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Reconstruction of the breast: Where do we fall short?
Reconstruction of the Breast: Where Do We Fall Short? An Evolution of Ideas
Luis 0. Vasconez, MD, San Francisco, California James C. Grottlng, MD, San Francisco, California Wiltredo Calderon, MD, San Francisco, California Stephen J. Nlathes, MD, San Francisco, California
Breast reconstruction is still an imperfect operation. The demand for it, however, is increasing, and it is taxing the ingenuity and imagination of the reconstructive plastic surgeon. For us, it has been a learning experience-at times humbling, at other times depressing, but often most satisfying. When we undertake to do a breast reconstruction, we consider the patient’s safety, aim for relative simplicity, and strive to achieve symmetry with the other breast which is a frequently unfulfilled goal. Breast reconstruction began as an empirical procedure, first with the use of a variety of multistaged operations and tube flaps, and had its modern rebirth in 1971with the introduction of the silicone implant, which was an attempt to replace the breast mound lost at the time of mastectomy [j-4]. Initial breast reconstructions consisted of simple insertions of these implants and were, for the most part, unsatisfactory. Properly carried out symmetric reconstructions are now more common and are a source of satisfaction to the surgeon and the patient. To obtain symmetry, however, we have usually resorted to operations that alter the opposite breast, some of which have been ill-advised and counterproductive. In our practice, we have performed 22 reduction mammoplasties, 12 augmentation mammoplasties, and 9 mastopexies on the normal side. Herein we review our experience with 153 breast reconstructions over the past 5 years and analyze the reasons for our failures (Tables I and II). We hope to From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, California. Requests for reprints should be addressed to Luis 0. Vasconez, MD. Division of Plastic Surgery, Room U-147, University of California, San Francisco, California 94143. Presented at the 55th Annual Meeting of the Pacific Coast Surgical Association, Newport Beach, California, February 19-22, 1984.
Volume 148, July 1984
provide some helpful guidelines for avoiding or correcting these errors as well as our criteria and timing for reconstruction. Indications For and Timing of Reconstruction Breast reconstruction is an elective procedure that involves aesthetic objectives and, therefore, the common medical guidelines cannot be used. Generally, the indications for breast reconstruction involve personal quality of life issues and are clearly different from those of hernia repairs or mastectomies, From a psychologic point of view, breast reconstruction is a necessity for many women. It is estimated, however, that only 15 percent of all women who have undergone mastectomy seek breast reconstruction. The most important determinants that we use in our practice relate to the expectations of the patient and the limitations of the reconstructive surgeon. We believe it is imperative to work with the patient’s general surgeon and oncologist and, if possible, to obtain their acquiescence. Oncologic and psychologic factors, as well as the risk of further operative procedures, are considered. From the oncologic point of view, it is apparent that in most cases one should wait at least 2 years after mastectomy before starting reconstruction [5-71. Because of the potential detrimental effects of the chemotherapeutic agents on wound healing, it is also advisable to postpone reconstruction until after chemotherapy is completed. Of our 153 patients, 39 had chemotherapy and 23 had radiotherapy as an adjunct to the mastectomy. Psychologically, the patient’s expectations must be considered. If the patient seems overly anxious, it is probably better to reassure her and to delay reconstruction. The risk to the patient and the expense must always be considered because breast reconstruction is an elective
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TABLE I
Type of Reconstruction (n = 153) Unilateral
n
Latissimus dorsi & implant Lower rectus Abdominal advancement & implant Double Z-plasty & implant Implant only Upper rectus Thoracoepigastric flap & implant Skin expander Upper rectus & implant Thoracoepigastric & implant and latissimus dorsi de-epithelialized for subclavicular hollow
55 18 10 7 8 5 3 2 1 1
Total
Method of Reconstruction Reconstructions by simple insertion of a silicone implant were and still are appropriate in a number of patients (25 percent of our patients), especially those who have had the more recent conservative mastectomies. Introduction of the latissimus dorsi method of reconstruction offered the potential of reconstruction to patients with a Halsted radical mastectomy who have a total absence of the pectoralis major muscle, a deep subclavicular hollow, and often tight, thin skin or even skin grafts over the chest (Figure 1) [8,9]. Other methods are now available, including preformed implants [IO], skin expanders [11], and the spectacular transverse rectus abdominus flap of Hartrampf et al [12] (Figure 2). It is often not clear, even to experienced reconstructive surgeons, which method to use for a partic-
TABLE II
Latissimus dorsi & implant (bilateral) Latissimus dorsi 8 implant Implant only (bilateral) Latissimus dorsi & implant and upper rectus Latissimus dorsi & implant and lower rectus Radovan expander (bilateral) Double Z-plasty 8 implant (bilateral) Abdominal advancement & implant (bilateral) Double Z-plasty 8 implant Lower rectus and implant
14 10 10 2 2 2 2 1 1 1 45
ular patient. The mastectomy defect, however, should be analyzed and the objectives of obtaining symmetry kept constantly in mind. For the Halsted radical mastectomy, one needs to fill the subclavicular defect, add extra skin, and recreate the submammary fold, in addition to replacing the breast mound. With the modified mastectomy there is no subclavicular hollow, but we have observed in at least 75 percent of our patients, a certain amount of atrophy of the pectoralis major muscle and a loss of convexity of the chest wall (Figure 3). In all patients, the goal of reconstruction is to provide projection and ptosis to the reconstructed breast that matches the opposite breast. This ideal has met with only partial success in our series, and multistaged procedures or a combination of techniques are often needed to correct all of the defects. We have little experience with immediate reconstruction, having performed only 10, primarily because of logistics but also because of our inability to obtain a symmetric and satisfying reconstruction. Filling the subclavicular defect: The latissimus dorsi muscle, even when folded on itself, is not entirely adequate to fill the subclavicular defect. The best method has been to de-epithelialize the skin island of the latissimus dorsi muscle or to use the
Complications According to Type of Reconstruction (n = 153) Unilateral (n = 108)
104
n
108
procedure in which potential complications must be minimized. Nevertheless, we should point out that we have reconstructed two patients with known recurrence but have postponed reconstructions on young women whose degree of anxiety, anger, and expections were much more than available reconstructive techniques could offer. Each patient must be individually evaluated.
l
Bilateral
n
Capsule Seroma Hematoma Abdominal hernia Necrosis of distal lower rectus Dehiscence of wound Hypertrophic scar
20 2 2 3 1 1 1
Total + Percentage
31 28.7
Bilateral (n = 45)
n
Distal flap necrosis and contralateral capsule Hematoma and seroma Deflation of implant Infection Capsule, bilateral implants Implant extrusion, unilateral 7 15.5
The total number of all complications was 38. (24 percent).
