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The Use of Reduction Mammaplasty with Breast Conservation Therapy: An Analysis of Timing and Outcomes
The Use of Reduction Mammaplasty with Breast Conservation Therapy: An Analysis of Timing and Outcomes Egro FM, Pinell-White X, Hart AM, et al (Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA) Plast Reconstr Surg 135:963e-971e, 2015
Background.dOncoplastic reduction mammaplasty is often used to prevent or correct breast conservation therapy deformities. The purpose of this review was to evaluate surgical outcomes, patient satisfaction, and aesthetic outcomes of this procedure when performed before or after radiation therapy. Methods.dBreast cancer patients treated with breast conservation therapy and reduction mammaplasty between 2005 and 2012 were divided into immediate reconstruction, delayed immediate reconstruction, and delayed reconstruction. Greater than 6-month follow-up was required for inclusion. Patient demographics and clinical outcomes, including complications, patient satisfaction, and aesthetic result, were queried. Patient satisfaction was determined using the BREAST-Q survey. Postoperative photographs were used to rate aesthetic outcomes blinded to the timing of the procedure. Results.dPatients in the immediate reconstruction group had fewer complications (immediate reconstruction, 20.5 percent; delayed immediate reconstruction, 33.3 percent; delayed reconstruction, 60.0 percent; p < 0.001) and asymmetry (immediate reconstruction, 8.5 percent; delayed immediate reconstruction, 44.4 percent; delayed reconstruction, 24.0 percent; p < 0.001), and required fewer procedures to complete the reconstruction (immediate reconstruction, 1.2;
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delayed immediate reconstruction, 2.4; delayed reconstruction, 2.2; p < 0.001). Delayed reconstruction resulted in higher complication and fat necrosis rates (immediate reconstruction, 0.9 percent; delayed immediate reconstruction, 0.0 percent; delayed reconstruction, 8.0 percent; p ¼ 0.047). Although patient satisfaction and aesthetic outcomes were better in the immediate reconstruction group, this difference was not statistically significant. Conclusions.dOncoplastic reduction techniques performed before radiation therapy result in fewer complications. Good patient satisfaction and aesthetic outcomes can be achieved when reduction is performed before or after radiation therapy, but patient selection and education are important. Clinical Question/Level of Evidence.dTherapeutic, III. As reported in this article by Egro and colleagues, the Emory University plastic surgery group performed a retrospective review of prospectively collected data to evaluate the surgical outcomes, patient satisfaction, and aesthetic outcomes of reduction mammaplasty with breast conservation therapy. The authors performed a retrospective review of all breast cancer patients treated with breast conservation therapy who underwent breast reduction performed by the senior author from January 2005 to December 2012. One hundred sixty patients were identified and divided into 3 groups based on the timing of the breast reduction. Specifically, the groups were (1) immediate (breast reduction performed at the time of breast conservation therapy), (2) delayed-immediate (breast reduction performed following confirmation of negative margins), and (3) delayed (breast reduction performed following completion of breast conservation
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
therapy and adjuvant radiation). Demographics, comorbidities, oncologic and operative details, need for adjuvant chemotherapy, surgical outcomes (complications, asymmetry, number of revisions, and total number of operations), patient satisfaction, and aesthetic outcomes were reviewed. The authors concluded that oncoplastic reduction techniques performed before radiation therapy results in fewer complications, although good patient satisfaction and aesthetic outcomes can be achieved regardless of the timing of reduction mammaplasty. The oncologic safety of breast conservation therapy and the beneficial effects of adjuvant radiation treatment are well established in the breast surgical community. In recent years, we have witnessed an increase in the number of segmental mastectomies being performed by breast surgeons as well as an increase in the use of oncoplastic techniques by plastic surgeons to obliterate acquired segmental mastectomy defects and improve the breast’s overall appearance following radiation treatment.1 The current study addressed the use of oncoplastic reconstruction through the technique of reduction mammaplasty in patients with macromastia who were diagnosed with breast cancer and were amenable to segmental mastectomy. It is not surprising that the complication rate was lower with the immediate approach. Reoperating on a recently explored field or after radiation treatment increases the risk of complications secondary to inflammatory changes as well as altered vascular supply. Furthermore, as the authors emphasized, skin quality after adjuvant radiotherapy could have a negative effect on the wound healing process and overall outcomes. It was interesting to see that overall patient satisfaction was not affected to a
