How many procedures to make a breast?

British Journal of Plastic Surgery (00 ), 5, 7-3 9 00 The British Association of Plastic Surgeons doi: 0.05/bjps.000.3538 BRITISH JOURNAL OF PLASTIC SURGERY How many procedures to make a breast? A. D. Malyon, M. Husein and E. M. Weiler-Mithoff Plastic Surgery Unit, Canniesburn Hospital, Glasgow, UK SUMMARY. The construction of a new breast after mastectomy involves fashioning the breast mound and creating a projecting nipple and a coloured areola. This should involve three episodes for a patient, but is this the experience of patients embarking on breast? We identified 77 patients who had undergone breast between September 997 and 3 March 999. The clinical records for 6 of these patients were found and the data summarised. The techniques, complications and other ancillary procedures experienced by this group of patients are presented. Multiple procedures are likely to be required to complete breast, and the patient should be so counselled from the outset. Particular problems may be encountered with each technique and this should be borne in mind when selecting a procedure for each patient, especially in the context of immediate where avoiding any delay to adjuvant treatment is a consideration. 9 00 The British Association of Plastic Surgeons Keywords: breast, nipple, complications. The demand for breast after mastectomy appears to be increasing dramatically: only breast s were performed at Canniesburn Hospital in 987 against the much larger number found in this study. The procedures involved are not all straightforward, can give a variable quality of outcome and may have complications. In order to improve the counselling of patients considering this type of surgery we have reviewed all breast s performed in both the Plastic Surgery unit and the General Surgical units between September 997 and 3 March 999. In total, 77 cases of breast were identified and the records for 6 of these were obtained for review. The practice of this unit is to offer using an implant alone (placed in the submuscular plane), an implant with a flap, an autologous flap or free tissue transfer (usually from the abdomen, based on either the superficial or deep inferior epigastric vessels, sparing muscle where possible). The final choice of reconstructive method will depend upon the likelihood of postoperative radiotherapy, the general fitness of the patient for surgery, the availability of the techniques in a particular patient and the personal preference of the patient. Surgery to the contralateral breast is usually planned at the initial consultation but may also be discussed and held for a later date according to the patient's wishes. The timing of surgery is decided in conjunction with the general surgeon and the patient. The venue for the surgery may be the General Surgical unit or the Plastic Surgical unit, depending on the timing and type of surgery involved and is decided jointly with the general surgeons. The mechanism for referral of cases for consideration for immediate is via an 'immediate-access breast clinic'. This clinic runs on a weekly basis and offers a 'next clinic' appointment when any general surgeon refers a patient considering an immediate. Once the patient has been seen, detailed planning of where the surgery will be performed and which personnel will be required can proceed. It is normal practice to perform surgery within weeks of the breastclinic appointment. Nipple is offered to all patients once construction of the breast mound is complete and a period of around 3-6 months has passed to allow gravity to act on the new breast. Plastic nipples with adhesive, nipple sharing and local flaps with tattooing are offered. Methods Identification of cases Breast s performed at the Plastic Surgery unit were identified from the hospital coding database by trawling for procedures coded as either breast or nipple. The coding of cases is performed by the operating surgeon, all case notes pass through the coding department at the end of a patient episode and the codes for breast and nipple should therefore prove sufficient to identify all cases. For procedures performed away from the Plastic Surgery unit, a second hospital database was used. This database relies on the surgeon returning from a procedure performed elsewhere recording the details of the case. This database is therefore regarded as more likely to return incomplete data but still represents the simplest method of retrieving this data. In all, 77 cases of breast were identified during the study period. Only breast s commenced during this period were included in the study; s already were excluded. Details of all cases were then recorded in a PC database (MS Access) and analysed using MS Excel. 7

