Comparison of Postoperative Wound Complications and Early Cancer Recurrence Between Patients

Undergoing Mastectomy With or Without Immediate Breast Reconstruction

William O'Brien, MD, Per-Olof Hasselgren, MD, Robert P. Hummel, MD, Robert Coith, MD, David Hyams, MD, Lawrence Kurtzman, MD, Henry W. Neale, Mo, Cincinnati, Ohio

The incidence of postoperative wound complica- tions and early cancer recurrence was studied in 289 patients who had mastectomy alone and in 113 patients who underwent immediate reconstruction following mastectomy. Patients undergoing immedi- ate reconstruction were younger and had less ad- vanced disease than patients who had mastectomy alone. The postoperative hospital stay was 3.8 days and 4.4 days (p < 0 . 0 5 ) in patients with and with- out reconstruction, respectively. The overall inci- dence of postoperative complications was similar in the two groups of patients: 31% and 28% in pa- tients with and without reconstruction, respectively. The incidence of postoperative seroma was higher among patients with mastectomy alone (19% ver- sus 3%, p < 0 . 0 5 ) , whereas the incidence of other wound complications was similar in the two groups of patients. Prosthesis-specific complications oc- curred in 17%. Eight prostheses were removed be- cause of complications. During the relatively short follow-up period (approximately 20 months), local recurrence was noted in 16 patients (6%) who had mastectomy alone and in 1 patient (1%) who had immediate reconstruction after mastectomy (p < 0 . 0 5 ) . There was no significant difference in the incidence of distant metastases between the two groups of patients. The results suggest that immedi- ate breast reconstruction can be performed follow- ing mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or local recurrence. However, patients who choose to have immediate reconstruction need to be informed about risks for specific complica- tions associated with the procedure, especially if an implant is used.

From the Breast Consultation Center (WO, P-OH, RPH, RC, DH) and the Division of Plastic Surgery (LK, HWN), Department of Sur- gery, University of Cincinnati, Cincinnati, Ohio.

Requests for reprints should be addressed to Per-Olof Hasselgren, MD, Department of Surgery, University of Cincinnati Medical Center, 231 Bethesda Avenue, Cincinnati, Ohio 45267-0558.

Manuscript submitted August 7, 1992, and accepted in revised form December 1, 1992.

A lthough lumpectomy with postoperative radiation is frequently used in the treatment of breast cancer,

modified radical mastectomy is still performed in a large number of patients, either for medical reasons or because of patient preference [1,2]. For these patients, recon- structive breast surgery is an option that often makes it easier to cope with the loss of the breast.

Several recent studies suggest that immediate breast reconstruction following mastectomy for cancer is safe, both with respect to wound complications and cancer recurrence [3,4]. In contrast, other studies have reported wound complications, including infections, seromas, and epidermolysis, in up to one third of patients undergoing immediate breast reconstruction following mastectomy [5]. Others have expressed concern that implants may have a negative effect on tumor biology and that detec- tion of local recurrence may be more difficult following reconstruction, and have therefore advocated delayed, rather than immediate, reconstruction [6,7]. The recent, highly publicized debate about the potential risks associ- ated with silicone implants has made nonautologous breast reconstruction even more controversial.

Although a number of reports have described compli- cations after breast reconstruction, we are aware of only one study in which the incidence of wound complications was compared in patients having mastectomy with or without reconstruction [4]. The purpose of the present report is to review our recent experience with immediate breast reconstruction following mastectomy for cancer and to compare postoperative wound complications and early cancer recurrence among these patients with pa- tients having mastectomy alone.

