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Breast Reconstruction and Lymphedema
References 1. Clough KB, Kroll SS, Audretsch W. An approach to repair of partial mastectomy defects. Plast Reconstr Surg. 1999;104:409-420. 2. Clough KB, Nos C, Salmon RJ, Soussaline M, Durand JC. Conservative treatment of breast cancers by mammaplasty and
Breast Reconstruction and Lymphedema Chang DW, Kim S (Univ of Texas, MD Anderson Cancer Ctr, Houston) Plast Reconstr Surg 125:19-23, 2010
Background.—The authors conducted this study to determine the following: Does delayed breast reconstruction that requires surgical dissection in the previously operated on and/or irradiated axilla lead to a higher incidence of lymphedema? In patients who have developed lymphedema following mastectomy, does delayed breast reconstruction with autologous flap reduce the severity of the lymphedema? Methods.—Four hundred eightytwo consecutive delayed autologous breast reconstructions performed at the authors’ institution were evaluated. The authors evaluated the effects of flap choice, recipient vessel choice, previous radiotherapy, and previous axillary node dissection on lymphedema development after breast reconstruction. The authors also evaluated the effect of autologous breast reconstruction on the status of the preexisting lymphedema. Results.—Four hundred forty-four delayed breast reconstructions were performed using 394 free flaps and 50 latissimus dorsi flaps in patients with
irradiation: a new approach to lower quadrant tumors. Plast Reconstr Surg. 1995;96:363-370. 3. Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg. 2006;117:1-11.
no lymphedema. Lymphedema developed in 16 cases (3.6 percent). The type of flap, the site of recipient vessel, previous radiotherapy, and previous axillary node dissection did not have a significant effect on the incidence of lymphedema after breast reconstruction. Breast reconstructions were performed in 38 patients who already had lymphedema: nine (23.7 percent) demonstrated significant improvement, and none demonstrated worsening of lymphedema after breast reconstruction. Conclusions.—The incidence of lymphedema following delayed autologous breast reconstruction is low, and the use of thoracodorsal vessels or a latissimus dorsi flap, even in patients with previous axillary node dissection or irradiation, was not associated with a significantly higher risk of developing lymphedema. In patients who developed lymphedema following mastectomy, delayed autologous breast reconstruction may help reduce the severity of lymphedema. As Chang and Kim remark, lymphedema affects only a small percentage of patients who undergo mastectomy with sentinel or axillary lymph node dissection with or without radiation therapy, but it has a major negative impact on a patient’s quality of life. For many patients with lymphedema, ipsilateral breast
4. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Practical guidelines for repair of partial mastectomy defects using the breast reduction technique in patients undergoing breast conservation therapy. Plast Reconstr Surg. 2007; 120:1755-1768.
reconstruction is delayed, often to allow for postoperative radiation therapy. Because of the longstanding common opinion that delayed breast reconstruction is a potential problem in patients with lymphedema, patients and/or reconstructive surgeons may be swayed from proceeding with a delayed reconstruction for fear of making the lymphedema worse. Unfortunately, these patients may never undergo breast reconstruction, a procedure known to improve body image and sense of wholeness in most women. This study by Chang and Kim provides some information to help determine whether delayed breast reconstruction with autologous tissue is safe, particularly in patients who have preexisting lymphedema or patients who are considered to be at high risk for developing it. In many breast reconstruction practices, autologous tissue flaps (rather than breast implant-based reconstructions) are the primary option for patients with planned delayed reconstruction—particularly for those who have undergone postmastectomy radiation therapy. Therefore, abdominally based tissue flaps were used for the majority of the patients in this study. Chang and Kim concluded that there was no statistical difference in the incidence of lymphedema between
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
283
patients in whom the thoracodorsal or internal mammary vessel was used as the recipient vessel. Based on this study’s design and power, accepting the null hypothesis may unfortunately be misleading. In fact, the incidence of lymphedema was more than 3-fold higher in patients who had thoracodorsal recipient vessels than in those who had internal mammary recipient vessels. Although this trend did not reach statistical significance, we believe it may be clinically important. In fact, if just 1 additional patient in the thoracodorsal vessel group (4 rather than 3 of 29 patients) had been observed to have lymphedema, the difference would have been statistically significant. Therefore, it is possible that avoiding the harvest of recipient vessels in the axilla could actually reduce the risk of developing lymphedema after autologous breast reconstruction. It is reassuring, however, that the incidence of lymphedema after latissimus dorsi flap reconstruction was relatively low (4%). In addition, it is promising that 9 of 38 patients with preexisting lymphedema who underwent autologous breast reconstruction reported improvement in lymphedema symptoms. Furthermore, additional review and study will be important to determine whether the addition of well-vascularized flap tissue onto the chest wall can improve arm lymphedema and, if so, to help elucidate its mechanisms of action. Towards this end, it will be important to appropriately control for patients who do and do not receive autologous tissue flap reconstruction.