The American Journal of Surgery
Reconstruction
Figure 1. Young patient aRer mastectomy with a skin graft over chest waii ( top). Postoperative resuits after reconstructkn with the iatissimus ckrsi myowtaneous fiap ( middie and bottom). in a&tition to the skin is/and, a skin graft was used over the iatissimus dorsi muscie.
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Fiwre 2. Two years after mastectomy with atrophy of the pecr0r~~~~andperNalypperchestconcavlty(top).Note siigftt winging of the scapuia indkative of denervatkn of the iatissimus dorsi mu&e, due to division of thorawxtorsai nerve (middie). postoperative resuit after reconstructkn with a transverse recks aMomkus myocutaneuus fiap (bottom) [ 721. Note that the mediaiportkn of ths flap has been de-epithsiiaiized to f/ii the subciavkuiar and upper chest hollow.
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Figure 3. Young woman after mod/fled mastectomy. Note the upper chest ho&w due to removal of the breast andpartialahvphy of the pectoral/s major muscle.
transverse rectus abdominus myocutaneous flap with its associated large skin island, even though the most distal part may be subject to fat necrosis. Partial atrophy of the pectoralis major muscle: Partial atrophy of the pectoralis major muscle is of concern to the patient because it leaves a visible superior concavity in an otherwise satisfactory reconstruction. The concavity may be filled with dermal grafts or preformed silicone i&plants, but these have not always corrected the contour defect. Silicohe implants: Experience has shown that silicone implants are simple but not always satisfactory replacements for the breast tissue itself. The body tends to form a capsule that isolates the foreign-body implant and makes it round. Once the capsule forms, it may contract and become firm. It is difficult to achieve an aesthetic reconstruction in the obese patient, even with the insertion of a very large implant. The method employing the transverse rectus abdominus myocutaneous flap avoids the necessity for a silastic implant because of the considerable bulk of tissue that can be moved into the mastectomy defect. Symmetry
Symmetry remains the greatest challenge (Figure is obvious that in reconstructing a breast, one must convert the flat mastectomized surface into a three-dimensional one with a flowing contour, projection, and ptosis that matches the opposite breast. This is an area that we are presently studying, and 4). It
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Figure 4. Patient with a modifbsd radkai mastectomy on the right side and a subcutaneous mastectomy on the left side (top). A symmetrk reconst~kn is ditYk& to obtain, In this patient, the excess skin on the left side was de-epitheiialked to give the implant a doubie covering, and s&mammary foids we; created at the same level (bottom).
suffice it to say, some of our findings have been surprising [unpublished data]. At the present time, we are trying to determine empirically which patients will need additional skin in the form of a flap and which patients can be reconstructed by simple insertion of an implant and perhaps a relatively minor mastopexy or reduction of the opposite breast. Prophylactic Mastectomies
Which patients will benefit from a prophylactic mastectomy can be a very difficult decision [13]. As plastic surgeons, we work closely with our general surgery colleagues to try to carefully select these persons. There is so much information on the subject of breast cancer that few people can keep up with it, and even fewer can critically analyze it. Two factors have been used and abused in deciding whether to ablate the contralateral breast, namely, the family
The American Journal of Surgery
Reconstruction of the Breast
history and the type of cancer and its incidence of bilaterality. All too often, details of family history that can greatly affect our assessment are incomplete. For example, the incidence of breast cancer within families may indeed reach 50 percent but only for those patients whose mothers have had both premenopausal and bilateral cancer. If the mother’s cancer, however, was unilateral and postmenopausal, the cumulative incidence is only 17 percent [14171. The cancers that tend to be bilateral, such as medullary and lobular carcinomas, often occur in young women, but they are also the ones with the best prognosis. If close follow-up is provided, these patients do not show a decrease in life expectancy when contralateral cancer is found [18,19]. However, having undergone the trauma of one mastectomy, they often do not want to go through the same thing again, especially if they received chemotherapy. They are easily persuaded to undergo ablative procedures on the other breast and frequently regret it later on. One should note that carcinoma of the breast is mainly a disease of elderly women in the United States. The cumulative lifetime risk of breast cancer is 9 percent, but it is only 6 percent to age 70 and 1.5 percent to age 50. Younger women with breast cancer naturally tend to live longer. Nipple saving Interest in preserving or banking the nipple for future use arose out of an old plastic surgical principle: “Do not throw away any tissue-save it” [20]. However, banking the nipple in the lower abdomen or groin has no biologic value. In fact, this has caused cancer to be transplanted or transferred to remote sites. Additionally, the saved nipple gives an unsatisfactory result if reused for reconstruction. The double transferring of the nipple and areola flattens the projection of the nipple and produces depigmentation of the areola. Better nipples and areolas can be reconstructed by other methods. Local Recurrence After Reconstruction Local recurrences are occasionally seen. Although it is difficult for us to have exact numbers, review of our postreconstructive cases revealed six local recurrences (4 percent) and two deaths. No conclusions can be drawn from this data that include patients who have had reconstruction without strict adherence to the oncologic criteria for low-risk patients. A number of questions arise. Does reconstruction mask recurrences? We believe it does not. Local recurrences appear in the skin or subcutaneous tissues, in the supraclavicular area, or on the chest wall. These are usually readily apparent by palpation. Mammography is helpful, and a silicone implant does not interfere with diagnosis. If dealing with a patient with a transverse rectus abdominus myocutaneous flap, xerography and fine-needle aspiration may be
Vobumo 140, July 1004
TABLE III
Revision of Operation With AddItional Reconstructive Procedures (n = 153)
Unilateral (n = 108)
n
Bilateral (n = 45)
n
Change implant Capsulotomy Z-plasty Abdominal advancement Scar revision
21 21 7 8
Change implant Capsulotomy Change both implants Z-plasty and implant (other side)
2 2 3 1
Total
57
l
l
2 8
The total number of revisions was 65.