statistically significant degree by timing; however, that could be explained by the fact that patients in the delayed group were more comfortable with the acquired breast deformity, which could have affected their expectations. Also, fewer patients in the delayed group underwent adjuvant chemotherapy and experienced the adverse events associated with it. As the authors accurately pointed out, patient selection and careful technique are significantly important to successful breast reduction in the setting of radiation skin damage. Plastic surgeons should very carefully assess skin quality and apply conservative techniques when reducing a previously radiated breast parenchyma and skin envelope. Careful patient selection and technique could explain why in the authors’ study population, the difference in rates of wound healing complications did not reach statistical significance. The availability of plastic surgeons and good communication with the breast surgery team are key to a successful outcome. It would have been interesting to see what the resection volumes (by the breast surgeons) and margins were in patients who underwent immediate reconstruction. No additional malig-
nancy was identified in the immediate group, and we emphasize that breast surgeons may feel more comfortable resecting additional margins knowing that their plastic surgery colleagues will be performing reduction mammaplasty at the same time and rearranging the breast tissue. Plastic surgeons should be cautious to replace surgical clips in case the reduction specimen contains any of those previously placed by the breast surgeon. The reduction specimen should be marked appropriately and sent for pathologic analysis. In the case of positive final margins, the 2 teams should discuss pathology and determine a plan of action. Whether to proceed with a symmetry procedure on the contralateral breast at the time of the oncological surgery, as the authors did in 96% of cases, or at a later stage following completion of adjuvant radiation is important to discuss with patients. The reason for delaying the contralateral reduction mammaplasty would be to assess the final radiation effect and optimize chances for symmetry; however, performing it at the same time would mean 1 operation fewer if the patient does not opt for future revision. The findings of the multivariate analysis of statistically significant
variables were in agreement with the expected beneficial effects of reduction mammaplasty performed in an immediate setting. Specifically, delayed reconstruction cases were 7.7 times more likely to have complications and 86 times more likely to be complicated by infection. Although this study was limited by its retrospective nature, the inherent selection bias, and the modest sample size, it addressed a very important issue with a substantial effect on patient outcomes and satisfaction. Lumpectomy defect deformities following adjuvant radiation are significant and difficult to correct. Breast surgeons and plastic surgeons can and should work together to better serve breast cancer patients who opt for breast conservation therapy.
‘Reconstruction: Before or after postmastectomy radiotherapy?’ A systematic review of the literature
timing of the reconstruction and radiotherapy, with respect to complication rate and cosmetic outcome, with a special focus on the timing of the placement of the definite implant. Methods.dPubMed was searched for publications between January 2000 and December 2012. Of 37 eligible studies, timing of reconstruction, type, and incidence of complications were recorded. First, we calculated the weighted mean including confidence intervals for complications and cosmetic
outcome overall, and for the following subgroups: (1) Autologous reconstruction after radiotherapy; (2) Definite implant reconstruction after radiotherapy; (3) Autologous reconstruction before radiotherapy; (4) Definite implant reconstruction before radiotherapy. A second analysis was performed using only studies that directly compared group 1 versus 3 and 2 versus 4. Results.dA large variation in complication rates (8.7e70.0%) and in acceptable cosmetic outcome
Berbers J, van Baardwijk A, Houben R, et al (Maastricht Univ Med Ctr, The Netherlands) Eur J Cancer 50:2752-2762, 2014
Objective.dThe aim of this review is to investigate the effect of
V. J. Hassid, MD
Reference 1. Hassid VJ, Kronowitz SJ. Defect Reconstruction with Inferomedial Pedicle Technique. In Fitzal F, Schrenk P, eds. Oncoplastic Breast Surgery: A Guide to Clinical Practice. 2nd ed. Vienna: Springer; 2015. Chapter 27.