8 British Journal of Plastic Surgery Table Category minor moderate severe patient request Definitions of categories of complication Definition no record of any adverse event adverse event not requiting any surgical intervention adverse event requiring surgical intervention complete loss of patient requests surgical adjustment of or opposite breast Table 3 Uptake of nipple (expressed as a percentage) broken down by type of flap Autologous Awaited Not needed Not wanted Total 38.3 5..3 6. 00.0 dorsi 6.0.0 6.0 6.0 00.0 0.0 6.0 8.0 6.0 00.0 0.0 80.0 0.0 0.0 00.0 33.3 66.7 0.0 0.0 00.0 6.7 50.0 6.7 6.7 00.0 all flaps 6.8 8. 9.8 5. 00.0 Table Summary of type of surgery and mean age of patients Flap Mean age Flap Implant Implant Total (years) only flap only* 3.70 7 7 dorsi 8.78 3 9 50 5.33 50 50 37.00 5 5 3.50 6 6.33 6 6 all flaps 5.8 95 9 50 6 *All implants were placed submuscularly. r Table Breakdown of complications by procedure (expressed as percentages) s (%) Flap None Minor Moderate Severe Patient Total request 3. 3. 36. 0.0 7.0 00.0 dorsi 3.0 36.0 8.0.0 8.0 00.0 (implant only) 50.0.0 6.0 8.0.0 00.0 0.0 0.0 0.0 60.0 0.0 00.0 6.7 33.3 33.3 0.0 6.7 00.0 0.0 6.7 66.7 0.0 6.7 00.0 Total 33.5 0.7.0 8.5 5. 00.0 Classifications used The only data that required classification in order to facilitate data analysis were those regarding postoperative complications. It was decided to use a simple classification that reflected the effect of the complication on the patient and her. Definitions of the categories are listed in Table. The 'patient requests' category was included as this was seen as an event leading to a further surgical episode. Results We identified 77 cases of breast, and the notes for 6 of these were found. The mean age of patients undergoing was 5.8 years (range: 7-7 years). Immediate s accounted for 0 cases, and 66 patients were treated at the referring unit rather than the Plastic Surgery unit (all were immediate s). The mean follow-up was 0 months (range: -9 months). There appears to be a trend towards immediate over the study period. In the first six months of the study period 55% of the s were immediate, rising to 57% and then to 75% in the two following periods. Of the 6 s, were performed after mastectomy for established breast cancer, with a further following prophylactic mastectomy, the remainder being for congenital problems. The initial referral was from the general surgeon in 36 cases, with a further 3 from the oncologist. Six referrals were also seen from the breast-care nurse, with the remainder from general practitioners. The type of surgery performed is summarised in Table. There appears to be no particular skew of the different groups by age. Nipple is offered to all patients once construction of the breast mound is complete. This is always several months after the first procedure and therefore many patients are still to reach a point where a decision can be made. The uptake of nipple in all patients in the study is shown in Table 3. Although at first sight there appears to be a marked difference in the uptake of nipple according to procedure, this conclusion must be tempered by the large number of patients in all groups remaining undecided about proceeding. An analysis of the complications, broken down according to the groups already described, is shown in Table. The problems experienced in the total-loss group are detailed in Table 5. Although there were two (.0%) severe complications in the group who had undergone using flaps, in both these patients the loss was of the implant rather than the flap. There did not appear to be any significant difference in the incidence of smoking, the mean age or, indeed, any other likely predictive factor between the severe-loss group and the other implant-only patients that might explain the high number of failures in the implant-only group. In patients undergoing free tissue transfer moderate complications were usually related to the anastomoses or partial loss of the flaps. Partial necrosis of the mastectomy skin flaps was also a problem. In the implant-only group most problems were related to migration or exposure of the filling port. Two patients presented with

How many procedures to make a breast? 9 Table 5 Problems leading to of Table 7 Moderate complications Table 6 implant extrusion, no flap loss loss of implant, flap fine, implant replaced months later infection, implant removed complete loss, wound breakdown infected implant removed and replaced 6 months later exposed implant following revision implant lost after full-thickness cigarette burn 8 months postoperatively infection, explantation extrusion of implant, removal necrosis of skin flaps with exposure of expander extrusion, explantation Minor complications encountered small axillary collection aspirated, awaiting minor adjustment minor donor wound problems, revision of flap at time of NAC minor delayed wound healing minor abdominal wound dehiscence minor wound problems minor haematoma, no surgery required delayed wound healing abdominal wound infection, pulmonary embolism small area of delayed healing in abdominal wound donor-site, awaiting adjustment small area of delayed healing, donor-site donor-site, minor dog-ear revision at time of NAC wound infection after nipple share, slow healing wound infection loss of tip of flap, delayed healing grade III capsule, not currently wanting surgery, slow wound healing slow healing uneven expansion of breast (prior radiotherapy), previous bilateral augmentation minor delayed healing of abdominal wound donor-wound infection, delayed healing wound infection capsule formation within the limited follow-up period of this study. It is worthy of note that very few abdominal-wall complications were seen in this series following free tissue transfer from the