PATIENTS AND METHODS The charts of 289 patients undergoing mastectomy

alone for breast cancer and of 113 patients undergoing immediate reconstruction following mastectomy were re- viewed retrospectively. The procedures were performed during a 4.5-year period starting January 1, 1987. All patients were seen at the Breast Consultation Center by a team of general surgeons with special interest in breast surgery. After the diagnosis of breast cancer had been established by fine needle aspiration or open biopsy, pa- tients were offered immediate breast reconstruction when mastectomy was recommended as treatment. Most pa- tients, regardless of age and stage of the disease, were offered breast reconstruction. Patients who were interest- ed in reconstruction were seen by the plastic surgery team

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TABLE I P ~ i e n t P o p u l ~ i o n Data

Factom

Mastectomy Mastectomy With Alone Reconstruction

(n = 289) (n = 113) (%) (%)

Age (y) 59 (range 26-89) 50 (range 32-76)* Age >65 years 36 11" Smoking 53 29* Steroids 3 0 Diabetes 7 6 Obesity 30 23

*p < 0.Ol versus mastectomy alone.

TABLE II Breast Cancer Stage

Mastectorny Mastectomy With Alone Reconstruction

(n = 289) (n = 113) Stage (%) (%)

0 4 18" I 53 48 II 27 22 III 13 10 IV 3 2

*p <0.05 versus mastectomy alone.

TABLE III Postoperative Complications

Mastectomy Mastectomy With Alone Reconstruction

(n = 289) (n = 113) Complications (%) (%)

Hemorrhage 1 (0.3) 2 (2) Wound infection 15 (5) 3 (3) Seroma 55 (19)* 3 (3) Flap necrosis 5 (2) 6 (5) Other 6 (2) 5 (4) Prosthesis specific - - 16 (14)

Total (%) 82 (28) 35 (31)

*p < o.o5 versus rnastectomy with reconstruction.

and received additional information, both verbal and written, about breast reconstruction. When reconstruc- tion was to be performed, the general surgeon and plastic surgeon would plan the incision, but the general surgeon would always make the final decision regarding the inci- sion, in order not to compromise the margins.

The mastectomy was performed by the general sur- gery team and involved a modified radical mastectomy, with preservation of the pectoralis minor muscle in the majority of cases. After completion of the mastectomy,

gloves, gowns, instruments, and drapes were changed, and the plastic surgery team continued with the recon- structive procedure. When reconstruction was not per- formed, the wound was closed over two suction drains, one in the axilla and one under the skin flaps. Two drains were used following reconstruction; when a transverse rectus abdominis (TRAM) flap was used, two additional drains were placed under the abdominal incision. Drains were removed when the drainage was less than 20 to 25 mL/24 hours. Prophylactic antibiotics were routinely ad- ministered to patients undergoing reconstruction, but only occasionally in patients who had mastectomy with- out reconstruction. The general and plastic surgery teams jointly managed the patients' postoperative and postdis- charge care.

Information was collected regarding age, type of can- cer, disease stage, type of procedure(s), blood transfu- sions, postoperative complications, length of hospital stay, cancer recurrence, and mortality. Postoperative hemorrhage was defined as bleeding that necessitated blood transfusions and/or the patient's return to the oper- ating room for hemostasis. Wound infection was defined as drainage of pus from the wound, spontaneously or after drbridement. A local recurrence was defined as a recur- rence in the surgical scar or on the chest wall at the site of the previous mastectomy and was always confirmed with a biopsy.

Data were analyzed by Yates' continuity-corrected X 2 test, Student's t-test, or Fisher's exact test where appro- priate.

RESULTS During the 4.5-year study period, 289 patients under-

went mastectomy alone for breast cancer (258 modified radical mastectomy; 31 simple mastectomy) and 113 pa- tients had immediate reconstruction following mastecto- my. In the majority of patients undergoing reconstruc- tion, the procedure consisted of placement of a subpectoral tissue expander (88 patients). A permanent prosthesis was placed in six patients at the time of mastec- tomy. Sixteen patients had a TRAM flap, and 3 patients a latissimus dorsi (LD) flap.