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
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Background.dOncoplastic reduction mammaplasty is often used to prevent or correct breast conservation therapy deformities. The purpose of this review was to evaluate surgical outcomes, patient satisfaction, and aesthetic outcomes of this procedure when performed before or after radiation therapy. Methods.dBreast cancer patients treated with breast conservation therapy and reduction mammaplasty between 2005 and 2012 were divided into immediate reconstruction, delayed immediate reconstruction, and delayed reconstruction. Greater than 6-month follow-up was required for inclusion. Patient demographics and clinical outcomes, including complications, patient satisfaction, and aesthetic result, were queried. Patient satisfaction was determined using the BREAST-Q survey. Postoperative photographs were used to rate aesthetic outcomes blinded to the timing of the procedure. Results.dPatients in the immediate reconstruction group had fewer complications (immediate reconstruction, 20.5 percent; delayed immediate reconstruction, 33.3 percent; delayed reconstruction, 60.0 percent; p < 0.001) and asymmetry (immediate reconstruction, 8.5 percent; delayed immediate reconstruction, 44.4 percent; delayed reconstruction, 24.0 percent; p < 0.001), and required fewer procedures to complete the reconstruction (immediate reconstruction, 1.2;
60
delayed immediate reconstruction, 2.4; delayed reconstruction, 2.2; p < 0.001). Delayed reconstruction resulted in higher complication and fat necrosis rates (immediate reconstruction, 0.9 percent; delayed immediate reconstruction, 0.0 percent; delayed reconstruction, 8.0 percent; p ¼ 0.047). Although patient satisfaction and aesthetic outcomes were better in the immediate reconstruction group, this difference was not statistically significant. Conclusions.dOncoplastic reduction techniques performed before radiation therapy result in fewer complications. Good patient satisfaction and aesthetic outcomes can be achieved when reduction is performed before or after radiation therapy, but patient selection and education are important. Clinical Question/Level of Evidence.dTherapeutic, III. As reported in this article by Egro and colleagues, the Emory University plastic surgery group performed a retrospective review of prospectively collected data to evaluate the surgical outcomes, patient satisfaction, and aesthetic outcomes of reduction mammaplasty with breast conservation therapy. The authors performed a retrospective review of all breast cancer patients treated with breast conservation therapy who underwent breast reduction performed by the senior author from January 2005 to December 2012. One hundred sixty patients were identified and divided into 3 groups based on the timing of the breast reduction. Specifically, the groups were (1) immediate (breast reduction performed at the time of breast conservation therapy), (2) delayed-immediate (breast reduction performed following confirmation of negative margins), and (3) delayed (breast reduction performed following completion of breast conservation
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
therapy and adjuvant radiation). Demographics, comorbidities, oncologic and operative details, need for adjuvant chemotherapy, surgical outcomes (complications, asymmetry, number of revisions, and total number of operations), patient satisfaction, and aesthetic outcomes were reviewed. The authors concluded that oncoplastic reduction techniques performed before radiation therapy results in fewer complications, although good patient satisfaction and aesthetic outcomes can be achieved regardless of the timing of reduction mammaplasty. The oncologic safety of breast conservation therapy and the beneficial effects of adjuvant radiation treatment are well established in the breast surgical community. In recent years, we have witnessed an increase in the number of segmental mastectomies being performed by breast surgeons as well as an increase in the use of oncoplastic techniques by plastic surgeons to obliterate acquired segmental mastectomy defects and improve the breast’s overall appearance following radiation treatment.1 The current study addressed the use of oncoplastic reconstruction through the technique of reduction mammaplasty in patients with macromastia who were diagnosed with breast cancer and were amenable to segmental mastectomy. It is not surprising that the complication rate was lower with the immediate approach. Reoperating on a recently explored field or after radiation treatment increases the risk of complications secondary to inflammatory changes as well as altered vascular supply. Furthermore, as the authors emphasized, skin quality after adjuvant radiotherapy could have a negative effect on the wound healing process and overall outcomes. It was interesting to see that overall patient satisfaction was not affected to a