abdomen. In the minor-complication group, some free-flap patients had minor delays in wound DEP DEP DEP DEP haematoma, free nipple grafts lost re-exploration of anastomosis, flowing OK, no flap loss revision of abdominal scar venous anastomosis redone, still poor flow, partial flap loss partial flap loss, two debridements donor wound breakdown, debrided and closed inguinal hernia (resolved spontaneously), abdominal-wound sinus small area of flap loss two re-explorations of anastomosis with success, some loss of flap volume partial flap loss, volume insufficient, implant inserted then extruded flap did not heal to surrounding tissue, further pedicled required cavity deep to breast, debridement (fat necrosis and infection) debridement and split-skin graft of abdominal and breast wounds required two re-explorations for haematoma, one revision of venous anastomosis, late debridement of partial (< 0%) loss, later minor adjustments sinus requiring excision, minor adjustments to reconstructed breast partial loss of mastectomy flap, 'twitching breast' tethering of implant to, thoracodorsal nerve division outcome awaited grade III capsule, capsulotomy, subsequent revision with contralateral mastopexy lateral migration of requiring repositioning, implant too high, awaiting change of implant and repositioning port turned requiring re-exploration port eroded through skin, resited port required turning, adjust implant partial loss of skin flap, debrided and closed grade III capsule, malposition, capsulotomy tube leak, port turned, post-tranmatic partial loss of right nipple (flee graft), subsequent necrosis of mastectomy skin flap, debridement lymph collection, insertion of drain loss of medial 5% of flap, debrided and closed primarily partial loss (-0%) hernia revision of flap inset minor wound breakdown, large of abdomen and breast healing (usually of the abdominal wound). In those who had undergone -dorsi the most common minor complication was formation. Full details of the problems experienced by these patients are given in Tables 6, 7 and 8. Finally, the number of procedures required to complete the or undergone by the end of the study period was recorded. Table 9 shows a breakdown of the number of procedures undergone taking into account the nipple status.

30 British Journal of Plastic Surgery Table 8 Reasons for patient requests latissimns dorsi adjustment of reconstructed breast at time of mastopexy ('double bubble') droop, bilateral mastopexy wants contralateral augmentation bulges revised, haematoma after revisionary surgery, delayed wound healing minor adjustments required asymmetry asymmetry, needs contralaterai reduction required revision wants revision of breast, no surgical problems required contralateral augmentation, scar revisions to breast and abdomen at time of NAC required augmentation of reconstructed breast (second stage), first implant due to infection, second successful liposuction of dog ears, implant inserted at NAC wants replacement with flap delayed healing, required subsequent revision droop, bilateral mastopexy adjustment required minor adjustments required adjustment required minor adjustment required, at flap donor site considering free tissue transfer unhappy with appearance of wants contralaterai reduction very unhappy with appearance, implant exchanged, 'twitching breast' minor adjustment to flap awaiting minor adjustments Table 9 Number of procedures broken down by uptake of nipple Number of procedures Nipple 3 5 6 Totals 0 6 awaited 0 9 not wanted 0 awaited 5 not wanted 3 3 awaited 6 5 not wanted 9 5 awaited not wanted awaited not wanted awaited not wanted 8 5 7 3 6 50 0 3 7 50 0 5 0 6 3 6 Discussion A series of 6 breast s is presented. The immediately obvious feature is that in over half the patients in the series two or more procedures were required. This is in a series with limited follow-up where further procedures will be required for some of these patients, making the final tally higher still. Obviously, three procedures will be required to achieve a complete (breast mound, nipple and nipple areola tattooing) but we have found a significant number of patients requesting further surgery to achieve better symmetry or to revise scars. Even leaving aside these possibly aesthetic procedures, 30% of all patients undergoing breast required at least one further visit to theatre for a complication of some kind. These complications were not limited to the patients undergoing the most complex surgery, with a relatively high rate of complications in the group undergoing using implants alone. This group were studied in greater detail and did not show a difference in any obvious patient factor (age, smoking status, preoperative general health) from those who had no complications. The influence of radiotherapy may have some part to play in these problems. The number of immediate s being performed has implications for resources. Immediate has to be performed at the time of mastectomy, making planning of these cases difficult. Clinically, relations between general surgeons and plastic surgeons are excellent, with cooperative effort made to achieve the right for each patient at the right unit and at the most appropriate time. The effect of this is that the plastic surgeon must be available