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The Breast 20 (2011) S3, S104–S107
Contents lists available at ScienceDirect
The Breast
journal homepage: www.elsevier .com/brst
Original Article
Immediate breast reconstruction after mastectomy
Paolo Veronesia,b, *, Francesca De Lorenzic, Bettina Ballardinia, Francesca Magnonia, Germana Lissidinia,Pietro Caldarellaa, Viviana Galimbertia
aDepartment of Breast Surgery, European Institute of Oncology, Milan, ItalybUniversity of Milan, School of Medicine, cDepartment of Plastic Surgery, European Institute of Oncology, Milan, Italy
a r t i c l e i n f o
Keywords:
Immediate reconstruction
Mastectomy
Invasive cancer
Elderly
s u m m a r y
Aims: There is a general agreement for immediate breast reconstruction in case of in situ tumors,
while the reconstruction is often still delayed in cases of invasive cancers or not performed in the
elderly cohort.
Aim of this review is to investigate the safety of immediate postmastectomy reconstruction for
invasive cancers and in the elderly population.
Methods and results: We reviewed our series and the recent literature on this topic. While there
is a general consensus that advanced age is not a contraindication to immediate reconstruction
and breast reconstruction can be successfully performed on well-selected elderly patients, many
oncologists in Europe do not prefer immediate reconstruction for invasive carcinoma, advocating
the risk of delay of the medical adjuvant treatment in case of complications due to the
reconstructive procedure. Our experience and a lot of studies suggest that immediate breast
reconstruction is a safe and reliable treatment option in case of invasive cancers. However, if
postmastectomy irradiation is necessary on the basis of the final pathological finding, this is
associated with a high rate of surgical complications and implant loss among patients who
underwent immediate reconstruction with prostheses. Moreover, current evidence suggests that
postmastectomy radiation therapy also adversely affects autologous tissue reconstruction.
Conclusions: Immediate breast reconstruction after mastectomy is an integral part of the complete
management of breast cancer. Determining the risk of postmastectomy irradiation prior to
definitive resection and reconstructive operations may reduce complications and improve aesthetic
outcomes by guiding surgical decision making.
© 2011 Elsevier Ltd. All rights reserved.
Introduction
Immediate breast reconstruction is actually an integral part of
breast cancer treatment with positive aesthetic and psychological
results. At present, the surgical options available involve either
the use of autologous tissue, alone and in combination with an
expander/implant, or the use of prosthetic implant only: the choice
is based on patients’ characteristics and preference, stage of disease,
adjuvant therapies and surgeons’ attitude. Autologous tissue
are definitely preferable to breast implant within an irradiated
operative filed, in example in case of mastectomy after conservative
treatment.1 Immediate reconstruction is considered more practical,
and it is technically and economically more advantageous than
a delayed procedure. In term of psychological impact, immediate
reconstruction gives a greater sense of self-esteem and freedom
to wear the kind of clothes they desire, although the perception
of altered body image remains for a long time.2,3 Furthermore,
immediate reconstruction has an impact on proper body posture.4
* Corresponding author. Prof Dr Paolo Veronesi. Department of Breast
Surgery, European Institute of Oncology, Via Ripamonti 435, 20141
Milan, Italy. Tel.: +390257489656; Fax: +390294379228.
E-mail address: paolo.veronesi@ieo.it (P. Veronesi).
Moreover, since the first introduction of the skin sparing
mastectomy in 1991,5 immediate breast reconstruction has resulted
in better aesthetic results, also thanks to the preservation of
the inframammary fold. Even in women with macromastia, for
which there tends to be a mismatch between the retained skin
envelope and the reconstructed mound, whether this is with an
implant or an autologous flap, the Wise pattern skin-reducing
mastectomy provides the best options for shape and symmetry.6–8
And more recently, nipple-sparing mastectomies provide more
options for immediate breast reconstruction.9–16 Conservation of the
skin envelope and nipple areola complex with its vascularisation17
has led to improved aesthetic results following both autologous and
implant based reconstruction.18,19
In this article, we explore the current controversies regarding
immediate breast reconstruction, especially in cases of invasive
cancers and in the elderly cohort.
Methods
The Authors reviewed their series and searched the MEDLINE
database for studies of immediate breast reconstruction after
0960-9776/ $ – see front matter © 2011 Elsevier Ltd. All rights reserved.
P. Veronesi et al. / The Breast 20 (2011) S104–S107 S105
mastectomy. Studies were included if published after the 1990s and
a mean follow-up period was more than 1 year.
