Breast Reconstruction: Current Strategies and Future Opportunities Hani Sbitany, MD Assistant Professor of Surgery University of California, San Francisco Division of Plastic and Reconstructive Surgery 11 th Annual School of Breast Oncology 2013 Atlanta, Georgia November 8, 2013
Repair of Partial Mastectomy Defects with Oncoplastic Surgery
SOBO 2012 Presentation
SOBO 2012 Presentation
Oncoplastic Reconstruction Effects of Timing on Complication Rates All Reconstruction following Partial Mastectomy Immediate Reconstruction Before XRT Delayed Reconstruction after XRT 30% 26% 42% Kronowitz, SJ, et.al. Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg. Jan. 2006.
Techniques for Oncoplastic Surgery Local Tissue Rearrangement B to C cup breast Small tumor Grade 1 ptosis No skin resection Oncoplastic Reduction Mammoplasty C to D cup breast Grade 2 to 3 ptosis Some skin resection Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial Mastectomy Defects. PRS 2008.
Local Tissue Rearrangement Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial Mastectomy Defects. PRS 2008.
Local Tissue Rearrangement
Oncoplastic Reduction Mammoplasty -Use of neoadjuvant chemotherapy -Breast conservation therapy (BCT) Indications - Minimal Skin Resection or Tumor within Wise Pattern - C-Cup Breast Size with ptosis or Small Tumor - D-Cup Breast size -Oncoplastic mammoplasty -Extends BCT option -Improved cosmetic results -Minimizes adverse effects of XRT SOBO 2012 Presentation
Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial Mastectomy Defects. PRS 2008.
Review of prospectively-maintained surgical outcomes database Locally advanced breast cancer - Neoadjuvant chemotherapy - Post-operative radiation therapy Oncoplastic mammoplasty (N = 37) Mastectomy with immediate breast reconstruction (N = 64) Two-stage TE (N = 40) Autologous (N = 24) Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California. October 12, 2013.
Patients Oncoplastic mammoplasty (N = 37) Mastectomy/reconstruction (N = 64) Mean age 52.3 years 45.5 years Mean BMI 29.2 kg/m 2 25.2 kg/m 2 Diabetes 2 (5.4%) 1 (1.6%) Tobacco use 1 (2.7%) 0 Tumor stage I 0 0 II 20 (54.1%) 29 (45.3%) III 14 (37.8%) 33 (51.6%) IV 3 (8.1%) 2 (3.1%) Median follow-up 32 months (4 116) 30.5 months (8 74) Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California. October 12, 2013.
Oncologic Outcomes Recurrence-free survival P = 0.29 Oncoplastic mammoplasty Mastectomy/reconstruction Cancer-specific survival P = 0.27 Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California. October 12, 2013. Oncoplastic mammoplasty Mastectomy/reconstruction
Complications 50 40 30 20 10 0 19% 45% 3% 38% 11% 30% ** 16% 36% 5% 8% Oncoplastic mammoplasty Mastectomy/reconstruction Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California. October 12, 2013.
Conclusions Oncoplastic Reduction Oncoplastic mammoplasty with equivalent oncologic safety and fewer complications in setting of neoadjuvant chemo and PMRT Early evaluation by plastic surgeon/multi-disciplinary approach Role in pre-operative patient counseling/decision-making Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California. October 12, 2013.
Treatment Algorithm Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California. October 12, 2013.
Oncoplastic Reduction Mammoplasty
Breast Reconstruction After Mastectomy
Immediate Reconstruction
Immediate Reconstruction SOBO 2012 Presentation
Delayed Reconstruction
Implant-Based Breast Reconstruction Two-Stage Implant One-Stage Implant
Two-Stage Breast Reconstruction Tissue Expander Followed By Permanent Implant
Two-Stage Breast Reconstruction Tissue Expander Followed By Permanent Implant
Two-Stage Implant Example of Outcome
Two-Stage Implant: 2 nd Stage Additional Enhancements ADM: Acellular Dermal Matrices
Acellular Dermal Matrix
Autologous Fat Grafting
Microsurgical Breast Reconstruction
TRAM/DIEP Flap Breast Reconstruction
Pedicled TRAM Flap
Free (Microvascular) TRAM Flap
Free & Pedicled TRAM Flap ABDOMINAL DONOR SITE
VARIATIONS ON BLOOD SUPPLY TO FLAP Muscle Sparing Free TRAM Flap
Perforator Flaps DIEP: Deep Inferior Epigastric Perforator Flap GAP: Gluteal Artery Perforator
Abdominal Wall Perforators
Abdominal Wall Perforators
Deep Inferior Epigastric Perforator
Deep Inferior Epigastric Perforator (DIEP) Flaps SOBO 2012 Presentation
Case Example: DIEP Flap SOBO 2012 Presentation
Redesigned GAP Flap Kronowitz, SJ. The Gluteal Artery Perforator Flap Re-designed for Breast Reconstruction. PRS, March 2008.