to attend the general surgeon's theatre sessions (or vice versa) at relatively short notice if the request for immediate is not to delay the mastectomy and any adjuvant treatment that the patient may require. Indeed, the apparently high complication rate seen with simple implant s in this series may suggest that alternative s to the apparently simple 'implant only' would be most suitable in this setting. In the present finance-aware environment it should be borne in mind that in addition to any psychological benefit claimed for immediate there is also a significant reduction in cost when compared with delayed ) There may also be another funding issue, in that if the plastic surgeon attends the General Surgery unit to perform a, does this procedure count as plastic surgery or general surgery, and where are the financial resources directed subsequently? The patients who suffered of their were examined in more detail and appeared to have had no predictive factors preoperatively. One of the implant losses (infection following a full-thickness cigarette burn 8 months postoperatively) could be considered unfortunate, and one loss followed revisionary surgery, but the remainder were lost in the early postoperative period. The rate of implant loss in this study is at the upper end of the range reported from other studies of between 6.% and 6.5%. 5 The flaps that were lost all occurred early in the experience of this technique

How many procedures to make a breast? 3 at this unit and hopefully represent problems with the 'learning curve' seen with any technique. Since the study period ended this technique has been performed with more success. Closer inspection of Table 9 gives the most insight into the number of procedures required. Any patient who is 'awaiting' nipple (i.e. has yet to decide whether to proceed or is not yet ready) should ideally have had only one procedure, whereas those where of the nipple is would be expected to have undergone two or three procedures. Our results show that 7/7 (36%) -flap patients, 8/50 (6%) -dorsi-flap patients and /50 (%) implant-only patients who had not commenced nipple had already undergone two or more procedures. Some of these procedures were due to patient requests rather than complications requiring reoperation. These requests occurred at varying times after and may represent 'upgrading' of the expectations of patients who initially had relatively low demands of the surgery. Also of interest is the uptake of nipple. Of the implant-only patients 7/50 (3%) opted not to undergo any nipple, compared with 6/50 (3%) in the and 5/7 (%) in the groups. Although there appears to be a highly significant difference between the groups this should be accepted with some caution as the largest group of patients were still to decide whether or not to proceed with nipple. If, however, the difference is real then this could contribute to the slightly higher rate of patient requests seen in the patients undergoing -flap as they may have higher expectations of the. The mean age of the patients opting not to proceed with nipple was significantly higher (p=0.000, Student's t-test) than the remainder of the study group. Breast is a complex undertaking, which may require several procedures to achieve the final goal of a new breast that is symmetric with the remaining side and bears a nipple. Adjustments to the reconstructed breast and the remaining breast may be required. More than one procedure should be expected from the outset. In selecting procedures for immediate it is important to ensure that there is no delay to any adjuvant treatment; from our series an autologous seems to fit this criterion best, as it had the lowest rate of reoperation and the majority of the minor complications were donor-site s (which need not delay chemotherapy or radiotherapy). Our series shows that there are a significant number of patients undergoing with an implant alone who are requiring further procedures, and this technique should perhaps be regarded with caution when planning an immediate where adjuvant treatment may be required. References. Arne~ ZM, Khan U, Pogorelec D, Planin~ek E Breast using the free superficial inferior epigastric artery () flap. Br J Plast Surg 999; 5: 76-9.. Evans GRD, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated breast: is there a role for implants? Plast Reconstr Surg 995; 96: -5. 3. Khoo A, Kroll SS, Reece GP, et al. A comparison of resource costs of immediate and delayed breast. Plast Reconstr Surg 998; 0: 96-8.. Camilleri IG, Malata CM, Stavrianos S, McLean NR. A review of 0 Becker permanent tissue expanders in of the breast. Br J Plast Surg 996; 9: 36-5. 5. Kroll SS, Evans GRD, Reece GP, et al. Comparison of resource costs between implant-based and flap breast. Plast Reconstr Surg 996; 97: 36-7. The Authors A. D. Malyon FRCS(Plast), Consultant Plastic Surgeon Plastic Surgery Unit, Royal Hospital Haslar, Gosport, Hampshire PO AA, UK. M. Husein, Registrar in General Surgery E. M. Weiler-Mithoff FRCS(Plast), Consultant Plastic Surgeon Plastic Surgery Unit, Canniesbum Hospital, Switchback Road, Bearsden, Glasgow G6 QL, UK. Correspondence to Mr A. D. Malyon. Paper received 3 March 000. Accepted 6 October 000, after revision. Published online 3 February 00.