diagnostic for indurations that could be either recurring cancer or fat necrosis. More difficult than making the diagnosis is knowing what to do when a local recurrence appears. If the recurrence is localized in the chest wall, excision, radiotherapy, or both are options. If radiotherapy is chosen, it should be mentioned that the presence of a Silastic@ implant does not alter the recommended dose. On two occasions, we excised the previous mastectomy scar and days later were surprised to find that histologic examination revealed tumor in the scar. In such cases, the proper course of treatment has not been clear. In one case, we opted for radiotherapy to the chest wall and in the other, for close observation of the patient. Revisional Surgery Persistent defects or lack of symmetry often call for additional reconstructive procedures (Table III). If the implant is too high, it may be lowered to create a symmetric submammary fold. Softening the reconstructed breast by either opened or closed capsulotomy is usually less successful. We are still uncertain as to how to obtain the proper amount of projection and ptosis, and at present, the persistent subclavicular hollow is only a partially solved problem. The Changing Field of Breast Reconstructkm There is increasing patient demand for breast reconstruction, and the field is constantly changing. As plastic surgeons, our reconstructive plans must address individual defects as they are presented. For example, it is just as challenging to reconstruct the breast of a patient who has been treated by lumpectomy or quadrantectomy and radiation as it is for a patient who has undergone a radical mastectomy [2122]. We know that simple insertion of an implant, even if preformed, is almost never satisfactory. The problem of persistent or recurrent breast cancer after radiotherapy needs to be addressed with specific guidelines established for treatment. We have encountered this frustrating problem and believe that, in time, it will become even more common.
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It is in these patients that we have undertaken socalled immediate reconstruction at the time of mastectomy, using tissue that brings its own blood supply, such as the latissimus dorsi muscle, the omentum, or the transverse rectus abdominus myocutaneous flap. It is performed not only because reconstruction is desired by the patient but more importantly, to ensure wound healing. The introduction of skin expanders has been an exciting addition to this field, but their ultimate role has yet to be determined. We have been inserting the expander at the time of mastectomy and fill it at intervals during the postoperative period to obtain a larger projection than that of the opposite breast. It is then replaced by a silicone gel implant in a second operative procedure in an attempt to obtain symmetry with the opposite breast. Patient acceptance of insertion of the skin expander at the time of mastectomy has been universally high. Its insertion has not significantly prolonged the operative time nor has it increased the rate of complications. In fact, it is possible that the amount of postoperative drainage is decreased. The expander is placed submuscularly, and when the wound has healed at approximately 2 weeks after mastectomy, it is filled with 50 ml of saline solution at weekly intervals until the desired expansion has been achieved. We have not observed any disruption of the wound, skin necrosis, or infections in our patients. The reconstructive aspect after skin expansion, however, has not been as simple as we had expected. The removal of the expander is easy enough, but the valve can be difficult to remove. In addition, the implant has invariably been placed higher than desired and had to be lowered. Determination of size to match the opposite breast has been difficult to judge, and capsular contracture seems to be just as common as it is with insertion of the implant secondarily. Satisfactory reconstructions, however, have been obtained with this method, and the patient’s psychologic reassurance has been the most satisfying aspect. We continue to strive for simple, safe, and symmetric reconstructions. Our aim is to avoid the use of the silastic implants, and if the opposite breast is aesthetically acceptable, to try to match it. We attempt to minimize or avoid scars, or at least to place them in less conspicuous places. Because complications can be disastrous, we make every attempt to avoid them. We are far from achieving these ideals, but we believe that we have made considerable progress. Summary We have analyzed our 5 year experience with 153 breast reconstructions. There were 83 latissimus dorsi reconstructions, 16 simple silicone implant insertions, 21 transverse rectus abdominus myocutaneous flaps, and 33 reconstructions using a variety of other methods. The rate of postoperative com-
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plications was 24 percent. The most common shortcoming was the inability to obtain symmetry with the other breast. Persistent problems included inability to fill the subclavicular hollow or the superior concavity due to partial atrophy of the pectoralis major muscle, and particularly, the lack of projection and ptosis in the reconstructed breast. Acknowledgment: Our sincere thanks to Drs. Thomas Hunt and William Goodson without whose help and advice we could not have performed the breast reconstructions.
References 1. Gillies HD. Surgical replacement of the breast. Proc R Sot Med 1959;52:597-602. 2. DeCholnoky T. Breast reconstruction after radical mastectomy: formation of a missing nipple by everted navel. Plast Reconstr Surg 1966;38:577-80. 3. Snyderman RK, Guthrie RH. Reconstruction of the female breast following radical mastectomy. Plast Reconstr Surg 1971; 47565-7. 4. Hueston J, McKenzie G. Breast reconstruction after radical mastectomy. Aust NZ J Surg 1970;39:367-70. 5. Schottenfeld D, Nash A, Robbins. G, et al. Ten year results of the treatment of primary operable breast cancer. Cancer 1976;38:1101-7. 6. Haagenser CD. Diseases of the breast, 2nd ed. Philadelphia: WB Saunders, 1971:648-707. 7. Mueller CB. Statistics of breast carcinoma. In: Gant T, Vasconez LO eds. Post mastectomy reconstruction. Baitimore: Williams and Wilkins, 19815-17. 8. Bostwick T, Vasconez LO, Jurkiewicz Ml. Breast reconstruction after radical mastectomy. Plast Reconstr Surg 1978;61: 682-93. 9. Vasconez LO, Johnson-Giebink R, Hall EJ. Breast reconstruction. Clin Plast Surg 1980;7:79-88. 10. Birnbaum L, Olsen JA. Breast reconstruction following radical mastectomy using custom-designed implants. Plast Reconstr Surg 1978;61:355-63. 11. Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg 1982;89:195208. 12. Hartrampf CR, Scleflam M, Block PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;89:216-24. 13. Buehler, PC. Patient selection for prophylactic mastectomy: who is at high risk? Plast Reconstr Surg 1983;72:324-9. 14. Anderson DE. Some characteristics of familial breast cancer. Cancer 1971;28:1500-4. 15. Kelly PT, Anderson DE. Your patient and cancer. Vol. 4. Roslyn Heights, NY: Dominos, 1981;25-32. 16. Kelly, PT. “High-risk” women: breast cancer concerns and health practices. Front Radiat Ther Oncol 1983;17:1 l-5. 17. Lynch HT. Management of familial breast cancer. Arch Surg 1978;113:1061-7. 18. McDivitt RW. Breast carcinoma. Hum Pathol 1978;9:3-21. 19. Mueller CB, Ames F. Bilateral carcinoma of the breast: frequency and mortality. Can J Surg 1978;21:459-65. 20. Millard DR, Devine J, Warren WD. Breast reconstruction: a plea for saving the uninvolved nipple. Am J Surg 1971;122: 763-4. 21. Goodson W, Ill. The next bit question in the treatment of carcinoma of the breast. Surg Gynecol Obstet 1983;156: 795-6. 22. Veronisi V, Saccazoni R, Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11.
