What is the optimal method and timing for breast reconstruction after mastectomy? What factors influence breast reconstruction?

OVERVIEW: Over the past 15 years, breast reconstruction has undergone a significant evolution. Controversies involving implant safety, new implant design, flap design, the increased use of radiation to treat breast cancer, and the pursuit of more aggressive breast-conserving surgeries have significantly influenced breast reconstruction procedures. Determining the optimal time and method of breast reconstruction cannot be reduced to an algorithm. Careful consideration of the patient’s disease profile as well as her objectives and understanding of reconstruction options are critical.

RECONSTRUCTION PROCEDURE PREFERENCES

The final degree of satisfaction of the woman is not always in agreement with the evaluation of the medical staff for which the shape and the symmetry of the reconstructed breast are the two main criteria. For this reason, the cosmetic aspect of the final result of the reconstruction cannot be the only criteria to chose the technique. Although the TRAM flap provides usually the best cosmetic results, there are patients who do not support the changes that result on the morphology and the function of their abdomen wall. Therefore, the choice of the technique should take in consideration both the technical difficulties and the psychological reactions of the woman when she is informed before the operation. It is of major importance to understand what are the expectations of the patient in order to maximize her final satisfaction.

—Petit JY et al. Critical Reviews in Oncology/Hematology
2001;38:231-239.

Patients who have undergone augmentation mammoplasty and who later develop breast cancer are a unique group. They tend to place great importance on body image, and most maintain their ideal body weight. Body habitus, small breast size, and the acceptance of breast implants seem to make the latissimus flap an ideal reconstructive method for breast cancer patients with implants.

—Carlson GW et al. Plast Reconstr Surg 2001;107:687-92.
Abstract

The latissimus flap is becoming a larger part of my practice. With the large autologous latissimus incision on the back...people get out of the hospital a lot faster.

—Carlson GW et al. Ann Plast Surg 2001; 46:222-8.
Abstract

Skin sparing mastectomy (SSM) and immediate reconstruction can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of various reconstructive methods are similar, but the method failure rate is higher for expander reconstruction. Ipsilateral pedicled TRAM flaps or free TRAM flaps may improve the aesthetic outcome by preserving the inframammary fold.

—Carlson GW et al. Ann Plast Surg 2001;46:222-8.
Abstract

TIMING OF RECONSTRUCTION

Immediate reconstruction has been shown to yield the greatest patient benefit and should be the treatment of choice for most patients. However, delayed reconstruction is preferable for patients who are unable to make a sound decision regarding reconstruction at the time of mastectomy.

—Shons A, Mosiello G. Cancer Control
2001;5(8):419-426.

In the past, the use of immediate or early breast reconstruction after mastectomy was an unpopular concept. Concerns about potentially compromising the surgical resection for the sake of reconstruction and the possibility of a decreased ability to detect local recurrences were used to justify delaying reconstruction for several years after mastectomy.

In addition, techniques for breast reconstruction had not been fully developed. Multiple procedures were required, hospital stays were prolonged, and end results were not consistently esthetically pleasing. Today, these concerns should no longer be significant barriers to the use of reconstruction.

Many retrospective studies have demonstrated that the use of postmastectomy reconstruction does not interfere with the ability to detect local recurrence, nor does it delay the administration of adjuvant chemotherapy. In addition, the use of skin-sparing mastectomy coupled with advances in plastic surgical technique, has resulted in a variety of reconstruction options with improved esthetic outcomes.

—Morrow M et al. J Am Coll Surg 2001;(192)1:1-8.
Abstract

INFLUENCE OF AGE ON BREAST RECONSTRUCTION

Age-related differences in the use of reconstruction may be a reflection of the reluctance of older women to undergo the additional surgical procedures to complete reconstruction or may indicate a lack of education of older women about their suitability for reconstruction. They may also reflect physician attitudes about the lack of importance of maintaining a breast in older women.

—Morrow M et al. J Am Coll Surg 2001;(192)1:1-8.
Abstract

INFLUENCE OF INCOME ON BREAST RECONSTRUCTION

With the passage of legislation mandating insurance coverage for breast reconstruction as part of cancer therapy, the financial reasons for this difference should be largely eliminated. But women of lower income may be less aware of reconstructive options, less likely to obtain care in a hospital with qualified reconstructive surgeons, or have less time and money to devote to their body image in general, making them less likely to pursue reconstruction.

—Morrow M et al. J Am Coll Surg 2001;(192)1:1-8.
Abstract

AESTHETIC ANALYSIS OF VARIOUS BREAST RECONSTRUCTION METHODS

	N	Volume	Contour	Placement	Fold	Overall
Latissimus Flap	13	1.62	1.52	1.79	1.88	6.81
Overall	86	1.51	1.42	1.72	1.55	6.21
Expander	15	1.47	1.40	1.62	1.68	6.17
TRAM Flap	58	1.50	1.41	1.74	1.44	6.09
Pedicled	52	1.52	1.42	1.74	1.41	6.09
Free	6	1.33	1.29	1.75	1.70	6.07

SCORING METHODOLOGY

Adapted from Carlson, et al. Ann Plast Surg 2001;46(3):222-8. Abstract

INFLUENCE OF GEOGRAPHIC REGION ON USE OF IMMEDIATE BREAST RECONSTRUCTION

	NORTHEAST: Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, and New Jersey
	SOUTHEAST: Delaware, District of Columbia, Maryland, West Virginia, Virginia, North Carolina, South Carolina, Georgia, and Florida
	MIDWEST: Wisconsin, Michigan, Illinois, Indiana, Ohio, Minnesota, North Dakota, South Dakota, Iowa, Nebraska, Kansas, and Missouri
	SOUTH: Kentucky, Tennessee, Mississippi, Alabama, Oklahoma, Arkansas, Texas, and Louisiana
	MOUNTAIN: Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, and New Mexico;
	PACIFIC: Washington, Oregon, California, Alaska, and Hawaii
Adapted from Morrow, et al. J Am Coll Surg. 2001;192(1):1-8 Abstract

USE OF IMMEDIATE BREAST RECONSTRUCTION BY AGE   1985-1990    1994-1995 1985-1990    1994-1995 1985-1990    1994-1995   n=155,463 (1985 - 1990)   n=63,348 (1994 - 1995)

USE OF IMMEDIATE BREAST RECONSTRUCTION BY INCOME   1985-1990    1994-1995 1985-1990    1994-1995 1985-1990    1994-1995   n=155,463 (1985 - 1990)   n=63,348 (1994 - 1995)

USE OF IMMEDIATE BREAST RECONSTRUCTION PATHOLOGIC STAGE     n=155,463 (1985 - 1990)   n=63,348 (1994 - 1995) Adapted from Morrow M et al. J Am Coll Surg 2001;192(1):1-8 Abstract

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