Case Example: Redesigned GAP flap SOBO 2012 Presentation
Case Example: Redesigned GAP flap SOBO 2012 Presentation
Total Skin Sparing Mastectomy
UCSF Data, January 2012 January 2013 Sbitany H, Foster RD, et al. Outcomes Comparison of Techniques for Tissue Expander Coverage Following Total Skin Sparing Mastectomy: A One-Year Institutional Experience. Submitted for Publication. 47
Outcomes after total skin-sparing mastectomy and immediate reconstruction: A 12-year experience Anne Warren Peled, MD Frederick Wang, MD Eric Wang, MD Robert D. Foster, MD Laura J. Esserman, MD, MBA Hani Sbitany, MD
Total skin-sparing mastectomy Preservation of entire breast skin envelope with excision of nipple-areolar complex (NAC) tissue Benefits Aesthetic Psychological
Purpose Review 12-year experience with nipple-sparing mastectomy (NSM) and immediate reconstruction -Oncologic outcomes -Surgical complications
Methods Prospectively-maintained database of TSSM and immediate reconstruction (2001-2012) Outcomes Tumor recurrence -Local-regional -NAC Post-operative complications -NAC necrosis -Mastectomy skin flap necrosis
Tumor characteristics Total patients 599 Total cases 924 Indication for mastectomy Therapeutic 604 (65.4%) Prophylactic 320 (34.6%) Contralateral 60% Bilateral 40% Tumor stage In situ 148 (16%) Stage I 204 (22.2%) Stage II 162 (17.5%) Stage III 84 (9.1%) Stage IV 6 (0.6%) Prophylactic 320 (34.6%)
Treatment characteristics Chemotherapy Any 294 (49%) Neoadjuvant 195 (66%) Adjuvant 99 (34%) Radiation therapy Any 181 (20%) Prior history 67 (37%) Post-mastectomy 114 (63%)
TSSM incisions Preferred No longer recommended Inframammary Radial Lateral/ Inferolateral Mastopexy Type Circumareolar/ Free Graft NAC Crossing Involving < 30% of the NAC Involving > 30% of the NAC 100% IMF 80% Radial 60% Lateral 40% Mastopexy (< 30% of NAC) 20% Mastopexy (>30% of NAC) 0% 1st 100 cases Next 557 cases Free graft NAC crossing
Reconstructions performed Immediate permanent implant Transverse rectus abdominis myocutaneous (TRAM) flap Microvascular (abdominal, gracilis) Two-stage expander-implant 100% 80% Immediate implant 60% 40% TRAM flap 20% 0% 1st 100 cases Next 557 cases Microvascular 2-stage expander-implant
Ischemic complications 20% 1st 100 cases Next 557 cases 15% Latest cohort 10% 5% 0% Nipple necrosis (partial or complete) Skin flap necrosis
Local-regional recurrence N Local recurrence, n (%) All patients (median followup: 28 months) Total Invasive cancer In situ cancer 412 301 111 8 (1.9) 5 (1.7) 3 (2.7) Patients with minimum 36 months follow-up (median: 45 months) Total Invasive cancer In situ cancer 126 95 31 3 (2.4) 2 (2.2) 1 (3.2) No recurrences in the NAC
Distant recurrence N Distant recurrence, n (%) All patients (median followup: 28 months) Total Invasive cancer In situ cancer 412 301 111 12 (2.9) 11 (3.7) 1 (0.9) Patients with minimum 36 months follow-up (median: 45 months) Total Invasive cancer In situ cancer 126 95 31 2 (1.6) 2 (2.2) 0 (0)
Conclusions Low rates of local-regional recurrence No recurrences in the NAC Low rates of ischemic complications Targeted technical improvements -Incisions avoiding NAC -Minimal pressure on NSM skin flaps --2-stage tissue expander reconstruction --Delayed autologous reconstruction
Thank You