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Discussion Philip R. Westdahl (San Francisco, CA): Dr. Vasconez and his coauthors have obviously had vast experience in the field of breast reconstruction. They seem to have encountered just about every problem to be found and have shown ingenuity and skill in attempting to solve them, not only from the technical aspect but also that of decisionmaking. The complications were presented candidly. I certainly have nothing to add relative to technique, but I would like to make a few observations from the point of view of the general surgeon based on my limited personal experience. Of 170 of my patients who had a modified radical mastectomy, only 10 have sought reconstruction. I like to believe that surgical technique may have played a part. I certainly agree that any mastectomy is a traumatic psychologic experience for most women. However, I do not concur that it must result in “mutilation,” as it is frequently described in lay as well as medical literature. My preference is for a modified radical mastectomy. In most instances, a low transverse or oblique incision is feasible. I was trained to use wide skin removal, frequently resulting in the need for a graft. This no longer seems necessary, particularly in the more favorable primary cancers we generally see. Reasonably thin skin flaps are preferable and facilitate dissection. Every effort should be made to preserve the nerve supply to the pectoralis major muscle to prevent atrophy. Local recurrence has been 7.5 percent, and axillary node persistence occurred in only one patient (an overlooked apical node). Patient acceptance, without seeking reconstruction, has been generally good. This is one reason why I have favored a delay of several months before proposing reconstruction. Under most circumstances, I would not consider a delay of 2 years, as advocated by the authors, to be necessary. The authors were obviously faced with a high percentage of selective and challenging problems. A modified radical mastectomy using the technique described should reduce the need for myocutaneous flaps. Reconstruction, if desired, is simplified. The use of a skin expander placed subpectorally at the time of mastectomy is on the increase. Although the authors used it in only a few patients thus far, it was indicated that patient satisfaction was high. If the need arises for some form of revision of the contralateral breast in order to obtain symmetry, this can be accomplished at the time of replacement of the expander. The authors raised the question of prophylactic mastectomy should revision be necessary, although they do not favor it and it has not been used in this series. Both the need for and the type of mastectomy are open to controversy. It should be reserved for patients at high risk of cancer development in the remaining breast, but how high is high? A very significant, well-documented family history or the presence of a primary cancer prone to bilaterality were mentioned. To this I would add a previous biopsy specimen showing a high degree of atypia. A contralateral biopsy specimen obtained at the time of the initial mastectomy might prove helpful. Finally, a word about breast conservation surgery and radiation which the authors alluded to. In my opinion, the primary indication for this method is the preservation of a cosmetically pleasing breast. If this cannot be accomplished because of a large tumor in proportion to breast size or a subareoler or medially located tumor that does not lend itself to adequate resection
Volume148,July 1884
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without deformity, the patient should be made aware of this before surgery and be further encouraged to have a total mastectomy. I concur with the authors that the resultant deformity does not lend itself to a satisfactory reconstruction. However, the demand for lesser surgery is on the increase. In the past 5 years, the number of my patients who have opted for it has increased from 10 to 50 percent. I continue to have reservations but an open mind on its relative merit as a means of local and regional control. John R. Benfield (Los Angeles, CA.): It isn’t often with the passage of time that one becomes more liberal rather than more conservative. In the area of breast reconstruction I must say I have become more liberal in the past 5 years based on our follow-up of literally hundreds of women who have had mastectomy. I now think it is quite appropriate to proceed with early reconstruction in carefully selected patients. I see breast reconstruction as a palliative operation, even in women who have had cure of their breast cancer. It is palliative for their psyche. I think it is quite appropriate in women who are properly prepared and properly motivated to proceed with breast reconstruction in large part because they want it and they need it for their own mental sense of well-being. Therefore, our approach to breast reconstruction has evolved to be quite liberal. We now utilize it as soon as we think that the patient is ready and in need of it. On rare occasion-and I emphasize rare-we will even proceed with breast reconstruction in women who have had evidence of systemic disease when they are in need of psychologic palliation. William S. Fletcher (Portland, OR): I would like to expand on one of the authors’ points regarding not transplanting the nipple, and I heartily concur. We looked at the problem of whether or not reduction in breast tissue proportionately reduces the incidence of breast cancer in a high-risk model, and we used the Brach-Dolly rat with a DMB-induced tumor and, as you know, rats have 12 breasts, so in one group we removed 3 breasts and in another we removed 6 breasts, and in another group we removed 9 breasts, and in the last group we removed all the breasts. We found that when you remove a quarter of the breast, you reduce the incidence of tumor in that quadrant but it goes up in the other three quadrants, and when you reduce the breast tissue by half, it doubles the other side, and when you reduce it by three quarters, it triples the incidence in the remaining quarter, so there must be a serve-all mechanism here that attacks the residual breast tissue more vigorously. If one leaves any breast tissue, the sum total number of tumors is the same no matter how much breast tissue is removed. Therefore, I do not believe in our present state of knowledge that there is any role for subcutaneous mastectomy or nipple preservation. I would appreciate Dr. Vasconez’s thoughts and comments on this point. Luis 0. Vasconez (closing): Only 10 to 15 percent of all patients with mastectomy undergo breast reconstruction, and I don’t know if this is increasing or not. However, I agree with what Dr. Benfield indicated. One of the criteria we use when considering reconstruction is the patient’s expectations and what we can offer as an operative result. Some patients may have expectations that are more than we can deliver with an imperfect product, and we would probably postpone that reconstruction. In other patients,
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we may perform reconstruction in less than the 2 years that I indicated as a general rule. The Silastic implant provides the easiest method of replacing the breast mound, but it is not ideal. This rounded effect and hardness detract from the result. We have a high incidence of capsular contracture. I know that our incidence is higher than most. I don’t know why, but fortunately, again with proper explanation to the patient, the problem can be minimized. We would like to avoid the use of the implants. That usually means the choice of the transverse rectus abdominus flap opera-
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tion, as described by Hartrampf and co-workers, which has the highest number of complications. As Dr. Westdahl said, the patients who have had quadrantectomy and irradiation, and occasionally a primary reconstruction present the most challenging reconstructive problems, and we have fallen very short of achieving a satisfactory result. Regarding subcutaneous mastectomy, I agree with Dr. Fletcher; its use is unclear. I find that operation still does not have a clear indication, and I perform it very infrequently.
