Indications and Patient Selection for Oncoplastic Breast Surgery




Introduction


The desire of many patients to preserve their breasts regardless of the cosmetic outcome has led to a more aggressive use of partial mastectomy, with more extensive local resections being classified in the category of partial mastectomy. As partial mastectomies become more extensive, the risk of suboptimal cosmetic results from such resections is likely to increase. In recent years, the proportion of breast cancer patients treated with partial mastectomy and radiation therapy (XRT) has increased. This approach is referred to as breast conservation therapy (BCT). This trend is due in part to increased mammographic screening, with a corresponding increase in the detection of early breast cancers. It is also due to the increasing use of preoperative chemotherapy in patients with large operable and locally advanced breast cancer, where significant clinical responses can allow for breast-preserving procedures in patients who would otherwise have required a mastectomy. After BCT, 20–30% of patients are reported to have a poor cosmetic result, with deformities of the treated breast. However, poor cosmetic outcomes after BCT are likely to be underestimated in the literature because many patients with poor outcomes are reluctant to seek further surgical treatment.


In this chapter, we present a management algorithm for repair of partial mastectomy defects based on clinically relevant parameters that should allow the clinician to better select the most appropriate patient indications for the various reparative surgical techniques.




Management algorithm for repair of partial mastectomy defects


It is well appreciated that most reconstructive breast procedures are based on principles and concepts, not on structured guidelines. The proposed management algorithm presented in Fig. 3.1 has been designed to serve as a guide to assist in the decision-making process for repairing partial mastectomy defects. However, the final decision regarding the optimal approach is ultimately made by the multidisciplinary breast cancer treatment team and the patient.




Figure 3.1


Management algorithm for repair of partial mastectomy defects. (Patient Presents After Partial Mastectomy and Partial Breast XRT.) This is an increasing group of patients who in the near future may become the largest presenting population for repair of partial mastectomy defects. In these patients, because the XRT was delivered only to the tumor site, the remainder of the breast parenchyma can be rearranged without the concerns of poor wound healing. Another advantage of this group is that a negative margin has already been obtained and the tumor cavity does not need to be elucidated (placement of surgical clips) for the radiation oncologist. The disadvantage is that an incision on the breast has already been made, which may interfere with the design of the skin resection pattern. The decision making with this group is based on the extent and location of the breast skin resection and the breast size. Patients with D cup sized breasts, or C cup sized breasts with small tumors, are excellent candidates for the breast reduction or breast-remodeling techniques. Patients with smaller-sized breasts will benefit most from a latissimus dorsi flap, especially since the XRT has already been delivered. It is unlikely that these smaller-breasted patients who only underwent partial breast irradiation will desire a completion mastectomy with immediate or delayed–immediate total breast reconstruction. (Patient Presents AFTER Partial Mastectomy BEFORE XRT.) This group presents both advantages and disadvantages to the reconstructive breast surgeon. The advantage is that these patients usually have already obtained a negative tumor margin. The disadvantage is that the specific location and extent of tumor resection are often not known. This is especially important in regard to determining whether the NAC has an adequate remaining blood supply from the underlying breast parenchyma. Patients who have undergone a central resection or by examination have evidence of sub-areola resection should have the blood supply to the NAC explored prior to committing to the breast reduction technique. Otherwise, the consideration for the best technique to repair a partial breast defect in these patients is also based on the location and extent of tumor resection as well as the breast size. (Patient Presents BEFORE Partial Mastectomy and XRT.) This situation represents the ideal scenario, incorporating the concept of the multidisciplinary approach in the care of the breast cancer patient. However, there are several important considerations in this patient population. Although most patients who undergo a partial mastectomy have localized disease, if a patient presents with multiple foci of disease the patient is probably better served with delayed repair because of their increased risk of a positive tumor margin or a severe breast deformity that would more likely benefit from a total mastectomy with an immediate or delayed–immediate breast reconstruction. The most important consideration in this patient group is the status of the tumor margin. The decision to proceed with an immediate repair or wait a week or two until a negative margin has been confirmed rests solely on the communication between the breast surgeon, the pathologist, and the reconstructive breast surgeon. Although it may seem intuitive to delay the repair until after confirmation of a negative tumor margin in every patient, many patients are at a low risk and would necessitate that they undergo additional surgery to perform the repair prior to XRT. After these issues have been addressed, further considerations in this group are also based upon the location and extent of skin resection and the breast size in relation to the tumor size. Patient presents AFTER partial mastectomy and whole-breast XRT. Unfortunately, currently this patient population tends to be the most common presenting to the reconstructive breast surgeon. The primary objective of this management algorithm and the techniques presented in this chapter is to eliminate this grouping. Although the decision making for this group is the most straightforward, these repairs usually require extensive reconstructive procedures that require the transfer of a flap. Although a flap provides its own blood supply to assist with healing within the irradiated operative field, its use to repair a partial breast deformity may hasten its use in the future, if additional reconstruction is required. The cosmetic outcomes of these more extensive procedures also tend to be less appealing because the skin of the flap does not match the remaining native breast skin. Attempting to repair a partial breast deformity after XRT using the remaining breast tissue is fraught with a very high complication rate. In some patients with significantly distorted breasts, it may be preferable to perform a completion mastectomy with an immediate breast reconstruction, rather than attempt a partial repair that will leave breast tissue that may be at risk of recurrent disease.


