Breast cancer is a major health risk for women. In the last decade or so, the treatment of breast cancer has undergone significant changes, including the use of sentinel lymph node biopsy, the increase in the proportion of breast-conserving lumpectomy plus postoperative radiation therapy, and the recognition and acceptance of immediate breast reconstruction after mastectomy.
However, in China, radical mastectomy and modified radical mastectomy are still the main surgical procedures for breast cancer due to many reasons. In the past, breast reconstruction and breast loss after breast cancer surgery were mostly performed months or even years after breast cancer surgery, mainly because of the fear that breast reconstruction might affect the treatment, the recurrence and metastasis of the tumor, and mask the diagnosis of recurrent tumor.
In recent years, several breast centers have reported that immediate breast reconstruction is safe for the patient and can provide psychological and physical benefits to the patient, thus suggesting that breast reconstruction should be an integral part of breast cancer treatment. In this article, we present the necessity and feasibility of immediate breast reconstruction after mastectomy for breast cancer, the indications for surgery, surgical methods, surgical complications, health economics and other issues.
1. The necessity and feasibility of immediate breast reconstruction after mastectomy for breast cancer
1.1 Impact of mastectomy on patients
The peak age of breast cancer incidence in China is 40-50 years earlier than that in western countries, and this is the age when individuals play an important role in their career, family and society. When diagnosed with breast cancer, patients not only have to suffer from the life-threatening effects of cancer, but also from the loss of one breast, an important female organ, due to breast cancer treatment. Breast cancer treatment can cause tremendous physical and psychological damage to the patient due to mastectomy.
Numerous studies have shown that breast-cancer treatment with breast conservation and mastectomy with breast reconstruction can improve the psychological damage caused by mastectomy. However, the number of patients suitable for breast-conserving surgery plus radiation therapy varies greatly from country to country and region to region, for example, up to 63% in the United Kingdom. On the other hand, for patients who need mastectomy due to breast cancer, the statistics in 1995 showed that the proportion of patients who underwent breast reconstruction was about 30% in the United States and 5%-10% in the United Kingdom [6], but it has increased to 30%-50% over the years.
Compared with western countries, there is a large gap in breast cancer preservation treatment and breast reconstruction in China. This is partly related to the different models of health care delivery and may also be related to cultural background differences. In further studies, immediate breast reconstruction was found to be more beneficial to patients’ psychological well-being than delayed breast reconstruction.
Multiple groups of studies have found that patient motivations for breast reconstruction include.
(1) To make their bodies whole;
(2) To restore a sense of femininity;
(3) ease of dressing;
(4) Reluctance to wear external prostheses;
(5) To regain self-confidence and facilitate physical activity;
(6) Not wanting to leave a large scar on the breast. Opponents, on the other hand, believe that they are too old, fear complications from surgery, and worry about the effect of reconstruction on cancer. Although the benefits of breast reconstruction after mastectomy for breast cancer, especially immediate breast reconstruction, have been recognized for patients. However, the psychological issue is a rather complex one, and there are a few reports with different opinions. However, the fact that breast reconstruction improves the physical appearance is the most undeniable fact.
Therefore, health care providers need to provide patients with comprehensive information about breast reconstruction, both about the benefits of the procedure and the possible complications, and provide adequate support to the patient, along with the support of family and friends. Breast reconstruction is part of the treatment of breast cancer and is not a matter of some mere cosmetic surgery.
1.2 Application and safety of breast cancer preserving breast skin mastectomy
Skin-preserving mastectomy was first proposed by Toth and Lappert in 1991. The main purpose of this procedure is to preserve the maximum amount of skin without tumor infiltration, to preserve the inferior breast fold, and to reconstruct the breast immediately using artificial breast implants or autologous tissues for better breast reconstruction results. The procedure requires excision of the nipple-areola complex, the surgical scar of the biopsy and all breast tissue. The skin at the site of the needle biopsy may not need to be excised, and sentinel lymph node biopsy or Ⅰ and Ⅱ level axillary lymph node dissection is performed at the same time as the procedure depending on the patient’s condition.
Modified skin-preserving mastectomy with simultaneous preservation of the nipple-areola complex or preservation of the areola has also been reported recently. The surgical incision options are periareolar incision, combined periareolar lateral incision, breast reduction incision, and modified oval incision. For axillary lymph node dissection, another incision can be chosen in the axilla if it is not easy to perform. The concern with skin-preserving mastectomy is whether the procedure affects local recurrence, distant metastases, patient survival, and whether it increases surgical complications.
