4.3.1 Skin-Sparing and Nipple-Sparing Mastectomy

SSM has markedly improved the aesthetic results of IBR (▶Fig. 4.1).

Preservation of the native skin envelope and the inframammary fold reduces the amount of tissue necessary for reconstruction. Breast symmetry can often be achieved without operating on the contralateral breast and the periareolar incisions are inconspicuous in clothes.

There have been concerns that the skin, nipple, and inframammary fold preservation reduce the effectiveness of total mastectomy. There is a large body of evidence that the LRs after SSM are comparable to non-SSM (▶Table 4.1). Care must be taken, however, in patients with superficial cancers or diffuse ductal carcinoma in situ (DCIS) to assure adequate surgical margins.

NSM is growing in popularity because of its perceived aesthetic benefits (▶Fig. 4.2). Patient satisfaction with nipple–areolar reconstruction following SSM can be disappointing. Data regarding the oncological safety of NSM are hampered by small sample size, varying indications and surgical techniques, and short follow-up (▶Table 4.2). There are limited oncological and reconstructive indications to perform NSM. Large tumors and those located in the central breast have an increased incidence of nipple involvement. Larger, more ptotic breasts are not good candidates for the procedure. Nipple elevation cannot be achieved without preservation of a dermoglandular pedicle, which impacts the completeness of mastectomy. The ideal candidate for a NSM has small-to-moderate–sized breasts with minimal ptosis.

4.3.2 Detection of Local Recurrence after Breast Reconstruction

The role of postreconstruction imaging after the treatment of breast cancer remains controversial. There is a paucity of data that addresses the issue and there are no established guidelines. The incidence of LR of breast cancer is related to tumor stage. Most LRs after total mastectomy are in the skin and subcutaneous tissue and are readily detected by physical examination. A flap or implant could potentially delay the discovery of chest wall recurrences.

Systemic relapse is not inevitable following LR, especially after the treatment of DCIS. This argues that early detection of LRs may have a potential survival impact. All forms of mastectomy leave residual breast tissue. The differences are in terms of the microscopic breast tissue left behind in the skin and inframammary fold, which are largely preserved after SSM. Torresan et al evaluated residual glandular tissue in the skin flaps that would have been preserved after SSM. They found that 60% contained residual glandular tissue and it correlated with skin flap thickness.

The completeness of mastectomy is important in the treatment of DCIS because most cases of recurrence represent unexcised residual disease. Several authors have reported local recurrence of DCIS treated by SSM and IBR. They found that the majority of local recurrences were invasive carcinomas. This suggests that postreconstruction mammography can have a role in the early detection of recurrences prior to the development of invasive carcinoma.

Physical examination of implant reconstruction is relatively easy. There is minimal soft tissue covering the implant except along the inframammary fold and in the axillary tail. Deep chest wall recurrences are extremely unlikely because the implants are placed in the submuscular plane. Conventional mammographic evaluation has limited utility because the implants obscure soft tissue visualization. Magnetic resonance imaging (MRI), which has been used extensively to evaluate the integrity of silicone gel implants, may have a role in the selective surveillance after implant reconstruction.

The sensitivity of physical examination of autologous reconstruction is lower than that seen with implant reconstruction. Deep chest wall recurrences often avoid detection until symptoms develop. Autologous reconstruction causes less impairment of mammographic tissue visualization. Benign mammographic findings after transverse rectus abdominis muscle (TRAM) flap reconstruction include fat necrosis, lipid cysts, calcifications, lymph nodes, and epidermal inclusion cysts (▶Fig. 4.3). Breast cancer recurrences in autologous tissue reconstruction are mammographically similar to that of primary tumors (▶Fig. 4.4). Proponents of surveillance mammography feel that screening breast cancer patients with autologous reconstructions can detect nonpalpable recurrences before clinical examination. Helvie et al evaluated surveillance mammography in 113 patients after TRAM flap reconstruction. Six patients underwent biopsy for suspicious mammographic findings and two LRs were detected. Two patients in the study group went on to develop recurrences that were detected by physical examination. There was one false-negative mammogram resulting in a sensitivity of 67% and specificity of 98% for surveillance mammography after TRAM flap reconstruction.

There is a paucity of data regarding the efficacy of MRI of the breast following autogenous breast reconstruction. Breast MRI has been shown to clearly delineate autogenous flaps from residual mammary adipose tissue. The absence of contrast medium uptake during breast MRI precludes recurrent carcinoma to a high probability. Fat necrosis in a TRAM flap will show early postoperative contrast enhancement, but this resolves within 6 to 12 months. Rieber et al evaluated MRI of the breast in the follow-up of 41 patients who had undergone autogenous tissue breast reconstruction. MRI was able to distinguish flaps from surrounding residual breast tissue in all cases. It excluded disease recurrence in four patients with suspicious mammographic or sonographic findings. It returned false-positive findings in three cases.

The potential indications for postreconstruction imaging include patients with close surgical margins and patients with diffuse DCIS treated by SSM. Its routine use after autologous reconstruction after SSM for invasive carcinoma warrants further study. The low detection rate and specificity do not justify the routine use of MRI in the follow-up of patients postreconstruction. MRI is most useful in patients with abnormal findings on physical examination or mammography and ultrasound. It is also helpful to delineate the extent of local disease recurrence.

4.3.3 Treatment of Local Recurrence after Breast Reconstruction

Surgical options following LR after breast reconstruction depend on the location and number of metastatic deposits and previous treatment. Imaging of the reconstructed breast and body scans are necessary to delineate the extent of tumor involvement (▶Fig. 4.4). Isolated LRs can be treated with removal of as much reconstructed tissue as necessary to achieve negative margins. Adjuvant chest wall radiation is usually administered (▶Fig. 4.5).

In cases of implant reconstruction, it may be necessary to remove a portion of the implant capsule necessitating implant removal in most cases. Howard et al reviewed 16 cases of LR after TRAM flap reconstruction. Eight recurrences occurred in the skin and were detected on physical examination. Eight recurrences occurred in the chest wall and were symptomatic, being detected on physical examination or diagnostic imaging. Twelve were felt amenable to surgical resection and three required removal of the entire TRAM flap.