Importance of timing of repair in relation to XRT


Waiting to repair a large partial mastectomy deformity until completion of whole-breast XRT usually necessitates the complex transfer of a large volume of autologous tissue. Patients who choose BCT often do so to limit the extent of surgery and therefore they are not eager to undergo a major secondary reconstructive procedure. In addition, the difficulties associated with secondary repair within an irradiated surgical field limit the use of the adjacent irradiated breast tissue because of high complication rates. The use of prosthetic devices in this setting has been fraught with increased morbidity and is not usually recommended. With the increasing use of partial breast irradiation as an alternative to whole-breast irradiation, the use of the remaining breast tissue for reconstruction may become a viable option for these patients.


Delayed reconstruction after XRT usually requires a latissimus dorsi or thoracodorsal artery perforator flap; however, use of these flaps may increase the likelihood of arm lymphedema and may leave the patient without an autologous tissue option if further reconstruction is required in the future. At the MD Anderson Cancer Center, the role of local pedicle flaps in the repair of partial mastectomy defects has been changing. Although these flaps are still the most commonly used flaps for delayed repairs after XRT, they are now being used more frequently for immediate repairs before XRT (after confirmation of negative tumor margins). These flaps have been demonstrated to be useful in small and moderate-volume breasts and in patients who present with locally advanced breast cancer that will require XRT, whether they undergo a partial mastectomy (i.e., become eligible for BCT after neoadjuvant chemotherapy) or total mastectomy ( Fig. 3.2 ).




Figure 3.2


An example of a patient who would be a good candidate for an immediate repair before XRT with a latissimus dorsi or other local pedicled flaps is this 47-year-old woman who presented with a T2N2 tumor of the left breast, had an excellent response to neoadjuvant chemotherapy, and desired BCT. With C cup size breasts, she did not have enough remaining breast tissue after tumor resection to undergo the breast reduction technique, so she underwent immediate repair with a latissimus dorsi myocutaneous (de-epithelialized) flap. The patient had extensive scarring on her abdomen and, most importantly, was going to require XRT regardless of whether she had a partial or total mastectomy – an increasing group of patients who present with locally advanced breast cancer and then after neoadjuvant chemotherapy the tumors become amenable to partial mastectomy. (A) Preoperative view of the tumor located in the lateral aspect of the breast (denoted by black X). Because the patient had no involvement of the breast skin, the tumor resection was performed using only a periareolar and axillary incision. The latissimus flap was tunneled through the axillary incision onto the chest wall. The latissimus muscle was plicated to the shape and dimensions of the parenchymal defect and the skin island was de-epithelialized and positioned underlying the breast skin in the region of the defect so that, after atrophy of the latissimus muscle, contracture could be avoided and the volume in this region could be retained. (B) Postoperative view 2 months after surgery. Because of immediate reconstruction, the patient does not have the stigma of breast cancer surgery. If this patient would have repaired in a delayed fashion after XRT, she would have most likely required the skin island of the latissimus dorsi flap to be used to replace breast skin that frequently becomes deficient because of the contracted nature of the breast skin in the location of the unrepaired deformity.


In some patients who have completed XRT, a contralateral breast reduction alone, without repair of the involved breast, will improve breast symmetry. The advantage of this strategy is that the radiated breast is not operated on, thus eliminating the possibility for additional morbidity. The extent of the surgical procedure is limited and reasonable breast symmetry can be achieved.


In the case of a severe breast deformity following BCT, the option of a completion mastectomy with total reconstruction is considered. The cosmetic outcomes of total breast reconstruction after BCT are less than optimal, primarily because of the relative inelasticity of the irradiated breast skin envelope and the increased risk of mastectomy skin flap necrosis.


At the MD Anderson Cancer Center, the most frequently used technique for repairing the partial mastectomy defect is to use local breast tissue. This is primarily because of the simplicity of these approaches and also because these techniques using local tissue will usually maintain the color and texture of the breast. If, however, an unexpected deformity results after partial mastectomy ( Fig. 3.3 ) or the tumor margin status is unclear at the time of the partial mastectomy, consideration should still be given to performing the repair prior to XRT. In these circumstances, we prefer to use the remaining breast tissue for local reconstruction.


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Apr 3, 2019 | Posted by in General Surgery | Comments Off on Indications and Patient Selection for Oncoplastic Breast Surgery

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