Several groups have demonstrated that the procedure is safe and does not increase local recurrence, distant metastasis, or affect patient survival compared to non-skin-preserving conventional mastectomy [18-20].Carlson et al. reported a local recurrence rate of 5.5% in 539 skin-preserving mastectomies with 65 months of follow-up. Another group of 177 cases with 118 months of follow-up data showed a local recurrence rate of 5.6%, and none of the differences were significant when compared with the recurrence rate of conventional non-skin-preserving mastectomy [.
In addition, flap necrosis was 10.7% in the skin-preserving mastectomy group compared with 11.2% in the non-skin-preserving mastectomy group, which was also not statistically different. Although this surgical approach has been reported for locally advanced cancers and is considered to have not increased recurrence and metastasis [23, 24]. However, it is not suitable for patients with inflammatory breast cancer and tumor invasion to the skin.
In conclusion, appropriate patient selection for skin-preserving mastectomy combined with immediate breast reconstruction can result in reconstructed breasts with more natural skin color, softer texture, and less scarring, with better surgical cosmetic results, while reducing the need for contralateral breast adjustments to obtain symmetry. In addition, surgery does not increase tumor recurrence or metastasis, nor does it delay adjuvant therapy.
2. Indications for immediate breast reconstruction
Although some breast centers suggest that breast reconstruction should be an integral part of breast cancer treatment, not all patients are suitable for immediate breast reconstruction. The patient’s desire to undergo breast reconstruction is the most important determinant. The next consideration is the patient’s systemic condition, such as significant cardiopulmonary or other systemic diseases (e.g., chronic obstructive pulmonary disease, severe cardiovascular disease, uncontrollable hypertension, diabetes), obesity, smoking, etc. From the oncological aspect immediate breast reconstruction is mainly suitable for patients with stage I and II breast cancer.
Several groups of studies have proposed more refined indications, and they include.
(1) Extensive carcinoma in situ;
(2) Multifocal invasive carcinoma;
(3) Tumors that are relatively large or centrally located in the breast are not suitable for breast-conserving treatment;
(4) Local recurrence after breast-conserving treatment;
(5) Patients with high risk of breast cancer, who opt for prophylactic mastectomy, such as BRCA1 or BRCA2 mutation. In addition, preoperative clinical or ultrasound examination is required to clarify the absence of lymph node metastases in these patients. However, Newman et al. reported that immediate breast reconstruction for locally advanced cancer did not increase tumor recurrence or compromise treatment compared with patients who did not undergo reconstruction, and they concluded that immediate breast reconstruction for locally advanced cancer is feasible. Other scholars have also reported similar results.
Because preoperative and postoperative adjuvant treatment affects the cosmetic outcome, especially when breast reconstruction is performed with breast implants. Therefore, most scholars advocate that second-stage surgery should be performed for locally advanced cancer after treatment is completed and the patient has recovered. Patients with distant metastases are an absolute contraindication to breast reconstruction.
3.Surgical methods of immediate breast reconstruction
The surgical methods of immediate breast reconstruction include breast implant placement, autologous breast reconstruction or a combination of both. In general, the results of autologous breast reconstruction are better than breast implant reconstruction. However, the specific method to be used for each patient is determined by the patient’s own conditions, the patient’s wishes and the surgeon’s technical skills.
3.1 Breast Implant Placement Breast Reconstruction
Immediate breast reconstruction with breast implants refers to the reconstruction of the excised breast by placing an implant under the skin or pectoralis major muscle or under the flap at the same time as the surgical treatment of breast cancer. Since the use of silicone gel breast implants for breast augmentation in 1963, breast implants have been used progressively for breast reconstruction. Breast implants are available in silicone, silicone gel and saline implants. Depending on the shape and surface, they are divided into round, anatomical, and smooth and hairy types.
Prior to the application of skin-preserving mastectomy, the application of breast implants resulted in complications such as incisional infection, skin flap necrosis, wound dehiscence, exposed prosthesis, severe envelope contracture, and poor postoperative cosmetic results due to the lack of adequate skin. Therefore, the use of breast implants alone for breast reconstruction is gradually decreasing, and the use of dilators placed under the pectoralis major muscle, which are periodically expanded after surgery and then surgically removed and replaced with breast implants after the expected results are achieved, is increasing.