The American Journal ol Surgery
Luis 0. Vasconez, MD, San Francisco, California James C. Grottlng, MD, San Francisco, California Wiltredo Calderon, MD, San Francisco, California Stephen J. Nlathes, MD, San Francisco, California
Breast reconstruction is still an imperfect operation. The demand for it, however, is increasing, and it is taxing the ingenuity and imagination of the reconstructive plastic surgeon. For us, it has been a learning experience-at times humbling, at other times depressing, but often most satisfying. When we undertake to do a breast reconstruction, we consider the patient’s safety, aim for relative simplicity, and strive to achieve symmetry with the other breast which is a frequently unfulfilled goal. Breast reconstruction began as an empirical procedure, first with the use of a variety of multistaged operations and tube flaps, and had its modern rebirth in 1971with the introduction of the silicone implant, which was an attempt to replace the breast mound lost at the time of mastectomy [j-4]. Initial breast reconstructions consisted of simple insertions of these implants and were, for the most part, unsatisfactory. Properly carried out symmetric reconstructions are now more common and are a source of satisfaction to the surgeon and the patient. To obtain symmetry, however, we have usually resorted to operations that alter the opposite breast, some of which have been ill-advised and counterproductive. In our practice, we have performed 22 reduction mammoplasties, 12 augmentation mammoplasties, and 9 mastopexies on the normal side. Herein we review our experience with 153 breast reconstructions over the past 5 years and analyze the reasons for our failures (Tables I and II). We hope to From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, California. Requests for reprints should be addressed to Luis 0. Vasconez, MD. Division of Plastic Surgery, Room U-147, University of California, San Francisco, California 94143. Presented at the 55th Annual Meeting of the Pacific Coast Surgical Association, Newport Beach, California, February 19-22, 1984.
Volume 148, July 1984
provide some helpful guidelines for avoiding or correcting these errors as well as our criteria and timing for reconstruction. Indications For and Timing of Reconstruction Breast reconstruction is an elective procedure that involves aesthetic objectives and, therefore, the common medical guidelines cannot be used. Generally, the indications for breast reconstruction involve personal quality of life issues and are clearly different from those of hernia repairs or mastectomies, From a psychologic point of view, breast reconstruction is a necessity for many women. It is estimated, however, that only 15 percent of all women who have undergone mastectomy seek breast reconstruction. The most important determinants that we use in our practice relate to the expectations of the patient and the limitations of the reconstructive surgeon. We believe it is imperative to work with the patient’s general surgeon and oncologist and, if possible, to obtain their acquiescence. Oncologic and psychologic factors, as well as the risk of further operative procedures, are considered. From the oncologic point of view, it is apparent that in most cases one should wait at least 2 years after mastectomy before starting reconstruction [5-71. Because of the potential detrimental effects of the chemotherapeutic agents on wound healing, it is also advisable to postpone reconstruction until after chemotherapy is completed. Of our 153 patients, 39 had chemotherapy and 23 had radiotherapy as an adjunct to the mastectomy. Psychologically, the patient’s expectations must be considered. If the patient seems overly anxious, it is probably better to reassure her and to delay reconstruction. The risk to the patient and the expense must always be considered because breast reconstruction is an elective
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TABLE I
Type of Reconstruction (n = 153) Unilateral
n
Latissimus dorsi & implant Lower rectus Abdominal advancement & implant Double Z-plasty & implant Implant only Upper rectus Thoracoepigastric flap & implant Skin expander Upper rectus & implant Thoracoepigastric & implant and latissimus dorsi de-epithelialized for subclavicular hollow
55 18 10 7 8 5 3 2 1 1
Total
Method of Reconstruction Reconstructions by simple insertion of a silicone implant were and still are appropriate in a number of patients (25 percent of our patients), especially those who have had the more recent conservative mastectomies. Introduction of the latissimus dorsi method of reconstruction offered the potential of reconstruction to patients with a Halsted radical mastectomy who have a total absence of the pectoralis major muscle, a deep subclavicular hollow, and often tight, thin skin or even skin grafts over the chest (Figure 1) [8,9]. Other methods are now available, including preformed implants [IO], skin expanders [11], and the spectacular transverse rectus abdominus flap of Hartrampf et al [12] (Figure 2). It is often not clear, even to experienced reconstructive surgeons, which method to use for a partic-
TABLE II
Latissimus dorsi & implant (bilateral) Latissimus dorsi 8 implant Implant only (bilateral) Latissimus dorsi & implant and upper rectus Latissimus dorsi & implant and lower rectus Radovan expander (bilateral) Double Z-plasty 8 implant (bilateral) Abdominal advancement & implant (bilateral) Double Z-plasty 8 implant Lower rectus and implant
14 10 10 2 2 2 2 1 1 1 45
ular patient. The mastectomy defect, however, should be analyzed and the objectives of obtaining symmetry kept constantly in mind. For the Halsted radical mastectomy, one needs to fill the subclavicular defect, add extra skin, and recreate the submammary fold, in addition to replacing the breast mound. With the modified mastectomy there is no subclavicular hollow, but we have observed in at least 75 percent of our patients, a certain amount of atrophy of the pectoralis major muscle and a loss of convexity of the chest wall (Figure 3). In all patients, the goal of reconstruction is to provide projection and ptosis to the reconstructed breast that matches the opposite breast. This ideal has met with only partial success in our series, and multistaged procedures or a combination of techniques are often needed to correct all of the defects. We have little experience with immediate reconstruction, having performed only 10, primarily because of logistics but also because of our inability to obtain a symmetric and satisfying reconstruction. Filling the subclavicular defect: The latissimus dorsi muscle, even when folded on itself, is not entirely adequate to fill the subclavicular defect. The best method has been to de-epithelialize the skin island of the latissimus dorsi muscle or to use the
Complications According to Type of Reconstruction (n = 153) Unilateral (n = 108)
104
n
108
procedure in which potential complications must be minimized. Nevertheless, we should point out that we have reconstructed two patients with known recurrence but have postponed reconstructions on young women whose degree of anxiety, anger, and expections were much more than available reconstructive techniques could offer. Each patient must be individually evaluated.
l
Bilateral
n
Capsule Seroma Hematoma Abdominal hernia Necrosis of distal lower rectus Dehiscence of wound Hypertrophic scar
20 2 2 3 1 1 1
Total + Percentage
31 28.7
Bilateral (n = 45)
n
Distal flap necrosis and contralateral capsule Hematoma and seroma Deflation of implant Infection Capsule, bilateral implants Implant extrusion, unilateral 7 15.5
The total number of all complications was 38. (24 percent).
