Current Strategies in Breast Reconstruction

Current Strategies in Breast Reconstruction Hani Sbitany, MD Assistant Professor of Surgery University of California, San Francisco Division of Plastic and Reconstructive Surgery 12 th Annual School of Breast Oncology Atlanta, Georgia November 7, 2014

Repair of Partial Mastectomy Defects with Oncoplastic Surgery

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 Indications - Minimal Skin Resection or Tumor within Wise Pattern - C-Cup Breast Size with ptosis or Small Tumor - D-Cup Breast size therapy (BCT) -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.

20(3), 2014; 302-307 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)

20(3), 2014; 302-307 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)

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 Bilateral DIEP free flaps

Delayed Reconstruction

Implant-Based Breast Reconstruction Two-Stage Implant One-Stage 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

Plast Reconstr Surg. 134: 396, 2014

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

Perforator Flaps DIEP: Deep Inferior Epigastric Perforator Flap GAP: Gluteal Artery Perforator

Abdominal Wall Perforators

Deep Inferior Epigastric Perforator

Deep Inferior Epigastric Perforator (DIEP) Flaps SOBO 2012 Presentation

Case example: DIEP flap SOBO 2012 Presentation

Autologous Tissue + PMRT

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

Total Skin Sparing Mastectomy

Annals of Plastic Surgery. Accepted for Publication - In Press. Epub ahead of print, 2014 Jul 23.

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

Expanded Experience Plast Reconstr Surg. 134: 396, 2014 Plast Reconstr Surg. 134: 169, 2014

FIGURE 1. Complication rates for inframammary fold incisions (IMF) compared to all other types of incisions * Plast Reconstr Surg. 134: 169, 2014 35% 30% 25% 20% 15% 10% 5% 0% 21.0% 21.0% Incisional breakdown p=0.2 10.3% 10.3% Unplanned OR for incisional breakdown p=0.2 11.3% 0.0% Implant loss due to incisional breakdown p=0.06 29.0% 17.2% Significant infection p=0.2 11.3% 6.9% Implant loss from infection p=0.5 0.0% 0.0% NAC necrosis p=1.0!!! Inframammary Fold Incision (IMF) All Other Incision Types * Review * Other of incision prospectively-collected types includes sub-areolar, radial, lateral, complications circumareolar incisions database of TSSM/expanderimplant reconstruction from 2005-2012 Compared IMF incision to all incisions in non-dependent areas of breast

Expanded Experience Effects of Hormonal and Anti-HER Therapy No Hormonal (n=342) Hormonal (n=425) P-value Chi-Square Wound Breakdown 26 (8%) 42 (10%).3 Infections PO Antibiotics 35 (10%) 78 (18%).002 IV Antibiotics 33 (10%) 52 (12%).3 Procedure 18 (5%) 35 (8%).1 Implant Exposure 14 (4%) 21 (5%).6 Implant Loss 24 (7%) 31 (7%).9 Overall Complications by hormonal therapy (n=767) Wang F, Peled A, Alvarado M, Ewing C, Fowble B, Esserman L, Foster R, Sbitany H. The Impact of Hormonal and Anti-HER Therapy on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Reconstruction. Plast Reconstr Surg. Submitted for Publication

Expanded Experience Effects of Hormonal and Anti-HER Therapy No Anti-HER (n=675) Anti-HER (n=92) P-value Chi-Square Wound Breakdown 63 (9%) 5 (5%).2 Infections PO Antibiotics 102 (15%) 11 (12%).4 IV Antibiotics 78 (12%) 7 (8%).3 Procedure 48 (7%) 5 (5%).6 Implant Exposure 31 (5%) 4 (4%).9 Implant Loss 48 (7%) 7 (8%).9 Overall Complications by anti-her therapy (n=767) Wang F, Peled A, Alvarado M, Ewing C, Fowble B, Esserman L, Foster R, Sbitany H. The Impact of Hormonal and Anti-HER Therapy on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Reconstruction. Plast Reconstr Surg. Submitted for Publication

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