In 1987, a permanent expander breast implant or adjustable breast implant was invented to avoid the need for reoperation to replace the expander with a breast prosthesis. The advantages of immediate breast reconstruction with breast implants are the simplicity of the procedure, the short hospital stay, and the flexibility to adjust the size of the reconstructed breast in combination with the use of the expander technique to facilitate a symmetrical result. In addition, a relatively large reconstructed breast with a certain degree of ptosis can be obtained in combination with overexpansion or with the application of the latissimus dorsi muscle flap.
However, it is usually difficult to obtain a breast with ptosis, and radiation therapy can aggravate the contracture of the envelope and affect the postoperative cosmetic results.
Therefore, breast reconstruction with implants is mainly suitable for.
(1) Patients with moderate or small volume and no significant sagging breasts;
(2) Patients who have not undergone radiotherapy in the past or do not need radiotherapy after surgery;
(3) Patients who are not suitable for or do not want to undergo other surgical breast reconstruction;
(4) Patients with bilateral breast reconstruction.
3.2 Immediate breast reconstruction with autologous tissue
Autologous breast reconstruction provides a more natural, saggy, soft, consistent temperature breast that can tolerate radiation therapy. Autologous tissue can be derived from the back, abdomen, buttocks, thighs, and greater omentum. Depending on the blood supply of the flap, it can be divided into a tipped flap and a free flap. The most widely used flaps are the Latissimus Dorsi Musculocutaneous Flap (LDP) and the Transverse Rectus Abdominis Musculocutaneous Flap (TRAMP).
3.2.1 Immediate breast reconstruction with the latissimus dorsi muscle flap (LD)
The latissimus dorsi muscle flap was initially used to cover the wound after radical breast cancer surgery. The flap is supplied by the thoracodorsal artery and is a very reliable flap with abundant blood flow. The flap has a high degree of flexibility in the orientation and position of the attached skin island. In addition to the surgical requirements, the patient’s wishes can be taken into account in the selection of the incision, which can be made in a transverse or diagonal direction from superior to inferior, so that the incision is located low or concealed under the bra strap.
Alternatively, in skin-preserving mastectomy immediate breast reconstruction, since no or minimal skin is required, a dorsal scar can be eliminated by obtaining a latissimus dorsi flap through an axillary incision or using a laparoscopic technique. The conventional latissimus dorsi muscle flap is the most widely used type of flap, consisting of all or most of the latissimus dorsi muscle and the corresponding skin and subcutaneous tissue to repair the size of the defect after mastectomy for breast cancer. Due to the limited amount of tissue it can be combined with a breast prosthesis or a permanent expander breast implant.
A tipped muscle flap is transferred forward from the back to the breast mastectomy area, and the latissimus dorsi muscle is sutured to the chest wall at the inframammary fold to form a cavity for placement of the breast implant along with the pectoralis major muscle. In addition, care must be taken to secure the muscle to the lateral chest wall to prevent displacement of the implant to the back. This procedure results in larger reconstructed breasts with some ptosis. Complications are significantly reduced because the breast implant is located in a more appropriate muscle cavity.
The surgery is suitable for.
(1) Those who do not have enough skin after mastectomy, do not have enough lower abdominal tissue to reconstruct the breast or are medically unsuitable for the TRAM flap breast reconstruction option;
(2) Patients who have undergone previous breast radiation therapy for mastectomy;
(3) For smaller breasts, the expanded latissimus dorsi muscle flap technique can be used for full autologous breast reconstruction. During surgery, the entire latissimus dorsi muscle is separated from the corresponding subcutaneous fat, and the excess skin can be removed and placed under the flap of the breast after mastectomy to increase the size of the breast. However, it should be noted that sufficient subcutaneous tissue should be preserved when separating the dorsal flap to prevent necrosis of the donor flap.
3.2.2 Transverse rectus abdominis muscle flap for immediate breast reconstruction (TRAM)
In 1982, Hartrampf et al. first reported the use of the TRAM flap, in which an oval-shaped myocutaneous flap from the lower and middle abdomen is surgically transferred to the mastectomy area of the chest and shaped into a new breast. It is currently the most widely used autologous tissue flap for breast reconstruction. The flap is supplied by the superior abdominal artery from the terminal branch of the internal thoracic artery. Depending on the blood supply to the flap, the flap is divided into tipped and free TRAM, and tipped is divided into unilateral or bilateral, ipsilateral or contralateral tissues.