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Reconstruction
Figure 1. Young patient aRer mastectomy with a skin graft over chest waii ( top). Postoperative resuits after reconstructkn with the iatissimus ckrsi myowtaneous fiap ( middie and bottom). in a&tition to the skin is/and, a skin graft was used over the iatissimus dorsi muscie.
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Fiwre 2. Two years after mastectomy with atrophy of the pecr0r~~~~andperNalypperchestconcavlty(top).Note siigftt winging of the scapuia indkative of denervatkn of the iatissimus dorsi mu&e, due to division of thorawxtorsai nerve (middie). postoperative resuit after reconstructkn with a transverse recks aMomkus myocutaneuus fiap (bottom) [ 721. Note that the mediaiportkn of ths flap has been de-epithsiiaiized to f/ii the subciavkuiar and upper chest hollow.
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Figure 3. Young woman after mod/fled mastectomy. Note the upper chest ho&w due to removal of the breast andpartialahvphy of the pectoral/s major muscle.
transverse rectus abdominus myocutaneous flap with its associated large skin island, even though the most distal part may be subject to fat necrosis. Partial atrophy of the pectoralis major muscle: Partial atrophy of the pectoralis major muscle is of concern to the patient because it leaves a visible superior concavity in an otherwise satisfactory reconstruction. The concavity may be filled with dermal grafts or preformed silicone i&plants, but these have not always corrected the contour defect. Silicohe implants: Experience has shown that silicone implants are simple but not always satisfactory replacements for the breast tissue itself. The body tends to form a capsule that isolates the foreign-body implant and makes it round. Once the capsule forms, it may contract and become firm. It is difficult to achieve an aesthetic reconstruction in the obese patient, even with the insertion of a very large implant. The method employing the transverse rectus abdominus myocutaneous flap avoids the necessity for a silastic implant because of the considerable bulk of tissue that can be moved into the mastectomy defect. Symmetry
Symmetry remains the greatest challenge (Figure is obvious that in reconstructing a breast, one must convert the flat mastectomized surface into a three-dimensional one with a flowing contour, projection, and ptosis that matches the opposite breast. This is an area that we are presently studying, and 4). It
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Figure 4. Patient with a modifbsd radkai mastectomy on the right side and a subcutaneous mastectomy on the left side (top). A symmetrk reconst~kn is ditYk& to obtain, In this patient, the excess skin on the left side was de-epitheiialked to give the implant a doubie covering, and s&mammary foids we; created at the same level (bottom).
suffice it to say, some of our findings have been surprising [unpublished data]. At the present time, we are trying to determine empirically which patients will need additional skin in the form of a flap and which patients can be reconstructed by simple insertion of an implant and perhaps a relatively minor mastopexy or reduction of the opposite breast. Prophylactic Mastectomies
Which patients will benefit from a prophylactic mastectomy can be a very difficult decision [13]. As plastic surgeons, we work closely with our general surgery colleagues to try to carefully select these persons. There is so much information on the subject of breast cancer that few people can keep up with it, and even fewer can critically analyze it. Two factors have been used and abused in deciding whether to ablate the contralateral breast, namely, the family
The American Journal of Surgery
Reconstruction of the Breast
history and the type of cancer and its incidence of bilaterality. All too often, details of family history that can greatly affect our assessment are incomplete. For example, the incidence of breast cancer within families may indeed reach 50 percent but only for those patients whose mothers have had both premenopausal and bilateral cancer. If the mother’s cancer, however, was unilateral and postmenopausal, the cumulative incidence is only 17 percent [14171. The cancers that tend to be bilateral, such as medullary and lobular carcinomas, often occur in young women, but they are also the ones with the best prognosis. If close follow-up is provided, these patients do not show a decrease in life expectancy when contralateral cancer is found [18,19]. However, having undergone the trauma of one mastectomy, they often do not want to go through the same thing again, especially if they received chemotherapy. They are easily persuaded to undergo ablative procedures on the other breast and frequently regret it later on. One should note that carcinoma of the breast is mainly a disease of elderly women in the United States. The cumulative lifetime risk of breast cancer is 9 percent, but it is only 6 percent to age 70 and 1.5 percent to age 50. Younger women with breast cancer naturally tend to live longer. Nipple saving Interest in preserving or banking the nipple for future use arose out of an old plastic surgical principle: “Do not throw away any tissue-save it” [20]. However, banking the nipple in the lower abdomen or groin has no biologic value. In fact, this has caused cancer to be transplanted or transferred to remote sites. Additionally, the saved nipple gives an unsatisfactory result if reused for reconstruction. The double transferring of the nipple and areola flattens the projection of the nipple and produces depigmentation of the areola. Better nipples and areolas can be reconstructed by other methods. Local Recurrence After Reconstruction Local recurrences are occasionally seen. Although it is difficult for us to have exact numbers, review of our postreconstructive cases revealed six local recurrences (4 percent) and two deaths. No conclusions can be drawn from this data that include patients who have had reconstruction without strict adherence to the oncologic criteria for low-risk patients. A number of questions arise. Does reconstruction mask recurrences? We believe it does not. Local recurrences appear in the skin or subcutaneous tissues, in the supraclavicular area, or on the chest wall. These are usually readily apparent by palpation. Mammography is helpful, and a silicone implant does not interfere with diagnosis. If dealing with a patient with a transverse rectus abdominus myocutaneous flap, xerography and fine-needle aspiration may be
Vobumo 140, July 1004
TABLE III
Revision of Operation With AddItional Reconstructive Procedures (n = 153)
Unilateral (n = 108)
n
Bilateral (n = 45)
n
Change implant Capsulotomy Z-plasty Abdominal advancement Scar revision
21 21 7 8
Change implant Capsulotomy Change both implants Z-plasty and implant (other side)
2 2 3 1
Total
57
l
l
2 8
The total number of revisions was 65.
