Introduction

Breast conservation therapy (BCT) may be considered a mainstay therapy for early-stage breast cancer and an oncological equivalent to mastectomy in selected cases. As reviewed elsewhere in this text, BCT comprises partial breast resection, lymph node dissection, and whole breast irradiation. Specifically, for Stage I and II breast cancer, no significant difference was found in overall or disease-free survival between BCT and mastectomy after follow-up times of up to 20 years. The most important difference which has been identified between BCT and mastectomy is a significantly higher rate of local recurrence after BCT. This was found in only two of the six existing randomized controlled trials, and the differences are of questionable relevance to current practice given the lack of microscopic margin control in those two trials.

Although the oncologic outcome is well defined, the ultimate aesthetic outcome after BCT remains highly variable. Conventional reports in the radiation oncology literature indicate unsatisfactory appearance in 10–31% of patients following BCT at late reporting by patients or radiation oncologists. In fact, 50% of post-BCT aesthetic results were only considered to be fair or poor when assessed by a plastic surgeon at 34 months median follow-up.

Specific conditions which lead to poor aesthetic outcomes following BCT have been described. In absolute terms, if cancer removal requires excision of more than 25% of the breast parenchyma or a large amount of skin, a poor aesthetic outcome can be anticipated. In relative terms, the size of the tumor excision must be compared to the size of the affected breast in order to estimate the final aesthetic impact. Three specific scenarios have been identified as unfavorable: (1) a large excision in a very large breast; (2) a medium excision in a small breast; and (3) a large excision in a small or medium breast. To summarize, the larger the breast, the more easily it accommodates larger resections up to a certain size; small to medium breasts are far less tolerant of increasing resection sizes than large breasts.

Our preference is to perform immediate reconstruction for the scenarios described above. Clinical outcomes and expert impressions support this approach. These sources suggest that post-BCT breast contour deformity develops primarily from an inappropriate surgical defect and secondarily from the injury and fibrosis induced by radiotherapy. In other words, radiotherapy tends to ‘exaggerate’ the surgically created deformity, but the aesthetic impact of BCT can be minimized by performing oncoplastic or reconstructive surgery to fill the unfavorable resection cavity with local or distant tissues prior to administering radiation. Immediate reconstruction has definite advantages over delayed reconstruction, as lower complication rates and substantially more straightforward corrections can be expected because the surgical field has not received prior irradiation with its widespread implications for tissue injury and scarring.

If immediate reconstruction is not performed in cases with unfavorable resection defects, significant breast deformities will likely manifest following completion of the BCT regimen. These deformities have been stratified by two major competing schemas. Berrino and colleagues were the first to classify post-BCT deformities, by identifying the morphology of the deformity and then referencing this to select a technique for correction. They described the following deformity types: (I) displacement of the nipple–areolar complex; (II) localized deficiency of parenchyma and/or skin; (III) generalized breast contracture with no localized defects; (IV) severe damage with heavily scarred parenchyma and skin. Clough et al have altered this classification by reordering and combining groups, emphasizing reconstructive choices, and including comparison with the opposite breast. Their three types are: (I) deformity of the affected breast with no contour defects and leading to asymmetry with the contralateral breast; (II) deformity requiring delayed partial reconstruction; (III) severe deformity requiring mastectomy and whole breast reconstruction. In clinical application, these classifications help to clarify the deformities which typically result when BCT is performed under suboptimal conditions. The classification schema also guides us in reconstruction by emphasis on identifying what is missing or disordered and on seeking a reasonable match between the two breasts.

When these post-BCT deformities occur, delayed partial breast reconstruction must be considered. We consider these cases to be difficult and fraught with potential problems on three separate fronts. First, these patients often present to us with ongoing disappointment about their breast appearance following BCT, and with higher cosmetic expectations than when they were in the primary cancer treatment phase. Second, breasts previously treated with BCT present limited options for reconstruction due to reduced breast volume, scarring, distorted anatomy, and disturbed vascularity. Third, post-radiation changes must be approached with caution, as correction is technically difficult and results and complications are highly unpredictable. Studies have estimated the complication rate to be as high as 50% and the final aesthetic result to be poor when extensive tissue rearrangement is performed in the previously irradiated breast. Owing to these serious concerns, we limit post-BCT reconstruction to contralateral symmetry procedures, local flaps, or scar revisions requiring minimal dissection of the affected breast, and importing of distant tissues, pedicled or free, to correct the skin and/or parenchymal deficiencies.