Several surgical techniques can be used to increase the blood flow to the flap, improve flap survival, and reduce the incidence of fat necrosis. One is to ligate the ipsilateral and/or contralateral inferior abdominal wall artery and superficial abdominal wall artery 2 to 3 weeks prior to surgery to increase the blood supply to the flap via the superior abdominal wall artery; this flap is called delayed TRAM.
Alternatively, the superficial abdominal artery vein on the contralateral side of the pedicled flap or the inferior abdominal artery vein distal to the flap can be anastomosed to a vessel in the chest or axilla, called a Supercharged Pedicled TRAM flap, or the inferior abdominal artery vein branches on either side of the pedicled flap can be anastomosed to increase the contralateral blood flow, called a Turbocharged Pedicled TRAM. Turbocharged Pedicled TRAM).
Although the free TRAM flap, especially the Deep Inferior Epigastric Perforator Flap (DIEP), has the advantages of better blood flow, more tissue volume, less disruption of abdominal wall strength, and fewer abdominal wall incisional hernia complications than the tipped flap, the procedure is technically demanding and requires microvascular anastomosis technique. At the same time, the operating time is long and there is a possibility of total flap loss, with an incidence of 0.5% to 6%, and if anastomotic vascular complications occur, reoperative exploration is required, with a reported exploration rate of 10% to 15%.
Because the TRAM flap has the ability to provide a larger volume of autologous tissue with more adequate blood flow, can tolerate postoperative radiation therapy, can be used for those who have had previous radiation therapy or tighter skin on the chest, reconstructed breasts have a more natural degree of sagging, soft texture, consistent temperature, while removing excess fatty tissue from the abdomen, the abdominal scar is more concealed and other features are more recommended surgical modalities for autologous tissue breast reconstruction, even called “gold standard surgery”. However, this surgery is not suitable for those who are excessively obese, smokers, have diabetes, hypertension, collagen tissue disease, and have a history of multiple previous abdominal surgeries.
3.2.3 Other autologous tissue flaps for immediate breast reconstruction
In addition to the LD and TRAM flaps, there are also gluteus maximus flaps, lateral transverse thigh flaps, Taylor-Rubens, and iliolumbar free flaps. Since all these flaps require microvascular anastomosis technique, they are more difficult to operate and can also cause scarring of the donor area and asymmetry with the contralateral side. The surgery is mainly used for patients who do not have enough tissue in the abdomen or back or do not want to leave a scar in the abdomen or back.
4. Surgical complications of immediate breast reconstruction
4.1 Complications related to breast implants
Similar to the application of breast implants for augmentation surgery, complications such as displacement, exposure, leakage, rupture and contracture of the implant can occur, the most common of which is contracture of the envelope. Although placing the prosthesis under the muscle layer and using a hairy surface prosthesis can significantly reduce the occurrence of periosteal contracture, the incidence is 40%. The peri-implant is a fibrotic scar tissue that forms around the implant and is a manifestation of the body’s reaction to a foreign body. Contracture of the envelope can lead to hardening and deformation of the reconstructed breast and cause pain. The fundamental solution is reoperation.
To date there is no evidence that silicone gel implants are associated with autoimmune diseases and tumors.
4.2 Surgery-related complications
Breast reconstruction with autologous tissue flaps is a complex surgery, especially TRAM flap surgery, which takes a long time and sometimes requires blood transfusion due to high blood loss. In addition to the usual surgical complications, such as incisional infection, incisional dehiscence, delayed wound healing, and surgical scarring, there is also the possibility of partial necrosis of the flap (7%-41%), fat necrosis (10%-50%), and total flap loss (2.9%-6%). The most common problem for the latissimus dorsi flap is subcutaneous fluid in the donor area, with an incidence of 9% to 33%. However, this procedure does not have a significant impact on shoulder function.
Complications of TRAM flap surgery are more common, as the surgery affects the strength of the abdominal wall thus limiting certain activities of the patient to varying degrees. An incisional hernia or localized abdominal bulge is another possible complication, with an incidence of approximately 12%. The incidence of abdominal wall incisional hernia can be reduced by using a free flap through the rectus abdominis muscle or by strengthening the abdominal wall with mesh. In addition, the use of free tissue flaps from other sites also has the same problems of postoperative bleeding, anastomotic vascular embolism, scarring of the donor area and causing asymmetry on both sides of the body.