diagnostic for indurations that could be either recurring cancer or fat necrosis. More difficult than making the diagnosis is knowing what to do when a local recurrence appears. If the recurrence is localized in the chest wall, excision, radiotherapy, or both are options. If radiotherapy is chosen, it should be mentioned that the presence of a Silastic@ implant does not alter the recommended dose. On two occasions, we excised the previous mastectomy scar and days later were surprised to find that histologic examination revealed tumor in the scar. In such cases, the proper course of treatment has not been clear. In one case, we opted for radiotherapy to the chest wall and in the other, for close observation of the patient. Revisional Surgery Persistent defects or lack of symmetry often call for additional reconstructive procedures (Table III). If the implant is too high, it may be lowered to create a symmetric submammary fold. Softening the reconstructed breast by either opened or closed capsulotomy is usually less successful. We are still uncertain as to how to obtain the proper amount of projection and ptosis, and at present, the persistent subclavicular hollow is only a partially solved problem. The Changing Field of Breast Reconstructkm There is increasing patient demand for breast reconstruction, and the field is constantly changing. As plastic surgeons, our reconstructive plans must address individual defects as they are presented. For example, it is just as challenging to reconstruct the breast of a patient who has been treated by lumpectomy or quadrantectomy and radiation as it is for a patient who has undergone a radical mastectomy [2122]. We know that simple insertion of an implant, even if preformed, is almost never satisfactory. The problem of persistent or recurrent breast cancer after radiotherapy needs to be addressed with specific guidelines established for treatment. We have encountered this frustrating problem and believe that, in time, it will become even more common.
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It is in these patients that we have undertaken socalled immediate reconstruction at the time of mastectomy, using tissue that brings its own blood supply, such as the latissimus dorsi muscle, the omentum, or the transverse rectus abdominus myocutaneous flap. It is performed not only because reconstruction is desired by the patient but more importantly, to ensure wound healing. The introduction of skin expanders has been an exciting addition to this field, but their ultimate role has yet to be determined. We have been inserting the expander at the time of mastectomy and fill it at intervals during the postoperative period to obtain a larger projection than that of the opposite breast. It is then replaced by a silicone gel implant in a second operative procedure in an attempt to obtain symmetry with the opposite breast. Patient acceptance of insertion of the skin expander at the time of mastectomy has been universally high. Its insertion has not significantly prolonged the operative time nor has it increased the rate of complications. In fact, it is possible that the amount of postoperative drainage is decreased. The expander is placed submuscularly, and when the wound has healed at approximately 2 weeks after mastectomy, it is filled with 50 ml of saline solution at weekly intervals until the desired expansion has been achieved. We have not observed any disruption of the wound, skin necrosis, or infections in our patients. The reconstructive aspect after skin expansion, however, has not been as simple as we had expected. The removal of the expander is easy enough, but the valve can be difficult to remove. In addition, the implant has invariably been placed higher than desired and had to be lowered. Determination of size to match the opposite breast has been difficult to judge, and capsular contracture seems to be just as common as it is with insertion of the implant secondarily. Satisfactory reconstructions, however, have been obtained with this method, and the patient’s psychologic reassurance has been the most satisfying aspect. We continue to strive for simple, safe, and symmetric reconstructions. Our aim is to avoid the use of the silastic implants, and if the opposite breast is aesthetically acceptable, to try to match it. We attempt to minimize or avoid scars, or at least to place them in less conspicuous places. Because complications can be disastrous, we make every attempt to avoid them. We are far from achieving these ideals, but we believe that we have made considerable progress. Summary We have analyzed our 5 year experience with 153 breast reconstructions. There were 83 latissimus dorsi reconstructions, 16 simple silicone implant insertions, 21 transverse rectus abdominus myocutaneous flaps, and 33 reconstructions using a variety of other methods. The rate of postoperative com-
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plications was 24 percent. The most common shortcoming was the inability to obtain symmetry with the other breast. Persistent problems included inability to fill the subclavicular hollow or the superior concavity due to partial atrophy of the pectoralis major muscle, and particularly, the lack of projection and ptosis in the reconstructed breast. Acknowledgment: Our sincere thanks to Drs. Thomas Hunt and William Goodson without whose help and advice we could not have performed the breast reconstructions.
References 1. Gillies HD. Surgical replacement of the breast. Proc R Sot Med 1959;52:597-602. 2. DeCholnoky T. Breast reconstruction after radical mastectomy: formation of a missing nipple by everted navel. Plast Reconstr Surg 1966;38:577-80. 3. Snyderman RK, Guthrie RH. Reconstruction of the female breast following radical mastectomy. Plast Reconstr Surg 1971; 47565-7. 4. Hueston J, McKenzie G. Breast reconstruction after radical mastectomy. Aust NZ J Surg 1970;39:367-70. 5. Schottenfeld D, Nash A, Robbins. G, et al. Ten year results of the treatment of primary operable breast cancer. Cancer 1976;38:1101-7. 6. Haagenser CD. Diseases of the breast, 2nd ed. Philadelphia: WB Saunders, 1971:648-707. 7. Mueller CB. Statistics of breast carcinoma. In: Gant T, Vasconez LO eds. Post mastectomy reconstruction. Baitimore: Williams and Wilkins, 19815-17. 8. Bostwick T, Vasconez LO, Jurkiewicz Ml. Breast reconstruction after radical mastectomy. Plast Reconstr Surg 1978;61: 682-93. 9. Vasconez LO, Johnson-Giebink R, Hall EJ. Breast reconstruction. Clin Plast Surg 1980;7:79-88. 10. Birnbaum L, Olsen JA. Breast reconstruction following radical mastectomy using custom-designed implants. Plast Reconstr Surg 1978;61:355-63. 11. Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg 1982;89:195208. 12. Hartrampf CR, Scleflam M, Block PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;89:216-24. 13. Buehler, PC. Patient selection for prophylactic mastectomy: who is at high risk? Plast Reconstr Surg 1983;72:324-9. 14. Anderson DE. Some characteristics of familial breast cancer. Cancer 1971;28:1500-4. 15. Kelly PT, Anderson DE. Your patient and cancer. Vol. 4. Roslyn Heights, NY: Dominos, 1981;25-32. 16. Kelly, PT. “High-risk” women: breast cancer concerns and health practices. Front Radiat Ther Oncol 1983;17:1 l-5. 17. Lynch HT. Management of familial breast cancer. Arch Surg 1978;113:1061-7. 18. McDivitt RW. Breast carcinoma. Hum Pathol 1978;9:3-21. 19. Mueller CB, Ames F. Bilateral carcinoma of the breast: frequency and mortality. Can J Surg 1978;21:459-65. 20. Millard DR, Devine J, Warren WD. Breast reconstruction: a plea for saving the uninvolved nipple. Am J Surg 1971;122: 763-4. 21. Goodson W, Ill. The next bit question in the treatment of carcinoma of the breast. Surg Gynecol Obstet 1983;156: 795-6. 22. Veronisi V, Saccazoni R, Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11.