Patients who underwent mastectomy without recon- struction were older than patients who had reconstruction (Table I). Other factors that are usually considered to influence the risk for wound complications are also listed in Table 1. Smoking was more common in the group of patients that had mastectomy alone. There were no sig- nificant differences in diabetes, obesity, or use of steroids between the two groups of patients.

Breast cancer staging was performed on the surgical specimen according to the TNM system. Patients who underwent immediate reconstruction had carcinoma in situ (stage 0) more frequently than patients who had mastectomy alone (Table II). The distribution between the other stages of the disease was similar between the two groups of patients. Infiltrating ductal carcinoma was the most common histologic type of cancer in both groups of patients. Approximately 4% of patients in both groups had infiltrating lobular carcinoma.

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Three of the patients (1%) who underwent mastecto- my alone received blood transfusions during the intraop- erative or immediately postoperative course. A signifi- cantly higher percentage (p <0.01) of patients who had immediate reconstruction received blood transfusions (15 patients: 13%). A majority of these patients underwent reconstruction with a TRAM flap; 12 of the 16 patients who underwent reconstruction with a TRAM flap re- ceived blood transfusions. Autologous blood was used in all these patients.

The mean length of postoperative hospital stay for patients who had mastectomy alone was 4.4 days. This was significantly longer (p <0.05) than the hospital stay of 3.8 days for patients who had immediate reconstruc- tion.

The total postoperative complication rate was not sig- nificantly different between patients with and those with- out immediate reconstruction (Table HI). With the ex- ception of seroma, which was more common among patients who had mastectomy alone than among patients who had reconstruction, the other complications occurred with similar frequency in the two groups of patients. The majority of the seromas listed in Table III required one or more aspirations. Complications listed as "other" compli- cations included urinary tract infection, deep venous thrombosis, skin rash, and phlebitis. There was no opera- tive mortality in either group.

Prosthesis-related complications occurred in 16 of 94 patients (17%) who had a subpectoral tissue expander or permanent prosthesis (Table III). The prosthesis-specific complications were infection of eight tissue expanders and of one permanent implant; exposure of two tissue expanders; leak from one tissue expander; migration of three tissue expanders; and capsule contracture around one tissue expander. Eight prostheses (9% of all tissue expanders and prostheses) were removed because of com- plications: five because of infection, two because of expo- sure, and one because of leak.

The mean follow-up time was similar for patients having mastectomy alone or mastectomy with recon- struction, i.e., 20 months (range: 1 to 53 months) and 18 months (range: 1 to 52 months), respectively. During this period of time, local recurrence was noted in 16 patients (6%) who had mastectomy alone and in 1 patient (1%) who had immediate reconstruction after mastectomy. This difference between the two groups of patients was statistically significant (p <0.05). Among the 16 patients who had local recurrence after mastectomy alone, 4 pa- tients had stage I disease by the TNM staging system, 4 patients had stage II, 3 patients had stage III, and 5 patients had stage IV disease at the time of mastectomy. The patient who had local recurrence following mastecto- my with reconstruction had stage II disease at the time of surgery. During the follow-up time, 35 patients (12%) who had mastectomy alone developed distant metastases. The corresponding figure for patients with reconstruction was 9 (8% [not significant, NS]). Eighteen (6%) of the patients who had mastectomy alone and 4 (4%) of the patients who had mastectomy with reconstruction (NS) died of the disease during the follow-up period.

COMMENTS Although more conservative breast surgery is replac-

ing mastectomy as treatment of breast cancer in an in- creasing number of patients, mastectomy still has to be performed relatively often because of tumor or breast size, or closeness to the nipple, or because of the patient's preference is to have a mastectomy. For those patients, immediate breast reconstruction may make it easier to accept the loss of the breast.

