Reconstruction options following breast conservation therapy

Risk factors for complications

Certain patient characteristics carry an increased risk for postoperative complications. These include tobacco smoking, previous breast surgeries, comorbidities that impair wound healing, and obesity.^4,15–17

The vasoconstrictive, thrombotic, and hypoxic effects of tobacco place patients who smoke at an increased risk for necrosis of the nipple-areola complex, as well as for pulmonary complications, when breast reduction is performed. The standard recommendation is cessation of smoking for 6 to 8 weeks preoperatively to reduce pulmonary risks, although rigorous scientific validation is lacking.¹⁷

Breasts that have been previously operated on have scarring of the skin and subcutaneous tissues, which may affect the surgical incision and technique. Additionally, vascular compromise of the underlying breast tissue and nipple-areola complex is a possibility in patients who have had previous breast operations.⁴ For these reasons, it is of utmost importance to obtain a full history of any previous breast procedures a patient has had.

Obesity is a risk factor for impaired wound healing, as delayed wound healing has been correlated with increased body mass index in patients undergoing breast reduction.¹⁵

What about positive margins?

Addressing positive margins can be problematic after breast conservation therapy with immediate reconstruction, as it is difficult to locate the resection margin after the breast tissue has been rearranged.^4,5,12,14 Patients who have positive margins will usually need to undergo completion mastectomy and opt for immediate reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi flap with an implant. Therefore, use of a TRAM flap for initial reconstruction after breast conservation therapy is discouraged.^4,14 If a TRAM flap is needed to restore the shape and contour of the breast after breast conservation, it is usually better to perform a mastectomy, as it provides a superior aesthetic result and reduces the risk of a subsequent malignancy since the breast tissue is removed.⁵

PATIENT COUNSELING, PREOPERATIVE PLANNING

The diagnosis of breast cancer is devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance.¹⁰ There is a psychological advantage to having reconstruction performed during the same operation as resection because the breast’s preoperative form is immediately restored and little to no asymmetry is seen postoperatively.¹² One study showed that breast cancer patients who underwent reconstructive surgery had better body images and felt they had more control over their treatment compared with patients who simply had breast conservation therapy or mastectomy without reconstruction; these perceptions also conferred a psychological benefit among the patients who had reconstructive procedures.¹⁸

At the same time, all patients need to be counseled about the potential drawbacks of reconstruction, including the possibility of reoperation for positive margins, wound complications, or a disappointing or unacceptable aesthetic outcome.

Oncoplastic surgery is a multispecialty collaboration. Good communication and preoperative planning is imperative and must include the general surgeon, plastic surgeon, oncologist, and, most importantly, the patient. Considerations in how to approach diagnostic biopsies, lymph node sampling, timing of contralateral breast symmetrizing procedures, and the possibility of positive margins all need to be discussed preoperatively.^8,10

ADDITIONAL CONSIDERATIONS

Timing of reconstruction

Immediate reconstruction is preferred for many reasons, including a reduced incidence of wound healing problems, facility in administering postoperative radiation therapy, and better aesthetic results.^3,4,11 A one-stage procedure also facilitates breast remodeling, as there is no scar tissue to deal with. Patients’ psychological trauma of coping with a deformity is also reduced because better symmetry is achieved with immediate reconstruction.¹⁰

Additionally, some authors have reported lower rates of local recurrence in breast conservation therapy patients who received immediate reconstruction, likely owing to the larger amount of tissue resected and subsequent lower incidence of positive margins.^4,11,14 Local recurrence in patients undergoing breast conservation therapy and oncoplasty is between 2% and 9%, depending on the study.^11,12

Postoperative surveillance

Postoperative surveillance can still be performed effectively despite the tissue transposition involved in any of the oncoplastic reconstruction techniques. A new baseline mammogram is obtained, to which future imaging studies are compared. Fat necrosis may appear to be new calcifications. Titanium clips may also be placed within the defect cavity so that it can be tracked to its new location. These clips also aid in localizing postoperative radiation therapy.¹¹

Patient satisfaction

Several studies have assessed patient satisfaction with breast conservation therapy without and with reconstruction. Following breast conservation therapy without reconstruction, cosmetic results are rated as poor by 15% to 20% of patients.¹⁰ Patients notice breast asymmetry and are generally dissatisfied to some degree after breast conservation with radiation therapy and no further reconstruction.³ In contrast, a survey in a series of patients who had oncoplasty found that 95% reported good aesthetic results at short-term follow-up.¹⁰ Another series found that 88% of patients undergoing oncoplastic techniques reported fair to excellent outcomes at 2 years, and 82% did so at 5 years.¹² When these patients were further analyzed, assessments of cosmetic outcomes were worse in those who received preoperative rather than postoperative radiation therapy.¹²

SUMMARY

Oncoplastic surgical approaches can be applied to the full spectrum of patients undergoing breast conservation therapy. They are particularly useful when a large defect is anticipated, when a symmetrizing procedure is desired for the contralateral breast, and when the tumor-to-breast volume ratio is unfavorable for simple closure.¹⁴ Immediate reconstruction is clearly preferred over delayed reconstruction, as it is associated with fewer complications, easier administration of postoperative radiation therapy, better aesthetic results, and possibly lower rates of local recurrence. Patients are more satisfied with the cosmetic outcome of oncoplastic procedures compared with breast conservation therapy alone. Successful oncoplasty requires thorough patient counseling and comprehensive preoperative planning among patient, oncologist, and general and plastic surgeons.