BREAST SURGERY
Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy Akhil K. Seth, MD, Hayley R. Silver, BS, Elliot M. Hirsch, MD, John Y.S. Kim, MD, and Neil A. Fine, MD Background: Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER). Methods: A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test. Results: There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P G 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts. Conclusions: This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients’ potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction. Key Words: breast reconstruction, delayed, immediate, radiation therapy, complications (Ann Plast Surg 2015;75: 503Y507)
B
reast reconstruction after mastectomy is an important part of both the treatment and outcome of women with breast cancer. In fact, it has become United States law for insurance companies to cover reconstruction of not only the breast with cancer, but also the Received November 6, 2013, and accepted for publication, after revision, February 3, 2014. From the Division of Plastic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL. Akhil K. Seth and Hayley R. Silver contributed equally to this work. Presented at the Plastic Surgery Research Council Annual Meeting, June 16, 2012, oral presentation format. Conflicts of interest and sources of funding: John Y.S. Kim received research funding from Mentor and the Musculoskeletal Transplant Foundation. Neil A. Fine received research funding from Allergan. The remaining authors have nothing to disclose. Reprints: Neil A. Fine, MD, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 676 N St Clair, Suite 1525A, Chicago, IL 60611. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7505-0503 DOI: 10.1097/SAP.0000000000000191
Annals of Plastic Surgery
unaffected breast to maintain symmetry.1,2 With regard to timing, breast reconstruction may be performed in an immediate (during the same surgery as mastectomy) or delayed (during a separate surgery after mastectomy) manner. Immediate reconstruction is becoming more common as it can provide better overall aesthetic outcomes through the preservation of the native breast skin envelope after either a skin-sparing or nipple-sparing mastectomies.2Y5 As a result, as compared to delayed reconstruction, there is easier and more rapid expansion to the appropriate and/or desired implant volume, as well as a greater ability to control shape and preserve some ptosis.1,2 In addition, some argue that immediate reconstruction potentially yields improved psychological and emotional outcomes by allowing a woman to wake up from surgery with at least a partially reconstructed breast mound.6Y8 Combining the mastectomy and reconstruction into 1 surgery also reduces the number of anesthetic exposures, and may be more cost-effective, when compared to a delayed approach.9 Although immediate reconstruction has gained favor over delayed reconstruction, delayed reconstruction remains a viable option for a number of women. Proponents of delayed reconstruction believe that it provides an overall decrease in complication rates relative to an immediate reconstruction.1,10 Delayed reconstructions allows for the mastectomy f lap to heal before implant placement, while also potentially minimizing contamination of the implant and seroma formation given the lower complexity of a delayed prosthetic reconstruction.1 Furthermore, in women whose postmastectomy radiation therapy (PMRT) needs are unknown at the time of mastectomy, delayed prosthetic reconstruction may have some use.2,11 Despite the feasibility of immediate reconstruction in patients requiring PMRT,12 and the standard approach after PMRT involving a delayed autologous muscle flap, delayed prosthetic reconstruction may also reduce the known negative impact of PMRT on reconstructive outcomes.1,11,13,14 Also, the psychological and emotional stress associated with a breast cancer diagnosis may leave some women unable to think about simultaneous breast reconstruction, in which case a delayed approach can be of some benefit.2 Given the popularity of immediate prosthetic breast reconstruction, there is a growing body of literature aimed at understanding and improving reconstructive outcomes in these patients.12,15Y22 However, there are few series that have critically evaluated and compared immediate and delayed prosthetic breast reconstruction.10,23,24 In particular, the overall impact of PMRT on these 2 distinct reconstructive algorithms has been described, but not rigorously quantified. Therefore, the goal of this study was to evaluate and compare complication rates after immediate tissue expander reconstruction (ITER) and delayed tissue expander reconstruction (DTER), including within the setting of PMRT.
METHODS This study was performed under the approval of Northwestern University Institutional Review Board. Retrospective review of medical records at Northwestern Memorial Hospital revealed 59 patients (74 breasts) and 834 patients (1127 breasts) who underwent DTER and ITER, respectively, from February 1999 to January 2008. The patients of 15 mastectomy surgeons and 6 reconstructive surgeons were
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included in the study. For each patient, individual inpatient and outpatient records were reviewed, with recording of relevant demographic information, preoperative and operative characteristics. Demographic data recorded for DTER patients were based on patient characteristics at the time of reconstruction, not mastectomy. Postoperative outcomes, complications, and follow-up after first stage, tissue expander placement, including exposure to PMRT, were recorded for comparison between ITER and DTER patients. For patients undergoing PMRT, the timing of therapy within the reconstructive algorithm was consistent within each group. For ITER patients, patients underwent first-stage tissue expander placement at the time of mastectomy, followed by simultaneous outpatient tissue expansion and radiation therapy if required, and then definitive second-stage tissue expander to implant exchange. In contrast, DTER patients underwent mastectomy, followed by tissue expander reconstruction during a subsequent procedure months to years after mastectomy, and then permanent implant exchange. Postmastectomy radiation therapy was performed between the initial mastectomy procedure and the placement of the tissue expander if necessary. Patients recorded as having an axillary dissection included patients who underwent a planned modified radical mastectomy and those with an unplanned axillary dissection after a simple mastectomy with a concurrent, positive sentinel lymph node biopsy. In addition, patients reported as having smoked in the past 3 months were recorded as smokers. The main focus of this review was complication rates per breast. Complications were reported as an overall rate per breast, as well as subdivided into categories including extrusion (evidence of tissue expander exposure without explantation), infection (requiring at a minimum intravenous antibiotics and/or hospital readmission), pain/tightness (if explicitly documented by the surgeon after at least 1 subjective patient complaint), hematoma (only those requiring reoperation), seroma (requiring drainage), and mastectomy f lap necrosis (requiring surgical excision with or without closure in the office or in the operating room). Total complications were also categorized by end-outcome, including nonoperative, operative except explantation, and explantation with or without conversion to autologous f lap. Statistical analysis was performed using Student t test and Fisher exact test to determine significant differences in clinical characteristics, operative factors, and complication rates between ITER and DTER breasts. Multiple regression analysis was performed with each complication subtype as the dependent variable. Several independent variables were evaluated in the analyses including age, body mass index (BMI), smoking status, type and extent of mastectomy,
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tissue expander intraoperative, and final fill volumes. Odds ratio calculations were performed to compare the risk of complications attributable to the type of reconstruction. Statistical significance was set at P G 0.05. All analyses were performed using Prism, version 4.0b (GraphPad Software, La Jolla, Calif ).