284
The advantages of this study include its relatively large number of patients treated at a major cancer center and the relatively low incidence of lymphedema with delayed autologous breast reconstruction using both abdominally based and latissimus dorsi–based flap reconstruction. The weaknesses of this study include its retrospective nature, lack of long-term follow-up, and lack of quantitative objective data regarding the severity of lymphedema in the patient population. Also, preexisting lymphedema in some of these patients may have spontaneously improved had they not undergone breast reconstruction, and this variable needs to be studied and controlled for. Currently, some reconstructive surgeons advocate additional surgical procedures when conventional lymphedema management is inadequate. These include vascularized lymph node transfer1 and lymphovenous bypass.2 Both are technically challenging surgeries with highly variable and oftentimes unpredictable outcomes. A major implication of this study by Chang and Kim is that autologous breast reconstruction in these patients may not increase, and could even decrease, the incidence and severity of lymphedema. If this implication is true, patients and surgeons may be willing to proceed with breast reconstruction for patients at risk for or currently suffering from lymphedema. These patients may then benefit both aesthetically and functionally from autologous breast reconstruction. How might the data from Chang and Kim’s study affect your practice? It
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
seems that many patients are potentially at risk for developing lymphedema after mastectomy and nodal dissection with or without radiation therapy. Although quality of life is significantly diminished for those who are affected, the vast majority of patients with these risk factors do not develop lymphedema. This study provides important information for medical oncologists and surgeons to use when counseling patients about the risks and benefits of delayed autologous breast reconstruction. Although this work is preliminary, it suggests that most patients will not suffer increased risk or exacerbation of lymphedema after delayed autologous breast reconstruction, and some may even find that their lymphedema improves. Thus, the fear that breast reconstruction may worsen lymphedema may be unfounded. As a result, more patients may be offered the benefits of breast reconstruction. D. M. Adelman, MD, PhD C. E. Butler, MD
References 1. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123:1265-1275. 2. Campisi C, Bellini C, Campisi C, Accogli S, Bonioli E, Boccardo F. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery. 2010;30:256-260.
Breast Reconstruction and Lymphedema Chang DW, Kim S (Univ of Texas, MD Anderson Cancer Ctr, Houston) Plast Reconstr Surg 125:19-23, 2010
Background.—The authors conducted this study to determine the following: Does delayed breast reconstruction that requires surgical dissection in the previously operated on and/or irradiated axilla lead to a higher incidence of lymphedema? In patients who have developed lymphedema following mastectomy, does delayed breast reconstruction with autologous flap reduce the severity of the lymphedema? Methods.—Four hundred eightytwo consecutive delayed autologous breast reconstructions performed at the authors’ institution were evaluated. The authors evaluated the effects of flap choice, recipient vessel choice, previous radiotherapy, and previous axillary node dissection on lymphedema development after breast reconstruction. The authors also evaluated the effect of autologous breast reconstruction on the status of the preexisting lymphedema. Results.—Four hundred forty-four delayed breast reconstructions were performed using 394 free flaps and 50 latissimus dorsi flaps in patients with
irradiation: a new approach to lower quadrant tumors. Plast Reconstr Surg. 1995;96:363-370. 3. Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg. 2006;117:1-11.
no lymphedema. Lymphedema developed in 16 cases (3.6 percent). The type of flap, the site of recipient vessel, previous radiotherapy, and previous axillary node dissection did not have a significant effect on the incidence of lymphedema after breast reconstruction. Breast reconstructions were performed in 38 patients who already had lymphedema: nine (23.7 percent) demonstrated significant improvement, and none demonstrated worsening of lymphedema after breast reconstruction. Conclusions.—The incidence of lymphedema following delayed autologous breast reconstruction is low, and the use of thoracodorsal vessels or a latissimus dorsi flap, even in patients with previous axillary node dissection or irradiation, was not associated with a significantly higher risk of developing lymphedema. In patients who developed lymphedema following mastectomy, delayed autologous breast reconstruction may help reduce the severity of lymphedema. As Chang and Kim remark, lymphedema affects only a small percentage of patients who undergo mastectomy with sentinel or axillary lymph node dissection with or without radiation therapy, but it has a major negative impact on a patient’s quality of life. For many patients with lymphedema, ipsilateral breast
4. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Practical guidelines for repair of partial mastectomy defects using the breast reduction technique in patients undergoing breast conservation therapy. Plast Reconstr Surg. 2007; 120:1755-1768.
