Immediate Reconstruction

Immediate reconstruction provides significant advantages for the newly diagnosed breast cancer patient (Table 11-1). Greater understanding


Diminished psychologic trauma Facilitates coverage of radical defects Eases recipient pedicle dissection Superior esthetic results Incorporates skin sparing mastectomy Minimizes anemhesia and improves cost of tumor biology and technical advances in reconstructive surgery have led to greater acceptance of immediate postmastectomy reconstruction. The first large series reported in 1982, conveyed excellent outcome, less expense than delayed reconstruction, and no apparent effect on the natural course of the malignancy.4 Initial options for immediate reconstruction through the mid-1990s included various expanders and implants, yet now include various flaps and even free-flap reconstruction. Satisfactory outcome is dependent upon patient selection as well as communication between the ablative and reconstructive surgeons.

The advantages of immediate reconstruction include diminished psychosocial trauma, superior esthetic results, decreased surgical morbidity, and lower cost than delayed reconstruction. Historically, delayed reconstructions were more often performed due to heightened fear of recurrence, concerns that immediate reconstruction would mask subsequent detection of a recurrence, and the possibility that immediate reconstruction would be compromised by and hinder the initiation of adjuvant therapy. It was also felt that patients would be more appreciative of reconstruction if required to live for a time with the postmastectomy defect. These ideas have since been rendered obsolete by the need to consider the emotional impact of mastectomy and by the technical and therapeutic advances of the past 15 years.

Patients undergoing immediate reconstruction tend to incorporate the new breast into their body image, thereby maintaining greater selfesteem, personal sexuality, and confidence in interpersonal relationships.5 They tend to have less "cancer anxiety," less recall, and greater freedom in choosing clothing.6 Patients undergoing mastectomy and immediate reconstruction demonstrate a similar psychosocial outcome to that of breast conservation patients, having had lumpectomy with or without radia-tion.7 Body image may be adversely affected due to greater breast and donor site scarring compared to patients having undergone breast conservation. Overall, psychologic morbidity is similar, and clearly favorable compared to that of patients having had delayed reconstruction.8 The opportunity to attain optimal esthetic results is enhanced with immediate reconstruction. The newly raised mastectomy skin flaps tend to preserve the shape of the natural breast, providing a structural template that determines the shape of the underlying volume, whether an implant or flap reconstruction. Skin flap fibro-sis associated with delayed reconstruction represents inherent tissue loss and requires either greater tissue expansion or greater skin replacement at the time of autologous reconstruction. Fibrosis of the mastectomy skin flaps are an impediment in achieving a natural breast shape. Skin-sparing mastectomy in immediate reconstruction further increases the ability to attain a symmetric result, limits scarring to the periare-olar region, and minimizes the need for contralateral procedures such as reductions and mastopexies.9-13

Administration of adjuvant therapy is not delayed in patients undergoing immediate breast reconstruction, nor is the rate of complications higher after immediate reconstruc-tion.14-15 The usual 3 to 4 week interval prior to the initiation of adjuvant chemotherapy is ample time for uncomplicated, postreconstruc-tive wound healing and patient recovery. Only 1 to 2 percent of patients have their chemotherapy delayed beyond 3 to 4 weeks due to complications from immediate reconstruction, such as delayed healing.16

Although neoadjuvant and adjuvant chemotherapy have no relative impact upon immediate reconstruction, adjuvant radiation is known to unequivocally detract from the esthetic result and increase the local complication rate. This is influenced by many factors, including reconstructive technique and the type and dose of radiation. Historically, radiation exaggerated the extent of fibrous capsular contracture present, to some extent, in all expander/implant reconstructions.17-19 Poor outcome paralleled the need for substantial expansion and the use of large, smooth, silicone implants. The rate of poor cosmetic results in early series ranged from 18 to 40 percent, with a failure rate up to 40 percent.20 Evans and colleagues reported a 43 percent complication rate among radiated implant reconstruction patients, compared to a 12 percent rate in nonradiated patients.18 Schuster reported a 55 percent complication rate and unacceptable cosmesis in 24 percent of postreconstructive patients requiring adjuvant radiation.17 Of patients who had undergone a composite autogeneous/implant reconstruction, 40 percent of the radiated and 8.3 percent of the nonradiated patients had major complications.18 Dickson reported an overall complication rate of 70 percent for patients having immediate prosthetic reconstruction with radiation, and rates of 30 percent for skin necrosis and 67 percent for capsule contracture.21 Although the general consensus is to avoid prosthetic reconstruction in patients, an anticipated need for adjuvant radiation, the regiment is most often recommended postoperatively. Use of textured saline prosthesis as well as improved radiation techniques have demonstrated improved overall tolerance and diminished complications in some early reports, but there is no consensus.22-24

In contrast, tolerance of autologous tissue to radiation is generally good. Zimmerman reported the effect of postoperative radiation on immediate free transverse rectus abdominis myocuta-neous (TRAM) reconstruction. He reported no total or partial losses. Cosmesis, as rated by patients, was excellent in 60 percent of cases, good in 30 percent, and fair in 10 percent.25 Although some variable degree of cutaneous fibrous contracture may occur, this can usually be compensated for through surgical and design modifications. It is interesting that the rate of fat necrosis and volume loss in TRAM flaps, postradiation, was higher in pedicled (33%) than in free TRAMs (6%) reconstructions.26

Immediate postmastectomy reconstruction for locally advanced disease has been reported as encouraging. Sultan reported on 22 patients with stage IIB or III disease who had undergone neoadjuvant chemotherapy and completion of chemotherapy 3 weeks subsequent to surgery. Perioperative morbidity was 14 percent. Delay in resumption of chemotherapy occurred in no instances, and patients expressed appreciation for having been offered this option.27 Styblo reported on 21 patients with stage III disease who had undergone immediate TRAM reconstruction. There were no delays in reinstitution of adjuvant treatment and no increase in local relapse.28 It has been shown that breast reconstruction may facilitate resection, without an increase in local complications or relapse.

Immediate reconstruction also has economic advantages. Ablation and reconstruction are combined in one procedure, thereby limiting anesthetic risk and the time committed to postoperative recovery. Patients welcome the opportunity for a single procedure with less impact on occupational and domestic responsibilities. Avoidance of a staged second surgery and hospitalization in delayed reconstruction have obvious cost advantages.

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