RESULTS A total of 893 patients (1201 breasts) were included in this study, of which 59 patients (74 breasts) underwent DTER, and the remaining ITER. On comparison of clinical and operative characteristics between the 2 groups (Table 1), both groups were similar with regard to age, BMI, and smoking status; however, these characteristics did approach statistical significant difference. Similarly, there were no differences in the type of mastectomy received each group, with DTER and ITER breasts undergoing similar numbers of modified radical mastectomies and axillary dissections. However, during the actual reconstruction, DTER breasts received tissue expanders with larger volumes relative to ITER breasts (P = 0.009). Similarly, the intraoperative fill volume and percentage fill of the tissue expanders were both significantly higher in DTER breasts when compared to ITER breasts (P G 0.0001). After the initial expander placement and subsequent outpatient expansions, the final volume of the expanders was also higher in DTER patients (P = 0.008). Complication rates, categorized by both type and endoutcome, after DTER and ITER were measured and compared (Table 2). Although there were no differences in total complication rates between the 2 groups (P = 0.43), analysis of individual complication subtypes did reveal some significant differences between DTER and ITER. In particular, DTER breasts showed lower rates of mastectomy f lap necrosis than ITER breasts (P = 0.02). Furthermore, patients undergoing DTER also had fewer overall nonoperative (P = 0.02) and operative (P = 0.008) complications relative to ITER patients. These relationships were reconfirmed through odds ratio calculation and multiple regressions (Table 3), which adjusted for all of the aforementioned preoperative and operative clinical variables. Statistical analysis demonstrated that ITER breasts were approximately 5 to 7 times more likely to have mastectomy f lap necrosis (P = 0.03) or an operative (P = 0.02) or nonoperative (P = 0.03) complication than DTER breasts, and that ITER was an independent risk factor for these complications. To understand the effects of PMRT on complication rates within these 2 populations, DTER and ITER breasts were stratified by whether they received PMRT and then compared with regard to complication rates (Table 4). When comparing PMRT and non-PMRT
TABLE 1. Clinical and Operative Characteristics of DTER and ITER Breasts Characteristic
DTER (n = 74 Breasts) (59 Patients)
ITER (n = 1127 Breasts) (834 Patients)
P
50.9 (9.6) 26.5 (6.9) 15 (20.3)
48.6 (10.1) 25.3 (5.4) 143 (12.7)
0.06 0.07 0.07
10 (13.5) 14 (19.0) 428.9 (117.3)
237 (21.0) 335 (29.7) 392.9 (114.5)
0.14 0.05 0.009
223.5 (169.6) 50.9 (30.8) 496.0 (163.1)
141.4 (116.3) 36.3 (27.1) 444.2 (160.9)
G0.0001 G0.0001 0.008
Age, y BMI, kg/m2 Smoking Type of mastectomy MRM Axillary dissection TE volume, mL Intraoperative TE fill Volume, mL % Final TE volume, mL
Data reported as mean (SD) or number (percentage of breasts). Listed in bold when statistically significant at P G 0.05. MRM indicates modified radical mastectomy; TE, tissue expander
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Annals of Plastic Surgery
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Delayed Tissue Expander Breast Reconstruction
TABLE 2. Complications in DTER and ITER Breasts Complication
DTER (n = 74 Breasts) (59 Patients)
ITER (n = 1127 Breasts) (834 Patients)
P
10 (13.5) 2 (2.7) 3 (4.0) 4 (5.4) 1 (1.4) 1 (1.4) 1 (1.4) 1 (1.4) 2 (2.7) 6 (8.1)
198 (17.6) 17 (1.5) 56 (5.0) 38 (3.4) 28 (2.5) 39 (3.5) 95 (8.4) 99 (8.8) 139 (12.3) 88 (7.8)
0.43 0.11 1.00 0.32 1.00 0.51 0.02 0.02 0.008 0.83
Total complications* Extrusion Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF
Data reported as number (percentage of breasts). *Breasts with more than 1 complication were counted once. ECF indicates explantation or conversion to f lap.
breasts within the DTER group, PMRT did not seem to affect any of our measured complication rates. In contrast, ITER breasts exposed to PMRT demonstrated a significant increase in the rate of several complications, including exposure of the expander (P = 0.005), infection (P = 0.02), subjective pain or tightness (P G 0.001), and explantation (P G 0.0001). Radiated ITER breasts were also found to have a significantly higher rate of nonoperative (P = 0.04), operative (P = 0.02), and total complications (P G 0.0001), underscoring the detrimental impact of PMRT on breasts undergoing ITER. Further analysis of overall reconstructive success rates, including after initial expander placement and expander-to-implant exchange, reveals that PMRT impacts final reconstructive outcomes in ITER breasts relative to DTER (Table 5). There were no differences in overall, 2-stage reconstructive success rate between DTER and ITER breasts. However, when stratified by PMRT, DTER breasts receiving PMRT had a significantly higher success rate than ITER breasts undergoing PMRT (82.6% vs 60.0%, P = 0.04).
