastectomy (SSM) and Reconstruction Skin sparing mastectomy Oxford / AGO LoE / GR Safe (same recurrence rate as MX) 2b B ++ Higher QoL for patients 2b B ++ NAC can be preserved under special conditions 2b B + Skin incisions different options possible: Periareolar ( purse-string ) Hockey-stick : partially periareolar and horizontal Reduction pattern: inverted-t or vertical Inframammary fold
12 SSM / Nipple SM Author Kang S-H 2009 SABC (Abstract) Cases reported 202 NASM 133 Partial skin necrosis Local recurrence -- 8,9% NASM 6% SSM (n.s.) Time period Mean FU 67,6 mths Niemeyer M 2009 SABC (Abstract) 109 NASM % Mean FU 34 mths Chen CM 2009 PRS 115 (62 benign) Loss of NAC: 5.2% Occ.ca. 3.5% Necrosis Garwood ER 2009 Ann Surg 170 Cohort 1: 16% Cohort 2: 11% 0,6% Yano K et al Breast Cancer 128 3,1% 2,3% Petit JY et al Breast Cancer Res Treat 106 NSM 4,7% Loss of NAC 0,9% Far from NAC Gerber B et al Ann Surg 112 (Incl.61 NSM) 0% 5,4% Carlson GW et al Surg Oncol ,5%
13 Bilateral Prophylactic Mastectomy (BPM) Oxford / AGO LoE / GR BPM reduces breast cancer incidence 1b A ++ BPM in deleterious BRCA1/2 mutation 2a B +* BPM in high risk (i.e. lifetime risk >=30% or heterozygote risk >=20%) but index case negative for BRCA1/2 mutations 3a C +/-* High risk and no BRCA counselling in specialized centre* (list in chapter 15, slide 4) 5 D - - Non-directive counselling prior to BPM 2b B ++* BPM should be considered with other prophylactic surgical options incl. salpingoophorectomy (BSO) 2a A ++* *Counselling, risk predicton and follow-up in Familial Breast and * Ovarian Study participation Cancer Centres recommended
14 Types of Prophylactic Mastectomy Oxford / AGO LoE / GR Prophylactic bilateral mastectomy reduces breast cancer incidence; bc-spec mortality reduction likely Simple mastectomy 2b B +* Prophylactic SSM 2b C +/- Prophylactic s.c. MX (areola sparing) 2b C +/- Prophylactic s.c. MX (NAC sparing) 4 C +/- * Study participation recommended * Study participation recommended
15 DIEP-Flap (1)
16 DIEP-Flap (2) Author Cases reported Complete loss of flap Liponecrosis partial flap loss Hernias/ Bulges in donor region Munhoz AM et al 2007 Breast J (on DIEP and SSM) 30 3,7% 7,4% 3,7% Lindsey JT PRS Hofer SO et al Ann Plast Surg 140 6,4% ,6% 8,6% -- Peeters WJ 2009 PRS 202 n.a. 49% Clinical 14% US 35% n.a. Selber JC 2010 PRS ftram 569 DIEP 97 0,2% 1,0% n.s. 4,1% 2,1% n.s. 1,9% 0 n.s.
17 Pedicled / Free TRAM Author Watterson PA, Bostwick J PRS Kroll SS (f-tram) 2000 PRS Lacotte B, Lejour M 1994 Ann Chir Plast Esthet Clugston PA, Maxwell GP 2000 PRS Petit JY, Rietjens M 1997 Ann Chir Plast Esthet Reported cases Complete loss of flap Liponecrosis Hernias in donor region ,6% 8,8% 279 0,4%(1,1%) 15,1% % ,1% 5,8% 251 7% Rezai M unpublished ,2% 0,8% Brunnert 2001 unpublished ,4% 0,4% Kim EK 2009 Ann Plast Surg 500 major fl. 0,2 % 14,2% 3% (bulges) Chun YS 2010 PRS 105 biped, 0 11,4% 2,9%
18 Radiotherapy after Autologous Reconstruction Author Patient satisfaction Failure complications Observation period Pts. RT/CTR Williams JK 1997 PRS unchanged nature of complications changes from fat necrosis to fibrosis /680 Soong IS 2004 Clin Oncol (Radiol) cosmesis 85% good to excellent no difference /-- Mehta VK 2004 Breast no problems 10% skin desquam. 30% grade 2 erythema /-- Huang CJ fat fibrosis / PRS 8% n.s. Kronowitz SJ 2009 PRS Radiation Therapy and BR: A critical review of the literature > Articles reviewed
19 Algorithm of Breast Reconstruction *Brunnert, K. Gyn. Prax., Band 31, 2007
20 Algorithm of Autologous Breast Reconstruction (1)
21 Algorithm of Autologous Breast Reconstruction (2) (MS-2) Double MS-2 ptram or Free TRAM (MS-2) Bip TRAM (MS-2) ftram DIEP
22 Algorithm of Implant Breast Reconstruction Reduction pattern + perm. Exp./ Implantat
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