Results
Indications for immediate reconstruction in case of invasive tumors:
consensus and controversies
Although breast reconstruction has been a part of cancer treatment
for more than 30 years, many oncologists recommend delaying
the reconstruction in cases of invasive cancer, while immediate
reconstruction is widely accepted in case of in-situ cancers. They
advocate the risk of delay of the medical adjuvant treatment in
case of complications due to the reconstructive procedure. In a
previous publication20 we showed the absence of delay of the
chemotherapy despite the risk of local complications in relation
with the reconstruction. Moreover, it has been demonstrated
that neither the inclusion of chemotherapy nor the timing
of its administration significantly affect the complication rate
after mastectomy and immediate reconstruction.21 Although a
number of recent publications underline the safety of immediate
postmastectomy breast reconstruction for invasive carcinoma,22–30
no long term follow up of immediate reconstruction and no clear
comparison with a control group has been described until our
series in 2008.31 To reach a consensus on the safety of immediate
reconstruction after mastectomy for invasive breast cancer we
compared a consecutive series of 518 patients who have undergone
immediate reconstruction with 159 patients with no reconstruction
over a prolonged period time (average 70 months). All patients
underwent total mastectomy and complete axillary dissection,
including all three Berg’s levels. The same protocol of medical
treatment was delivered to the two groups. We observed that
disease-free survival (calculated from date of surgery to any local,
regional or distant relapse or death from cancer or to last visit
date in case of no events) and overall survival (defined as the time
interval from date of surgery to death from any cause or to the
last date of follow-up) were very similar for patients treated by
mastectomy only or mastectomy with reconstruction. Hence, the
type of immediate reconstruction does not influence the clinical
outcome of the disease. Most local recurrences observed were
cutaneous or subcutaneous and easily clinically diagnosed.32 The
presence of an implant facilities the palpation of the superficial
recurrence, whereas the deepest ones are diagnosed thanks to
the ultrasound examination or MRI. This data are consistent with
those in the literature26,33 No increased risk of local relapse has
been observed in other series of patients receiving postmastectomy
immediate reconstruction.27,34
Indications for immediate reconstruction in the elderly: consensus
and controversies
Elderly patients are defined as those patients exceeding 65 year
of age. In this population immediate reconstruction is performed
less frequently than in younger women, probably due to patient
preference or biases of advising medical personnel.35,36 In fact, it
is possible that at a later stage of life fewer women consider
breast reconstruction important, however breast reconstruction
often has not been offered to the elderly due to the reluctance of
clinicians who concerned about attendant serious co-morbidities.
These patients are still considered unfit for reconstruction due
to an inaccurate estimation of the operative risk.37 In our series
of consecutive 63 elderly patients who underwent immediate
reconstruction38 with a mean follow-up of 43.1 months, implant-
based breast reconstruction has been demonstrated to be feasible
and safe, although it is well known that the risk of perioperative
complications is proportionately increased because of the number
of co-morbidities and the relative risk of severe complications and
death are significantly greater in the geriatric population than in
the younger cohort. Accurate patient selection is mandatory. It is
necessary to address the overall status of the elderly patient when
reconstructive options are being considered. Acute and chronic
medical conditions, nutritional status and level of activity need to
be taken into consideration. Optimization of pre-existing medical
conditions is necessary.
Similar encouraging data are reported by Lipa et al.39 with
regard to autologous reconstructions in the elderly. They observed
acceptable rate of complications although the longer operative
times required for autologous tissue reconstruction, with prolonged
anaesthesia and greater fluid shifts.
There is a general agreement that elderly patients are less likely
to complete the reconstruction with the creation of a nipple–areola
complex and tattoo for colour symmetry.38–40
Indications for postmastectomy radiation therapy: consensus and
controversies
Postmastectomy radiation therapy improves the outcomes of
breast cancer patients with T3 or T4 or four or more positive
axillary lymph nodes.41–43 There is a general agreement that
reconstruction should be delayed in patients who are known at
mastectomy to require postmastectomy radiation therapy. In fact,
even with the latest prosthetic and modern radiation delivery
techniques, the complication rate for immediate implant-based
breast reconstruction in patients undergoing postmastectomy
radiation therapy is greater than 40 percent,44 and the extrusion
rate is 15 percent.45 Postmastectomy irradiation independently
predicts the occurrence of a complication and implant loss among
patients who underwent immediate reconstruction.46 The two-
stage breast reconstruction, with placement of a permanent
breast implant after postmastectomy radiation therapy, consistently
results in high rate of capsular contracture and poor cosmetic
outcomes.47 Specifically, for women with implants, radiation can
promote significant capsular fibrosis. Capsular contracture not only
distorts the appearance of the breast but also causes chronic chest
wall pain and tightness that can be crippling. Modified sequencing
of two-stage implant reconstruction, such that the expander is
exchanged for the permanent implant before postmastectomy
radiation therapy,48 can decrease the occurrence of acute wound-
healing problems (i.e. wound dehiscence, infection and implant
exposure) but results in higher rates of capsular contracture.