DISCUSSION Prosthetic-based reconstruction after mastectomy remains an integral part of caring for the breast cancer patient.1,2,6Y8 Although immediate reconstruction has emerged as the most popular option, reconstruction in a delayed fashion may provide unique benefits to certain patient populations.1,2,10Y14 However, despite the widespread availability of these 2 techniques, comparative data addressing the benefits of each method remain limited within the literature. Mandrekas et al23 evaluated a small, retrospective series of 19 and 25
TABLE 3. Multiple Linear Regression, DTER Complication
OR
95% CI
P
Total complications* Exposure Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF
0.73 1.81 0.80 1.64 0.54 0.38 0.15 0.14 0.20 1.04
0.37Y1.45 0.41Y8.00 0.25Y2.65 0.57Y4.72 0.07Y4.01 0.05Y2.82 0.02Y0.98 0.02Y0.96 0.05Y0.81 0.44Y2.47
0.37 0.43 0.74 0.34 0.55 0.34 0.03 0.03 0.02 0.93
*Breasts with more than 1 complication were counted once. CI indicates confidence interval; ECF, explantation or conversion to flap; OR, odds ratio.
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ITER and DTER, respectively, and found no significant differences in overall complication rates and final aesthetic results. Meanwhile, Sullivan et al24 performed a retrospective review of immediate and delayed prosthetic and autologous reconstructions, from which a subset analysis of 89 immediate and 53 delayed reconstructions revealed that the overall complication and capsular contracture rates were higher in the immediate group. Similarly, Alderman et al10 also looked at a subset of all immediate and delayed procedures and found an increased rate of complications after immediate reconstruction (34/65, 52% compared to 5/14, 36%); although in this case, the differences were not statistically significant. Given the relatively small sample sizes within the currently available literature, further analysis of the potential benefits of DTER is warranted. On the basis of our large, institutional experience, overall outcomes (excluding aesthetic outcomes) after delayed prosthetic reconstruction seem to be comparable to those associated with immediate reconstruction. However, our data also suggest that breasts undergoing delayed reconstruction may demonstrate lower rates of mastectomy f lap necrosis, as well as significantly less nonoperative and operative complications. This difference in outcomes seems to be independent of other preoperative and operative variables. Furthermore, when looking at those breasts requiring PMRT, delaying the reconstructive process until after the completion of radiation therapy may decrease the rate of radiation-related complications and improve overall reconstructive success rates over immediate reconstructions in a select group who clinically have acceptable skin after XRT, and again, without regard to aesthetic result. These results emphasize the importance of considering timing, along with other patient-related factors, during the prosthetic reconstructive process. The improved complication profile after delayed expander reconstruction over immediate can be traced primarily to the mastectomy skin f lap itself. Creation of the skin f lap requires a fine balance by the oncologic surgeon, with an effort to maximize oncologic outcomes while still preserving adequate thickness for postoperative f lap survival.25 The potential for a relative ischemic insult to the f lap increases wound-related complications, and thus both nonoperative and operative complication rates. This is further compounded by the need for PMRT, which creates its own adverse effect on wound healing outcomes. Delayed reconstruction, as previously described,1,11,13,14 allows for the healing of the mastectomy skin f lap after f lap creation and/or PMRT. In contrast, immediate reconstruction does not provide time for appropriate f lap healing, and instead may potentially compound the problem with the placement of a tissue expander. Interestingly, despite relatively conservative intraoperative fill volumes and percentages [141.4 (116.3) mL and 36.3% (27.1%)], our immediate reconstruction patients had higher www.annalsplasticsurgery.com
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TABLE 4. Complications in DTER and ITER Breasts, Stratified by PMRT DTER (n = 74 Breasts) (59 Patients) Complication Total complications* Exposure Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF Complication
No PMRT (n = 51 Breasts) (43 Patients)
PMRT (n = 23 Breasts) (16 Patients)
P
5 (9.8) 2 (3.9) 2 (3.9) 1 (2.0) 0 (0.0) 0 (0.0) 1 (2.0) 0 (0.0) 1 (2.0) 4 (7.8)
5 (21.7) 0 (0.0) 1 (4.4) 3 (13.0) 1 (4.4) 1 (4.4) 0 (0.0) 1 (4.4) 1 (4.4) 2 (8.7)
0.27 1.00 1.00 0.09 0.31 0.31 1.00 0.31 0.53 1.00 P
ITER (n = 1127 breasts) (834 patients) No PMRT (n = 879 Breasts) (626 Patients) PMRT (n = 248 Breasts) (208 Patients) 132 (15.0) 66 (26.6) 8 (0.90) 9 (3.6) 36 (4.1) 20 (8.1) 10 (1.1) 28 (11.3) 21 (2.4) 7 (2.8) 30 (3.4) 9 (3.6) 67 (7.7) 27 (10.9) 69 (7.9) 30 (12.1) 97 (11.0) 42 (16.9) 53 (6.0) 35 (14.1)
Total complications* Exposure Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF
G0.0001 0.005 0.02 G0.0001 0.65 0.85 0.12 0.04 0.02 G0.0001
Data reported as number (percentage of breasts). *Breasts with more than 1 complication were counted once.
levels of these complications, suggesting that the primary healing of the skin f lap is an important factor in predicting postoperative complications. It is important to recognize that the benefits of delayed reconstruction seen in our data to some degree ref lect an inherent selection bias that is difficult to eliminate in a retrospective series. Patients presenting as candidates for delayed reconstruction can be preoperatively evaluated for prosthetic reconstruction with particular consideration given to the extent of healing seen in their native mastectomy skin f lap. For example, a reconstructive surgeon may be more likely to perform a delayed autologous tissue transfer in a patient with evidence of skin breakdown or fibrosis from PMRT, eliminating this higher risk patient from our series of delayed tissue expander patients. In fact, most of these patients will typically undergo a delayed, autologous reconstruction, which is considered by
many the standard of care in these patients. However, delaying reconstruction allows surgeons to carefully choose those patients that might be suitable for a prosthetic reconstruction through evaluation of their skin f lap appearance, potentially allowing for a successful result with an expander/implant as seen in this study. It is important to note that this evaluation of the skin f lap is subjective and often difficult to assess and quantify, leaving the decision to offer a DTER in the hands of each surgeon and his/her individual comfort level. The results of this study must be taken in the context of how we have applied the use of DTER in practice. When seeing a patient in consultation to discuss breast reconstruction, we first identify and assess the patient’s psychological need for reconstruction, which can vary tremendously among individual women. For those unsure about reconstruction at the time of mastectomy, DTER provides a safe and potentially successful alternative. This decision is made after a
TABLE 5. Two-Stage Success Rate, DTER and ITER Breasts Stratified by PMRT Stage TE placement DTER ITER TE exchange DTER ITER Overall DTER ITER
All Patients
P
No PMRT
P
PMRT
P
67 (90.5) 1039 (92.2)
0.65
46 (90.2) 826 (94.0)
0.24
21 (91.3) 213 (85.9)
0.75
63 (94) 923 (95.5)
0.54
44 (95.6) 760 (96.9)
0.39
19 (90.5) 149 (81.9)
0.54
63 (85.1) 923 (81.9)
0.54
44 (86.3) 760 (86.5)
1.00
19 (82.6) 149 (60.0)
0.04
Data reported as number (percentage of breasts). Listed in bold when statistically significant at P G 0.05. TE indicates tissue expander.