reconstruction is delayed, often to allow for postoperative radiation therapy. Because of the longstanding common opinion that delayed breast reconstruction is a potential problem in patients with lymphedema, patients and/or reconstructive surgeons may be swayed from proceeding with a delayed reconstruction for fear of making the lymphedema worse. Unfortunately, these patients may never undergo breast reconstruction, a procedure known to improve body image and sense of wholeness in most women. This study by Chang and Kim provides some information to help determine whether delayed breast reconstruction with autologous tissue is safe, particularly in patients who have preexisting lymphedema or patients who are considered to be at high risk for developing it. In many breast reconstruction practices, autologous tissue flaps (rather than breast implant-based reconstructions) are the primary option for patients with planned delayed reconstruction—particularly for those who have undergone postmastectomy radiation therapy. Therefore, abdominally based tissue flaps were used for the majority of the patients in this study. Chang and Kim concluded that there was no statistical difference in the incidence of lymphedema between
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
283
patients in whom the thoracodorsal or internal mammary vessel was used as the recipient vessel. Based on this study’s design and power, accepting the null hypothesis may unfortunately be misleading. In fact, the incidence of lymphedema was more than 3-fold higher in patients who had thoracodorsal recipient vessels than in those who had internal mammary recipient vessels. Although this trend did not reach statistical significance, we believe it may be clinically important. In fact, if just 1 additional patient in the thoracodorsal vessel group (4 rather than 3 of 29 patients) had been observed to have lymphedema, the difference would have been statistically significant. Therefore, it is possible that avoiding the harvest of recipient vessels in the axilla could actually reduce the risk of developing lymphedema after autologous breast reconstruction. It is reassuring, however, that the incidence of lymphedema after latissimus dorsi flap reconstruction was relatively low (4%). In addition, it is promising that 9 of 38 patients with preexisting lymphedema who underwent autologous breast reconstruction reported improvement in lymphedema symptoms. Furthermore, additional review and study will be important to determine whether the addition of well-vascularized flap tissue onto the chest wall can improve arm lymphedema and, if so, to help elucidate its mechanisms of action. Towards this end, it will be important to appropriately control for patients who do and do not receive autologous tissue flap reconstruction.
284
The advantages of this study include its relatively large number of patients treated at a major cancer center and the relatively low incidence of lymphedema with delayed autologous breast reconstruction using both abdominally based and latissimus dorsi–based flap reconstruction. The weaknesses of this study include its retrospective nature, lack of long-term follow-up, and lack of quantitative objective data regarding the severity of lymphedema in the patient population. Also, preexisting lymphedema in some of these patients may have spontaneously improved had they not undergone breast reconstruction, and this variable needs to be studied and controlled for. Currently, some reconstructive surgeons advocate additional surgical procedures when conventional lymphedema management is inadequate. These include vascularized lymph node transfer1 and lymphovenous bypass.2 Both are technically challenging surgeries with highly variable and oftentimes unpredictable outcomes. A major implication of this study by Chang and Kim is that autologous breast reconstruction in these patients may not increase, and could even decrease, the incidence and severity of lymphedema. If this implication is true, patients and surgeons may be willing to proceed with breast reconstruction for patients at risk for or currently suffering from lymphedema. These patients may then benefit both aesthetically and functionally from autologous breast reconstruction. How might the data from Chang and Kim’s study affect your practice? It
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
seems that many patients are potentially at risk for developing lymphedema after mastectomy and nodal dissection with or without radiation therapy. Although quality of life is significantly diminished for those who are affected, the vast majority of patients with these risk factors do not develop lymphedema. This study provides important information for medical oncologists and surgeons to use when counseling patients about the risks and benefits of delayed autologous breast reconstruction. Although this work is preliminary, it suggests that most patients will not suffer increased risk or exacerbation of lymphedema after delayed autologous breast reconstruction, and some may even find that their lymphedema improves. Thus, the fear that breast reconstruction may worsen lymphedema may be unfounded. As a result, more patients may be offered the benefits of breast reconstruction. D. M. Adelman, MD, PhD C. E. Butler, MD
References 1. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123:1265-1275. 2. Campisi C, Bellini C, Campisi C, Accogli S, Bonioli E, Boccardo F. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery. 2010;30:256-260.