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Discussion Philip R. Westdahl (San Francisco, CA): Dr. Vasconez and his coauthors have obviously had vast experience in the field of breast reconstruction. They seem to have encountered just about every problem to be found and have shown ingenuity and skill in attempting to solve them, not only from the technical aspect but also that of decisionmaking. The complications were presented candidly. I certainly have nothing to add relative to technique, but I would like to make a few observations from the point of view of the general surgeon based on my limited personal experience. Of 170 of my patients who had a modified radical mastectomy, only 10 have sought reconstruction. I like to believe that surgical technique may have played a part. I certainly agree that any mastectomy is a traumatic psychologic experience for most women. However, I do not concur that it must result in “mutilation,” as it is frequently described in lay as well as medical literature. My preference is for a modified radical mastectomy. In most instances, a low transverse or oblique incision is feasible. I was trained to use wide skin removal, frequently resulting in the need for a graft. This no longer seems necessary, particularly in the more favorable primary cancers we generally see. Reasonably thin skin flaps are preferable and facilitate dissection. Every effort should be made to preserve the nerve supply to the pectoralis major muscle to prevent atrophy. Local recurrence has been 7.5 percent, and axillary node persistence occurred in only one patient (an overlooked apical node). Patient acceptance, without seeking reconstruction, has been generally good. This is one reason why I have favored a delay of several months before proposing reconstruction. Under most circumstances, I would not consider a delay of 2 years, as advocated by the authors, to be necessary. The authors were obviously faced with a high percentage of selective and challenging problems. A modified radical mastectomy using the technique described should reduce the need for myocutaneous flaps. Reconstruction, if desired, is simplified. The use of a skin expander placed subpectorally at the time of mastectomy is on the increase. Although the authors used it in only a few patients thus far, it was indicated that patient satisfaction was high. If the need arises for some form of revision of the contralateral breast in order to obtain symmetry, this can be accomplished at the time of replacement of the expander. The authors raised the question of prophylactic mastectomy should revision be necessary, although they do not favor it and it has not been used in this series. Both the need for and the type of mastectomy are open to controversy. It should be reserved for patients at high risk of cancer development in the remaining breast, but how high is high? A very significant, well-documented family history or the presence of a primary cancer prone to bilaterality were mentioned. To this I would add a previous biopsy specimen showing a high degree of atypia. A contralateral biopsy specimen obtained at the time of the initial mastectomy might prove helpful. Finally, a word about breast conservation surgery and radiation which the authors alluded to. In my opinion, the primary indication for this method is the preservation of a cosmetically pleasing breast. If this cannot be accomplished because of a large tumor in proportion to breast size or a subareoler or medially located tumor that does not lend itself to adequate resection
Volume148,July 1884
of the Breast
without deformity, the patient should be made aware of this before surgery and be further encouraged to have a total mastectomy. I concur with the authors that the resultant deformity does not lend itself to a satisfactory reconstruction. However, the demand for lesser surgery is on the increase. In the past 5 years, the number of my patients who have opted for it has increased from 10 to 50 percent. I continue to have reservations but an open mind on its relative merit as a means of local and regional control. John R. Benfield (Los Angeles, CA.): It isn’t often with the passage of time that one becomes more liberal rather than more conservative. In the area of breast reconstruction I must say I have become more liberal in the past 5 years based on our follow-up of literally hundreds of women who have had mastectomy. I now think it is quite appropriate to proceed with early reconstruction in carefully selected patients. I see breast reconstruction as a palliative operation, even in women who have had cure of their breast cancer. It is palliative for their psyche. I think it is quite appropriate in women who are properly prepared and properly motivated to proceed with breast reconstruction in large part because they want it and they need it for their own mental sense of well-being. Therefore, our approach to breast reconstruction has evolved to be quite liberal. We now utilize it as soon as we think that the patient is ready and in need of it. On rare occasion-and I emphasize rare-we will even proceed with breast reconstruction in women who have had evidence of systemic disease when they are in need of psychologic palliation. William S. Fletcher (Portland, OR): I would like to expand on one of the authors’ points regarding not transplanting the nipple, and I heartily concur. We looked at the problem of whether or not reduction in breast tissue proportionately reduces the incidence of breast cancer in a high-risk model, and we used the Brach-Dolly rat with a DMB-induced tumor and, as you know, rats have 12 breasts, so in one group we removed 3 breasts and in another we removed 6 breasts, and in another group we removed 9 breasts, and in the last group we removed all the breasts. We found that when you remove a quarter of the breast, you reduce the incidence of tumor in that quadrant but it goes up in the other three quadrants, and when you reduce the breast tissue by half, it doubles the other side, and when you reduce it by three quarters, it triples the incidence in the remaining quarter, so there must be a serve-all mechanism here that attacks the residual breast tissue more vigorously. If one leaves any breast tissue, the sum total number of tumors is the same no matter how much breast tissue is removed. Therefore, I do not believe in our present state of knowledge that there is any role for subcutaneous mastectomy or nipple preservation. I would appreciate Dr. Vasconez’s thoughts and comments on this point. Luis 0. Vasconez (closing): Only 10 to 15 percent of all patients with mastectomy undergo breast reconstruction, and I don’t know if this is increasing or not. However, I agree with what Dr. Benfield indicated. One of the criteria we use when considering reconstruction is the patient’s expectations and what we can offer as an operative result. Some patients may have expectations that are more than we can deliver with an imperfect product, and we would probably postpone that reconstruction. In other patients,
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we may perform reconstruction in less than the 2 years that I indicated as a general rule. The Silastic implant provides the easiest method of replacing the breast mound, but it is not ideal. This rounded effect and hardness detract from the result. We have a high incidence of capsular contracture. I know that our incidence is higher than most. I don’t know why, but fortunately, again with proper explanation to the patient, the problem can be minimized. We would like to avoid the use of the implants. That usually means the choice of the transverse rectus abdominus flap opera-
110
tion, as described by Hartrampf and co-workers, which has the highest number of complications. As Dr. Westdahl said, the patients who have had quadrantectomy and irradiation, and occasionally a primary reconstruction present the most challenging reconstructive problems, and we have fallen very short of achieving a satisfactory result. Regarding subcutaneous mastectomy, I agree with Dr. Fletcher; its use is unclear. I find that operation still does not have a clear indication, and I perform it very infrequently.
The American Journal ol Surgery