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Annals of Plastic Surgery
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thorough discussion of the well-described benefits of ITER, as well as the potential improved complication profile with DTER in certain populations. When delaying reconstruction due to the need for radiation therapy, the use of DTER or autologous f lap reconstruction is discussed, ensuring that patients understand that their qualification for an expander/implant reconstruction is dependent on a subjective evaluation of their mastectomy f lap postradiation. Furthermore, they must also understand that although DTER can be potentially successful, as seen in this study, the risk of conversion to autologous f lap is significant. This risk is often inf luenced by their satisfaction with their delayed expander/implant reconstruction, which is difficult to quantify and predict preoperatively, and is often inf luenced by their surgeon’s opinion as well. Surgeons can further inf luence this rate of conversion by how they frame their discussion of an autologous f lap, which is a more complex and involved surgery but one that will most likely further improve their aesthetic result. Therefore, we do not use DTER as our first-line reconstructive option, but rather as a viable alternative in a multistep process that involves continued discussion between patient and surgeon. As with all retrospective studies, our conclusions are subject to inherent limitations. The size of our delayed reconstruction cohort was relatively smaller than our immediate reconstruction group, ref lecting the recent bias toward immediate reconstructions among mastectomy patients. In addition, some of our preoperative variables, such as age and BMI, approached a significant difference from our immediate cohort. However, the actual clinical significance of these differences [eg, ages of 50.9 (9.6) and 48.6 (10.1) years] is minimal, and was further minimized through the use of multiple regression analysis. We also chose to compare patients with delayed or immediate reconstruction with PMRT patients, which are not completely analogous populations. Expander placement occurs before, rather than after, PMRT in an immediate reconstruction, once again emphasizing the selection bias with delayed reconstruction after PMRT that was previously discussed. A more analogous situation would be immediate reconstruction in patients receiving prereconstruction radiation (eg, salvage mastectomy and reconstruction after lumpectomy with radiation), but this pathway is not the most common, benchmark form of prosthetic reconstruction. Comparing our DTER patients to our ITER patients allowed for an assessment of the relative success rate of a more rare reconstructive protocol against the most common reconstructive protocol. Furthermore, the retrospective nature of our study design limited our ability to analyze aesthetic outcomes, which may be an important consideration for a delayed reconstruction when comparing prosthetic and autologous approaches. Finally, an additional consideration is the medical costs of performing a delayed reconstruction, requiring 2 separate operations for mastectomy and expander placement, as compared to one with an immediate reconstruction. These costs must be weighed against the potential improvement in complication profile and is better suited for an additional, independent study.
CONCLUSIONS Delayed tissue expander reconstruction remains a viable option for breast reconstruction after mastectomy, with the potential for improved wound healingYrelated complication rates. These benefits must be weighed against the well-described advantages of an immediate prosthetic reconstruction, allowing for a thorough discussion of reconstructive options between the patient and surgeon. Given its use in certain, carefully selected patient populations, the option of delayed prosthetic placement should be given consideration in the reconstructive algorithm.
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Delayed Tissue Expander Breast Reconstruction
REFERENCES 1. Chevray PM. Timing of breast reconstruction: immediate versus delayed. Cancer J. 2008;14:223Y229. 2. Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med. 2008;75:S30YS33. 3. Singletary SE, Kroll SS. Skin-sparing mastectomy with immediate breast reconstruction. Adv Surg. 1996;30:39Y52. 4. Carlson GW, Page AL, Peters K, et al. Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg. 2008;60:568Y572. 5. Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87: 1048Y1053. 6. Stevens LA, McGrath MH, Druss RG, et al. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg. 1984;73:619Y628. 7. Al-Ghazal SK, Sully L, Fallowfield L, et al. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol. 2000;26: 17Y19. 8. Asplund O, Korlof B. Late results following mastectomy for cancer and breast reconstruction. Scand J Plast Reconstr Surg. 1984;18:221. 9. Khoo A, Kroll SS, Reece GP, et al. A comparison of resource costs of immediate and delayed breast reconstruction. Plast Reconstr Surg. 1998;101:969Y970. 10. Alderman AK, Wilkins EG, Kim HM, et al. Complications in postmastectomy breast reconstruction: two-year results of the Michigan breast reconstruction outcome study. Plast Reconstr Surg. 2003;109:2265Y2274. 11. Kronowitz SJ, Robb GL. Breast reconstruction with postmastectomy radiation therapy: current issues. Plast Reconstr Surg. 2004;114:950Y960. 12. Hirsch EM, Seth AK, Dumanian GD, et al. Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of post mastectomy radiation therapy. Ann Plast Surg. 2014;72:274Y278. 13. Pomahac B, Recht A, May JW, et al. New trends in breast cancer management: is the era of immediate breast reconstruction changing? Ann Surg. 2006;244: 282Y288. 14. Spear SL, Onyewu C. Staged breast reconstruction saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg. 2000;105:930Y942. 15. Pinsolle V, Grinfeder C, Mathoulin-Pelissier S, et al. Complication analysis of 266 immediate breast reconstructions. J Plast Reconstr Aesthet Surg. 2006;59:1017Y1024. 16. Davies K, Allan L, Roblin P, et al. Factors affecting post-operative complications following skin-sparing mastectomy with immediate breast reconstruction. Breast. 2011;20:21Y25. 17. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous breast reconstruction. Ann Surg Oncol. 2010;17:S202YS210. 18. Seth AK, Hirsch EM, Fine NA, et al. Additive risk of tumescent technique in patients undergoing mastectomy with immediate reconstruction. Ann Surg Oncol. 2011;18:3041Y3046. 19. Hirsch EM, Seth AK, Dumanian GD, et al. Outcomes of tissue expander/ implant breast reconstruction in the setting of pre-reconstruction radiation. Plast Reconstr Surg. 2012;129:354Y361. 20. Seth AK, Hirsch EM, Fine NA, et al. Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: a long-term comparative analysis. Plast Reconstr Surg. 2012;130:750Y758. 21. Seth AK, Hirsch EM, Kim JYS, et al. Long-term outcomes following fat grafting in prosthetic breast reconstruction: a comparative analysis. Plast Reconstr Surg. 2012;215:388Y399. 22. Seth AK, Hirsch EM, Kim JYS, et al. Two surgeons, one patient: The impact of surgeon-surgeon familiarity on patient outcomes following mastectomy with immediate reconstruction. Breast. 2013;22:914Y918. 23. Mandrekas AD, Zambacos GJ, Katsantoni PN. Immediate and delayed breast reconstruction with permanent tissue expanders. Br J Plast Surg. 1995;48: 572Y578. 24. Sullivan SR, Fletcher DR, Isom CD, et al. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg. 2008;122:19Y28. 25. Larson DL, Basir Z, Bruce T. Is oncologic safety compatible with a predictably viable mastectomy skin flap? Plast Reconstr Surg. 2011;127:27Y33.
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Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy Akhil K. Seth, MD, Hayley R. Silver, BS, Elliot M. Hirsch, MD, John Y.S. Kim, MD, and Neil A. Fine, MD Background: Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER). Methods: A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test. Results: There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P G 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts. Conclusions: This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients’ potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction. Key Words: breast reconstruction, delayed, immediate, radiation therapy, complications (Ann Plast Surg 2015;75: 503Y507)
B
reast reconstruction after mastectomy is an important part of both the treatment and outcome of women with breast cancer. In fact, it has become United States law for insurance companies to cover reconstruction of not only the breast with cancer, but also the Received November 6, 2013, and accepted for publication, after revision, February 3, 2014. From the Division of Plastic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL. Akhil K. Seth and Hayley R. Silver contributed equally to this work. Presented at the Plastic Surgery Research Council Annual Meeting, June 16, 2012, oral presentation format. Conflicts of interest and sources of funding: John Y.S. Kim received research funding from Mentor and the Musculoskeletal Transplant Foundation. Neil A. Fine received research funding from Allergan. The remaining authors have nothing to disclose. Reprints: Neil A. Fine, MD, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 676 N St Clair, Suite 1525A, Chicago, IL 60611. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7505-0503 DOI: 10.1097/SAP.0000000000000191
Annals of Plastic Surgery
unaffected breast to maintain symmetry.1,2 With regard to timing, breast reconstruction may be performed in an immediate (during the same surgery as mastectomy) or delayed (during a separate surgery after mastectomy) manner. Immediate reconstruction is becoming more common as it can provide better overall aesthetic outcomes through the preservation of the native breast skin envelope after either a skin-sparing or nipple-sparing mastectomies.2Y5 As a result, as compared to delayed reconstruction, there is easier and more rapid expansion to the appropriate and/or desired implant volume, as well as a greater ability to control shape and preserve some ptosis.1,2 In addition, some argue that immediate reconstruction potentially yields improved psychological and emotional outcomes by allowing a woman to wake up from surgery with at least a partially reconstructed breast mound.6Y8 Combining the mastectomy and reconstruction into 1 surgery also reduces the number of anesthetic exposures, and may be more cost-effective, when compared to a delayed approach.9 Although immediate reconstruction has gained favor over delayed reconstruction, delayed reconstruction remains a viable option for a number of women. Proponents of delayed reconstruction believe that it provides an overall decrease in complication rates relative to an immediate reconstruction.1,10 Delayed reconstructions allows for the mastectomy f lap to heal before implant placement, while also potentially minimizing contamination of the implant and seroma formation given the lower complexity of a delayed prosthetic reconstruction.1 Furthermore, in women whose postmastectomy radiation therapy (PMRT) needs are unknown at the time of mastectomy, delayed prosthetic reconstruction may have some use.2,11 Despite the feasibility of immediate reconstruction in patients requiring PMRT,12 and the standard approach after PMRT involving a delayed autologous muscle flap, delayed prosthetic reconstruction may also reduce the known negative impact of PMRT on reconstructive outcomes.1,11,13,14 Also, the psychological and emotional stress associated with a breast cancer diagnosis may leave some women unable to think about simultaneous breast reconstruction, in which case a delayed approach can be of some benefit.2 Given the popularity of immediate prosthetic breast reconstruction, there is a growing body of literature aimed at understanding and improving reconstructive outcomes in these patients.12,15Y22 However, there are few series that have critically evaluated and compared immediate and delayed prosthetic breast reconstruction.10,23,24 In particular, the overall impact of PMRT on these 2 distinct reconstructive algorithms has been described, but not rigorously quantified. Therefore, the goal of this study was to evaluate and compare complication rates after immediate tissue expander reconstruction (ITER) and delayed tissue expander reconstruction (DTER), including within the setting of PMRT.