5. Nipple areola reconstruction
Nipple areola reconstruction is an integral part of breast reconstruction, the purpose of which is to make the reconstructed breast more natural and realistic and to improve patient satisfaction. It has been reported that nipple reconstruction is performed at the same time as immediate breast reconstruction [30], but nipple reconstruction is usually performed 3 months after breast reconstruction and when bilateral breast morphology has been stabilized. There are various methods of nipple reconstruction, which can be performed with free tissue grafts, and the tissue can be derived from the contralateral nipple, earlobe, and labia minora.
However, the most common method used today is the local flap method, which uses the skin and subcutaneous tissue of the new nipple area for nipple reconstruction. However, it is important to note that almost all flap techniques reduce the size and prominence of the nipple over time. Areola reconstruction requires that the size and color of the areola be compatible with the contralateral areola. In the past, free skin grafts were used for reconstruction, but nowadays, tattooing is used. Usually 2 to 3 months after nipple reconstruction using intradermal tattoo technology to obtain the best color match.
6, the treatment of the contralateral breast
Breast reconstruction is usually difficult to obtain a breast that is perfectly proportional and consistent with the normal breast on the opposite side. Breast reconstruction with artificial breast implants can obtain a B or small C shell size round breast, and the reconstructed breast usually does not have ptosis. In contrast, TRAM flap technique breast reconstruction can result in larger breasts with ptosis. However, if the volume of the transfer flap is too large, it increases surgical and post-surgical complications. Therefore, the volume of the reconstructed breast is somewhat limited.
Although a more proportional breast to the contralateral breast can be obtained with the immediate breast reconstruction technique, it is sometimes necessary to perform an adjustment procedure on the contralateral breast to obtain better symmetry. The surgical options for contralateral breast adjustment are breast reduction, augmentation, breast fixation, or prophylactic mastectomy with reconstruction of the contralateral breast. Prophylactic mastectomy is mainly used for patients who are at high risk of developing breast cancer, such as those with a family history of breast cancer especially in the first generation of family members and BRCA1 or BRCA2 gene mutations, which is largely related to the patient’s request for a psychological reassurance.
Does pre-surgical chemotherapy and radiotherapy affect breast reconstruction in breast cancer patients?
7. The impact of immediate breast reconstruction on adjuvant therapy
The choice of immediate breast reconstruction and whether it affects postoperative adjuvant chemotherapy or radiation therapy has been a matter of concern. Currently, it is believed that preoperative chemotherapy does not affect the choice of immediate breast reconstruction, but preoperative radiation therapy significantly affects the use of breast implants and expanders. Because of the local soft tissue fibrosis that occurs after radiation therapy, expansion is difficult and produces significant pain, and the reconstructed breast is smaller, stiffer, has no ptosis, and has poor cosmetic results.
Similarly postoperative radiotherapy significantly increases the incidence of breast implant envelope contracture, with Ringberg et al. reporting an incidence as high as 71%. However, either the tipped or free TRAM flap or LD flap tolerated radiation therapy better, and Zimmerman et al. reported 21 cases of free TRAM flap breast reconstruction with postoperative radiation therapy without an increase in flap-related complications. Radiotherapy had an effect on the cosmetic outcome of the reconstructed breast when compared to patients who did not receive radiation therapy.
In addition, several studies have shown that immediate breast reconstruction does not delay the administration of postoperative adjuvant chemotherapy. Immediate breast reconstruction can also be safely performed in patients who received preoperative chemotherapy. In conclusion, preoperative and postoperative radiation therapy affects the cosmetic outcome of immediate breast reconstruction and significantly increases the complications of breast reconstruction with implants. Breast reconstruction with breast implants should not be used for patients who require radiation therapy.
8. Health economics
Khoo et al. compared the cost of hospitalization for immediate breast reconstruction and delayed breast reconstruction and showed that delayed breast reconstruction cost 62% more than immediate breast reconstruction. In addition, the cost is also related to the method of breast reconstruction chosen. In the past, breast implant placement was thought to be a simple and less expensive procedure, but this is not true in the long run.
This is because breast reconstruction with implants may result in contracture, leakage, or rupture of the implant, which may require reoperation or replacement of the implant, so the cumulative cost increases over time. In addition, the patient’s age, nature of work, and return to work due to illness must also be taken into consideration. Immediate breast reconstruction requires only one surgery, one hospitalization, one recovery from the disease, and can have a positive impact on the patient’s mental and psychological well-being.