statistically significant degree by timing; however, that could be explained by the fact that patients in the delayed group were more comfortable with the acquired breast deformity, which could have affected their expectations. Also, fewer patients in the delayed group underwent adjuvant chemotherapy and experienced the adverse events associated with it. As the authors accurately pointed out, patient selection and careful technique are significantly important to successful breast reduction in the setting of radiation skin damage. Plastic surgeons should very carefully assess skin quality and apply conservative techniques when reducing a previously radiated breast parenchyma and skin envelope. Careful patient selection and technique could explain why in the authors’ study population, the difference in rates of wound healing complications did not reach statistical significance. The availability of plastic surgeons and good communication with the breast surgery team are key to a successful outcome. It would have been interesting to see what the resection volumes (by the breast surgeons) and margins were in patients who underwent immediate reconstruction. No additional malig-
nancy was identified in the immediate group, and we emphasize that breast surgeons may feel more comfortable resecting additional margins knowing that their plastic surgery colleagues will be performing reduction mammaplasty at the same time and rearranging the breast tissue. Plastic surgeons should be cautious to replace surgical clips in case the reduction specimen contains any of those previously placed by the breast surgeon. The reduction specimen should be marked appropriately and sent for pathologic analysis. In the case of positive final margins, the 2 teams should discuss pathology and determine a plan of action. Whether to proceed with a symmetry procedure on the contralateral breast at the time of the oncological surgery, as the authors did in 96% of cases, or at a later stage following completion of adjuvant radiation is important to discuss with patients. The reason for delaying the contralateral reduction mammaplasty would be to assess the final radiation effect and optimize chances for symmetry; however, performing it at the same time would mean 1 operation fewer if the patient does not opt for future revision. The findings of the multivariate analysis of statistically significant
variables were in agreement with the expected beneficial effects of reduction mammaplasty performed in an immediate setting. Specifically, delayed reconstruction cases were 7.7 times more likely to have complications and 86 times more likely to be complicated by infection. Although this study was limited by its retrospective nature, the inherent selection bias, and the modest sample size, it addressed a very important issue with a substantial effect on patient outcomes and satisfaction. Lumpectomy defect deformities following adjuvant radiation are significant and difficult to correct. Breast surgeons and plastic surgeons can and should work together to better serve breast cancer patients who opt for breast conservation therapy.
‘Reconstruction: Before or after postmastectomy radiotherapy?’ A systematic review of the literature
timing of the reconstruction and radiotherapy, with respect to complication rate and cosmetic outcome, with a special focus on the timing of the placement of the definite implant. Methods.dPubMed was searched for publications between January 2000 and December 2012. Of 37 eligible studies, timing of reconstruction, type, and incidence of complications were recorded. First, we calculated the weighted mean including confidence intervals for complications and cosmetic
outcome overall, and for the following subgroups: (1) Autologous reconstruction after radiotherapy; (2) Definite implant reconstruction after radiotherapy; (3) Autologous reconstruction before radiotherapy; (4) Definite implant reconstruction before radiotherapy. A second analysis was performed using only studies that directly compared group 1 versus 3 and 2 versus 4. Results.dA large variation in complication rates (8.7e70.0%) and in acceptable cosmetic outcome
Berbers J, van Baardwijk A, Houben R, et al (Maastricht Univ Med Ctr, The Netherlands) Eur J Cancer 50:2752-2762, 2014
Objective.dThe aim of this review is to investigate the effect of
V. J. Hassid, MD
Reference 1. Hassid VJ, Kronowitz SJ. Defect Reconstruction with Inferomedial Pedicle Technique. In Fitzal F, Schrenk P, eds. Oncoplastic Breast Surgery: A Guide to Clinical Practice. 2nd ed. Vienna: Springer; 2015. Chapter 27.
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
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