METHODS This study was performed under the approval of Northwestern University Institutional Review Board. Retrospective review of medical records at Northwestern Memorial Hospital revealed 59 patients (74 breasts) and 834 patients (1127 breasts) who underwent DTER and ITER, respectively, from February 1999 to January 2008. The patients of 15 mastectomy surgeons and 6 reconstructive surgeons were
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included in the study. For each patient, individual inpatient and outpatient records were reviewed, with recording of relevant demographic information, preoperative and operative characteristics. Demographic data recorded for DTER patients were based on patient characteristics at the time of reconstruction, not mastectomy. Postoperative outcomes, complications, and follow-up after first stage, tissue expander placement, including exposure to PMRT, were recorded for comparison between ITER and DTER patients. For patients undergoing PMRT, the timing of therapy within the reconstructive algorithm was consistent within each group. For ITER patients, patients underwent first-stage tissue expander placement at the time of mastectomy, followed by simultaneous outpatient tissue expansion and radiation therapy if required, and then definitive second-stage tissue expander to implant exchange. In contrast, DTER patients underwent mastectomy, followed by tissue expander reconstruction during a subsequent procedure months to years after mastectomy, and then permanent implant exchange. Postmastectomy radiation therapy was performed between the initial mastectomy procedure and the placement of the tissue expander if necessary. Patients recorded as having an axillary dissection included patients who underwent a planned modified radical mastectomy and those with an unplanned axillary dissection after a simple mastectomy with a concurrent, positive sentinel lymph node biopsy. In addition, patients reported as having smoked in the past 3 months were recorded as smokers. The main focus of this review was complication rates per breast. Complications were reported as an overall rate per breast, as well as subdivided into categories including extrusion (evidence of tissue expander exposure without explantation), infection (requiring at a minimum intravenous antibiotics and/or hospital readmission), pain/tightness (if explicitly documented by the surgeon after at least 1 subjective patient complaint), hematoma (only those requiring reoperation), seroma (requiring drainage), and mastectomy f lap necrosis (requiring surgical excision with or without closure in the office or in the operating room). Total complications were also categorized by end-outcome, including nonoperative, operative except explantation, and explantation with or without conversion to autologous f lap. Statistical analysis was performed using Student t test and Fisher exact test to determine significant differences in clinical characteristics, operative factors, and complication rates between ITER and DTER breasts. Multiple regression analysis was performed with each complication subtype as the dependent variable. Several independent variables were evaluated in the analyses including age, body mass index (BMI), smoking status, type and extent of mastectomy,
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tissue expander intraoperative, and final fill volumes. Odds ratio calculations were performed to compare the risk of complications attributable to the type of reconstruction. Statistical significance was set at P G 0.05. All analyses were performed using Prism, version 4.0b (GraphPad Software, La Jolla, Calif ).
RESULTS A total of 893 patients (1201 breasts) were included in this study, of which 59 patients (74 breasts) underwent DTER, and the remaining ITER. On comparison of clinical and operative characteristics between the 2 groups (Table 1), both groups were similar with regard to age, BMI, and smoking status; however, these characteristics did approach statistical significant difference. Similarly, there were no differences in the type of mastectomy received each group, with DTER and ITER breasts undergoing similar numbers of modified radical mastectomies and axillary dissections. However, during the actual reconstruction, DTER breasts received tissue expanders with larger volumes relative to ITER breasts (P = 0.009). Similarly, the intraoperative fill volume and percentage fill of the tissue expanders were both significantly higher in DTER breasts when compared to ITER breasts (P G 0.0001). After the initial expander placement and subsequent outpatient expansions, the final volume of the expanders was also higher in DTER patients (P = 0.008). Complication rates, categorized by both type and endoutcome, after DTER and ITER were measured and compared (Table 2). Although there were no differences in total complication rates between the 2 groups (P = 0.43), analysis of individual complication subtypes did reveal some significant differences between DTER and ITER. In particular, DTER breasts showed lower rates of mastectomy f lap necrosis than ITER breasts (P = 0.02). Furthermore, patients undergoing DTER also had fewer overall nonoperative (P = 0.02) and operative (P = 0.008) complications relative to ITER patients. These relationships were reconfirmed through odds ratio calculation and multiple regressions (Table 3), which adjusted for all of the aforementioned preoperative and operative clinical variables. Statistical analysis demonstrated that ITER breasts were approximately 5 to 7 times more likely to have mastectomy f lap necrosis (P = 0.03) or an operative (P = 0.02) or nonoperative (P = 0.03) complication than DTER breasts, and that ITER was an independent risk factor for these complications. To understand the effects of PMRT on complication rates within these 2 populations, DTER and ITER breasts were stratified by whether they received PMRT and then compared with regard to complication rates (Table 4). When comparing PMRT and non-PMRT
TABLE 1. Clinical and Operative Characteristics of DTER and ITER Breasts Characteristic
DTER (n = 74 Breasts) (59 Patients)
ITER (n = 1127 Breasts) (834 Patients)
P
50.9 (9.6) 26.5 (6.9) 15 (20.3)
48.6 (10.1) 25.3 (5.4) 143 (12.7)
0.06 0.07 0.07
10 (13.5) 14 (19.0) 428.9 (117.3)
237 (21.0) 335 (29.7) 392.9 (114.5)
0.14 0.05 0.009
223.5 (169.6) 50.9 (30.8) 496.0 (163.1)
141.4 (116.3) 36.3 (27.1) 444.2 (160.9)
G0.0001 G0.0001 0.008
Age, y BMI, kg/m2 Smoking Type of mastectomy MRM Axillary dissection TE volume, mL Intraoperative TE fill Volume, mL % Final TE volume, mL
Data reported as mean (SD) or number (percentage of breasts). Listed in bold when statistically significant at P G 0.05. MRM indicates modified radical mastectomy; TE, tissue expander
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Delayed Tissue Expander Breast Reconstruction
TABLE 2. Complications in DTER and ITER Breasts Complication
DTER (n = 74 Breasts) (59 Patients)
ITER (n = 1127 Breasts) (834 Patients)
P
10 (13.5) 2 (2.7) 3 (4.0) 4 (5.4) 1 (1.4) 1 (1.4) 1 (1.4) 1 (1.4) 2 (2.7) 6 (8.1)
198 (17.6) 17 (1.5) 56 (5.0) 38 (3.4) 28 (2.5) 39 (3.5) 95 (8.4) 99 (8.8) 139 (12.3) 88 (7.8)
0.43 0.11 1.00 0.32 1.00 0.51 0.02 0.02 0.008 0.83
Total complications* Extrusion Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF
Data reported as number (percentage of breasts). *Breasts with more than 1 complication were counted once. ECF indicates explantation or conversion to f lap.