Indications and contraindications

Our algorithm for recruiting distant tissues for partial breast reconstruction is to turn first to pedicled flaps and then to free flaps if pedicled flaps are insufficient or unavailable. Conventional pedicled flap options include the latissimus dorsi (LD) muscle or myocutaneous flap and the transverse rectus abdominis myocutaneous (TRAM) flap. These have been shown to be perfectly suitable for breast reconstruction following irradiation, with the accepted caveats of higher complication rates and poorer aesthetic results. The muscular component of the flaps is transferred in a denervated state, so any attempt to utilize muscle for parenchymal replacement must include substantial overcorrection to account for future denervation atrophy. Despite good results with the TRAM flap, we strongly discourage its use for partial breast reconstruction due to concern that this tissue may be needed in the future for reconstruction after completion mastectomy for local breast cancer recurrence, or after primary mastectomy for cancer of the contralateral breast. With the development of pedicled perforator flaps for partial breast reconstruction, more options and potentially lower donor site morbidity through muscle sparing are now available when a large amount of tissue is needed. A particular anatomical limitation to the use of pedicled flaps for partial breast reconstruction must be noted. Laterally based pedicled flaps (i.e., LD, lateral intercostal artery perforator, thoracodorsal artery perforator, lateral thoracic) generally are not suitable for reconstruction of large defects of the medial breast quadrants due to insufficient reach. Although this is a recognized limitation, it is only acknowledged in a few reports on this topic.

The TRAM is the only pedicled flap which reaches the medial breast quadrants easily. Its use for partial breast reconstruction, however, generally must be discouraged because this eliminates the use of the abdominal wall flap for a local recurrence or a new tumor in the contralateral breast as discussed in the preceding paragraph.

In the experience of the senior author, indications are real but limited for delayed free flap reconstruction of partial mastectomy defects:

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  for severe breast deformity (Clough Grade III) when non-abdominal pedicled flaps are inadequate or unavailable;

  
  
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  for large breast deformity (Clough Grade II) in the medial quadrants;

  
  
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  in conjunction with completion mastectomy for difficult tumor control or major glandular fibrosis post-irradiation (Berrino Grade IV);

  
  
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  as part of treatment consisting of contralateral mastectomy (therapeutic or prophylactic) and correction of ipsilateral post-BCT deformity;

  
  
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  with aesthetic abdominoplasty procedure in a patient with long-term follow-up and no further risk of recurrence or developing a new breast cancer.

Surgical technique

Surgical technique

During surgery, all damaged skin, scar, and fibrotic tissue are excised. Frozen section examination can be requested if recurrence is suspected within the excised tissue. A completion subcutaneous mastectomy is usually performed: thicker skin flaps are developed, with preservation of internal mammary perforators to the medial breast tissues. This maximizes vascularity and thereby minimizes ischemic slough of the previously irradiated skin. We believe that by performing a completion subcutaneous mastectomy a significant reduction in the cancer recurrence rate and a more complete release of the post-irradiation parenchymal fibrosis can be achieved.

The recipient vessels should be carefully prepared if irradiation was given specifically to the selected region. We prefer the internal mammary vessels, because these vessels usually have less damage post BCT when compared to the thoracodorsal vessels ( Fig. 9.1 ). In addition, sparing the thoracodorsal vessels allows future use of a pedicled TDAP or LD flap for breast salvage in the case of free flap failure or cancer recurrence.

The internal mammary artery and vein are depicted. As recipient vessels, these are preferred because they are relatively easy to expose, and high flow, and allow for optimal flap insetting.

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