Moreover, it has been observed colour change of silicone gel
implants with less formable gel after irradiation.49
Current evidence also suggests that postmastectomy radiation
therapy also adversely affects autologous tissue reconstruction.50,51
A further important question concerning immediate breast
reconstruction and postmastectomy irradiation is whether the re-
construction can impair the efficacy of postmastectomy irradiation
by interfering with the radiation targeted field. In fact, even with
modern radiation delivery techniques, immediate implant-based
or autologous tissue breast reconstruction can distort the chest
wall and limit the ability to treat the targeted tissue without
excessive exposure of the heart and lungs. Although some radiation
oncologist believe that the effect of a breast implant or inflated
expander or autologous reconstruction is negligible52 and recent
studies53,54 have found that the metallic port within a tissue
expander does not result in significant scatter, which could lead
to “hot” or “cold” spots that alter the homogeneous treatment
of the chest wall, there is an increasing evidence that such
reconstruction can interfere with the delivery of postmastectomy
radiation therapy. In fact, the sloping contour of a reconstructed
breast results in an imprecise geometric match of the medial and
lateral irradiation fields, which can lead to underdosing of the chest
S106 P. Veronesi et al. / The Breast 20 (2011) S104–S107
wall, especially centrally underneath the breast mound and near
the internal mammary nodes.55,56 On the contrary, other Authors57
confirm that in women undergoing immediate expander/implant
reconstruction, postmastectomy irradiation can achieve excellent
local control with acceptable heart and lung doses. These results
can be achieved even when the internal mammary nodes are being
treated, although doses to the heart and to the lungs will be
higher. However, the need to treat the internal mammary nodes
is controversial because irradiation of the internal mammary chain
has not been shown to confer a benefit in survival or rate of distant
metastases.58,59
Unfortunately, the need of post mastectomy irradiation is not
always known at the time of mastectomy. In fact, recommen-
dations regarding postmastectomy irradiation are often based
on pathological analysis of the mastectomy specimen and on
axillary involvement and it is hard to tell at the time of
mastectomy how many lymph nodes are positive. Until we can
reliably predict the need for postmastectomy radiation therapy, one
option is to always delay breast reconstruction until the need of
postmastectomy irradiation is known. However, this denies patients
who ultimately do not require postmastectomy radiotherapy the
aesthetic and psychological benefits of immediate reconstruction.
Many oncologists are increasingly using this approach.1
Second option is performing an immediate expander/implant
reconstruction and, in case of post mastectomy irradiation and
possible unfavourable cosmetic results, performing a second
stage autologous reconstruction, as a salvage procedure. This
approach gives the positive psychological impact of the immediate
reconstruction and allows preserving the breast skin flaps and
mound. At our institute, if postmastectomy irradiation appears
likely but not is required, patients are well informed about the
possibility of unfavourable events due to irradiation and aware
of these issues throughout the entire decision-making process
and contribute to decisions concerning the sequencing of breast
reconstruction and postmastectomy radiation.
Third option is the so called delayed-immediate reconstruction.60
In this approach a tissue expander is placed at the time of
mastectomy. If postmastectomy irradiation is required, the tissue
expander can be deflated before irradiation to create a flat chest
wall and facilitate irradiation itself. It can be reinflated after the
completion of irradiation and afterwards a second stage autologous
reconstruction is planned.
Conclusion
Immediate postmastectomy reconstruction is an integral part of
the complete management of breast cancer. It is reliable and
safe in elderly patients and in invasive cancers. Controversies
regarding immediate postmastectomy reconstruction and following
irradiation are still unanswered. In patients who will receive or
have already received post mastectomy radiation therapy, the
optimal approach is delayed autologous tissue reconstruction after
postmastectomy radiation therapy.
Conflict of interest statement
The authors have no conflict of interest to declare.
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