breasts within the DTER group, PMRT did not seem to affect any of our measured complication rates. In contrast, ITER breasts exposed to PMRT demonstrated a significant increase in the rate of several complications, including exposure of the expander (P = 0.005), infection (P = 0.02), subjective pain or tightness (P G 0.001), and explantation (P G 0.0001). Radiated ITER breasts were also found to have a significantly higher rate of nonoperative (P = 0.04), operative (P = 0.02), and total complications (P G 0.0001), underscoring the detrimental impact of PMRT on breasts undergoing ITER. Further analysis of overall reconstructive success rates, including after initial expander placement and expander-to-implant exchange, reveals that PMRT impacts final reconstructive outcomes in ITER breasts relative to DTER (Table 5). There were no differences in overall, 2-stage reconstructive success rate between DTER and ITER breasts. However, when stratified by PMRT, DTER breasts receiving PMRT had a significantly higher success rate than ITER breasts undergoing PMRT (82.6% vs 60.0%, P = 0.04).
DISCUSSION Prosthetic-based reconstruction after mastectomy remains an integral part of caring for the breast cancer patient.1,2,6Y8 Although immediate reconstruction has emerged as the most popular option, reconstruction in a delayed fashion may provide unique benefits to certain patient populations.1,2,10Y14 However, despite the widespread availability of these 2 techniques, comparative data addressing the benefits of each method remain limited within the literature. Mandrekas et al23 evaluated a small, retrospective series of 19 and 25
TABLE 3. Multiple Linear Regression, DTER Complication
OR
95% CI
P
Total complications* Exposure Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF
0.73 1.81 0.80 1.64 0.54 0.38 0.15 0.14 0.20 1.04
0.37Y1.45 0.41Y8.00 0.25Y2.65 0.57Y4.72 0.07Y4.01 0.05Y2.82 0.02Y0.98 0.02Y0.96 0.05Y0.81 0.44Y2.47
0.37 0.43 0.74 0.34 0.55 0.34 0.03 0.03 0.02 0.93
*Breasts with more than 1 complication were counted once. CI indicates confidence interval; ECF, explantation or conversion to flap; OR, odds ratio.
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ITER and DTER, respectively, and found no significant differences in overall complication rates and final aesthetic results. Meanwhile, Sullivan et al24 performed a retrospective review of immediate and delayed prosthetic and autologous reconstructions, from which a subset analysis of 89 immediate and 53 delayed reconstructions revealed that the overall complication and capsular contracture rates were higher in the immediate group. Similarly, Alderman et al10 also looked at a subset of all immediate and delayed procedures and found an increased rate of complications after immediate reconstruction (34/65, 52% compared to 5/14, 36%); although in this case, the differences were not statistically significant. Given the relatively small sample sizes within the currently available literature, further analysis of the potential benefits of DTER is warranted. On the basis of our large, institutional experience, overall outcomes (excluding aesthetic outcomes) after delayed prosthetic reconstruction seem to be comparable to those associated with immediate reconstruction. However, our data also suggest that breasts undergoing delayed reconstruction may demonstrate lower rates of mastectomy f lap necrosis, as well as significantly less nonoperative and operative complications. This difference in outcomes seems to be independent of other preoperative and operative variables. Furthermore, when looking at those breasts requiring PMRT, delaying the reconstructive process until after the completion of radiation therapy may decrease the rate of radiation-related complications and improve overall reconstructive success rates over immediate reconstructions in a select group who clinically have acceptable skin after XRT, and again, without regard to aesthetic result. These results emphasize the importance of considering timing, along with other patient-related factors, during the prosthetic reconstructive process. The improved complication profile after delayed expander reconstruction over immediate can be traced primarily to the mastectomy skin f lap itself. Creation of the skin f lap requires a fine balance by the oncologic surgeon, with an effort to maximize oncologic outcomes while still preserving adequate thickness for postoperative f lap survival.25 The potential for a relative ischemic insult to the f lap increases wound-related complications, and thus both nonoperative and operative complication rates. This is further compounded by the need for PMRT, which creates its own adverse effect on wound healing outcomes. Delayed reconstruction, as previously described,1,11,13,14 allows for the healing of the mastectomy skin f lap after f lap creation and/or PMRT. In contrast, immediate reconstruction does not provide time for appropriate f lap healing, and instead may potentially compound the problem with the placement of a tissue expander. Interestingly, despite relatively conservative intraoperative fill volumes and percentages [141.4 (116.3) mL and 36.3% (27.1%)], our immediate reconstruction patients had higher www.annalsplasticsurgery.com
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TABLE 4. Complications in DTER and ITER Breasts, Stratified by PMRT DTER (n = 74 Breasts) (59 Patients) Complication Total complications* Exposure Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF Complication
No PMRT (n = 51 Breasts) (43 Patients)
PMRT (n = 23 Breasts) (16 Patients)
P
5 (9.8) 2 (3.9) 2 (3.9) 1 (2.0) 0 (0.0) 0 (0.0) 1 (2.0) 0 (0.0) 1 (2.0) 4 (7.8)
5 (21.7) 0 (0.0) 1 (4.4) 3 (13.0) 1 (4.4) 1 (4.4) 0 (0.0) 1 (4.4) 1 (4.4) 2 (8.7)
0.27 1.00 1.00 0.09 0.31 0.31 1.00 0.31 0.53 1.00 P
ITER (n = 1127 breasts) (834 patients) No PMRT (n = 879 Breasts) (626 Patients) PMRT (n = 248 Breasts) (208 Patients) 132 (15.0) 66 (26.6) 8 (0.90) 9 (3.6) 36 (4.1) 20 (8.1) 10 (1.1) 28 (11.3) 21 (2.4) 7 (2.8) 30 (3.4) 9 (3.6) 67 (7.7) 27 (10.9) 69 (7.9) 30 (12.1) 97 (11.0) 42 (16.9) 53 (6.0) 35 (14.1)
Total complications* Exposure Infection Pain/tightness Hematoma Seroma Mastectomy flap necrosis Nonoperative Operative ECF
G0.0001 0.005 0.02 G0.0001 0.65 0.85 0.12 0.04 0.02 G0.0001
Data reported as number (percentage of breasts). *Breasts with more than 1 complication were counted once.
levels of these complications, suggesting that the primary healing of the skin f lap is an important factor in predicting postoperative complications. It is important to recognize that the benefits of delayed reconstruction seen in our data to some degree ref lect an inherent selection bias that is difficult to eliminate in a retrospective series. Patients presenting as candidates for delayed reconstruction can be preoperatively evaluated for prosthetic reconstruction with particular consideration given to the extent of healing seen in their native mastectomy skin f lap. For example, a reconstructive surgeon may be more likely to perform a delayed autologous tissue transfer in a patient with evidence of skin breakdown or fibrosis from PMRT, eliminating this higher risk patient from our series of delayed tissue expander patients. In fact, most of these patients will typically undergo a delayed, autologous reconstruction, which is considered by
many the standard of care in these patients. However, delaying reconstruction allows surgeons to carefully choose those patients that might be suitable for a prosthetic reconstruction through evaluation of their skin f lap appearance, potentially allowing for a successful result with an expander/implant as seen in this study. It is important to note that this evaluation of the skin f lap is subjective and often difficult to assess and quantify, leaving the decision to offer a DTER in the hands of each surgeon and his/her individual comfort level. The results of this study must be taken in the context of how we have applied the use of DTER in practice. When seeing a patient in consultation to discuss breast reconstruction, we first identify and assess the patient’s psychological need for reconstruction, which can vary tremendously among individual women. For those unsure about reconstruction at the time of mastectomy, DTER provides a safe and potentially successful alternative. This decision is made after a
TABLE 5. Two-Stage Success Rate, DTER and ITER Breasts Stratified by PMRT Stage TE placement DTER ITER TE exchange DTER ITER Overall DTER ITER
All Patients
P
No PMRT
P
PMRT
P
67 (90.5) 1039 (92.2)
0.65
46 (90.2) 826 (94.0)
0.24
21 (91.3) 213 (85.9)
0.75
63 (94) 923 (95.5)
0.54
44 (95.6) 760 (96.9)
0.39
19 (90.5) 149 (81.9)
0.54
63 (85.1) 923 (81.9)
0.54
44 (86.3) 760 (86.5)
1.00
19 (82.6) 149 (60.0)
0.04
Data reported as number (percentage of breasts). Listed in bold when statistically significant at P G 0.05. TE indicates tissue expander.
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Annals of Plastic Surgery
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thorough discussion of the well-described benefits of ITER, as well as the potential improved complication profile with DTER in certain populations. When delaying reconstruction due to the need for radiation therapy, the use of DTER or autologous f lap reconstruction is discussed, ensuring that patients understand that their qualification for an expander/implant reconstruction is dependent on a subjective evaluation of their mastectomy f lap postradiation. Furthermore, they must also understand that although DTER can be potentially successful, as seen in this study, the risk of conversion to autologous f lap is significant. This risk is often inf luenced by their satisfaction with their delayed expander/implant reconstruction, which is difficult to quantify and predict preoperatively, and is often inf luenced by their surgeon’s opinion as well. Surgeons can further inf luence this rate of conversion by how they frame their discussion of an autologous f lap, which is a more complex and involved surgery but one that will most likely further improve their aesthetic result. Therefore, we do not use DTER as our first-line reconstructive option, but rather as a viable alternative in a multistep process that involves continued discussion between patient and surgeon. As with all retrospective studies, our conclusions are subject to inherent limitations. The size of our delayed reconstruction cohort was relatively smaller than our immediate reconstruction group, ref lecting the recent bias toward immediate reconstructions among mastectomy patients. In addition, some of our preoperative variables, such as age and BMI, approached a significant difference from our immediate cohort. However, the actual clinical significance of these differences [eg, ages of 50.9 (9.6) and 48.6 (10.1) years] is minimal, and was further minimized through the use of multiple regression analysis. We also chose to compare patients with delayed or immediate reconstruction with PMRT patients, which are not completely analogous populations. Expander placement occurs before, rather than after, PMRT in an immediate reconstruction, once again emphasizing the selection bias with delayed reconstruction after PMRT that was previously discussed. A more analogous situation would be immediate reconstruction in patients receiving prereconstruction radiation (eg, salvage mastectomy and reconstruction after lumpectomy with radiation), but this pathway is not the most common, benchmark form of prosthetic reconstruction. Comparing our DTER patients to our ITER patients allowed for an assessment of the relative success rate of a more rare reconstructive protocol against the most common reconstructive protocol. Furthermore, the retrospective nature of our study design limited our ability to analyze aesthetic outcomes, which may be an important consideration for a delayed reconstruction when comparing prosthetic and autologous approaches. Finally, an additional consideration is the medical costs of performing a delayed reconstruction, requiring 2 separate operations for mastectomy and expander placement, as compared to one with an immediate reconstruction. These costs must be weighed against the potential improvement in complication profile and is better suited for an additional, independent study.
CONCLUSIONS Delayed tissue expander reconstruction remains a viable option for breast reconstruction after mastectomy, with the potential for improved wound healingYrelated complication rates. These benefits must be weighed against the well-described advantages of an immediate prosthetic reconstruction, allowing for a thorough discussion of reconstructive options between the patient and surgeon. Given its use in certain, carefully selected patient populations, the option of delayed prosthetic placement should be given consideration in the reconstructive algorithm.
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Delayed Tissue Expander Breast Reconstruction
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