The present study suggests that immediate breast re- construction can be performed without increased risk for overall postoperative complications and with a similar, or even shorter, hospital stay than for patients who have mastectomy alone. It should be noted, however, that pa- tients having immediate reconstruction had a number of reconstruction-specific complications. Thus, 17% of pa- tients who had a tissue expander or a permanent prosthe- sis (14% of all patients who had a reconstruction) experi- enced prosthesis-specific complications, such as infection, migration, exposure, or leak of the prosthesis, or contrac- ture of the capsule around the prosthesis. Other investiga- tors have reported prosthesis-related complications in 11% to 15% of patients and capsule contracture in up to 25% of patients [5]. The high percentage of patients requiring blood transfusion following reconstruction with a TRAM flap is also of some concern, considering recent reports of adverse effects of blood transfusions in cancer surgery [8]. This risk was probably negligible in the cur- rent series of patients, however, since patients undergoing TRAM flap reconstruction received autologous blood transfusions. Because of the recent controversy regarding breast implants, autologous reconstruction is presently requested by the majority of patients. We have therefore gained greater experience with the TRAM flap over the last 1 to 11A years, and these patients now seldom require blood transfusions.

It should be noted that comparison of complications between the two groups of patients is made more difficult by the fact that patients having mastectomy with recon- struction were younger and had noninvasive disease more frequently than patients having mastectomy alone. Al- though reconstruction is offered to almost all patients who need a mastectomy for breast cancer at our institu- tion, older patients and patients with advanced disease tend to decline reconstruction more frequently. The exact reasons why patients did not want reconstruction were not analyzed in the present study, but in a recent report, age was an important factor why patients decided against reconstruction [9].

A number of previous reports described complications in patients having immediate reconstruction following mastectomy for cancer [3,5,10,I I]. We are only aware of one previous study in which patients who had reconstruc- tion were compared with patients having mastectomy alone [4]. In that report, the total wound complication rate was 48% in patients having mastectomy alone and 31% in patients who had reconstruction following mastec- tomy. Similar to our study, seroma occurred more fre- quently in patients having mastectomy alone. The tissue expander, prosthesis, or the soft tissue of myocutaneous

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flaps probably prevents seroma formation by filling in potential dead space and exerting local compression.

The total rate of postoperative wound complications reported here, approximately 30%, may seem high but is similar to or even lower than in previous reports [4]. Although mastectomy is a clean procedure, postoperative wound infection rates of up to 14% have been reported [4,12], probably reflecting the fact that skin flaps with relative ischemia are created during the procedure. The closeness to the axilla may be another reason that wound infections are more common after mastectomy than after other types of clean surgery. Prophylactic use of antibiot- ics in breast surgery has been recommended by some authors [12], but this is controversial [4]. The fact that in the present study the incidence of wound infections in patients with reconstruction and who received prophylac- tic antibiotics routinely was similar to that in patients with mastectomy alone suggests that prophylactic antibi- otics are not the only solution to the problem of wound infection in breast surgery.

As for most other surgical procedures, the hospital stay after mastectomy for cancer has become progressive- ly shorter over the last two decades. As late as the mid- 1980s, postoperative hospital stays of 6 to 16 days were reported [3,5]. Previously, remaining drains were a limit- ing factor for early patient discharge. It has been our experience, however, that it is safe to send patients home with drains in place, and, in fact, most of our patients, both those with and without reconstruction, are dis- charged home with at least one remaining drain. The length of postoperative hospital stay reported in this study, i.e., approximately 4 days, compares favorably with previous reports. The significantly shorter hospital stay for patients with reconstruction, noted here, may reflect the lower age in this group of patients.

In addition to concern about wound complications and prolonged hospital stay following immediate recon- struction, it has also been proposed that there is an in- creased risk for local cancer recurrence, either because of less radical surgery when reconstruction is to follow the mastectomy or because the prosthesis may have a tumor- promoting effect. It has also been argued that detection of a local recurrence may be delayed in the presence of a prosthesis. Because most local recurrences are in the skin or subcutis and because most tissue expanders are placed under the pectoralis major muscle, there is no reason to believe that local recurrences would be more difficult to discover if reconstruction is performed. If anything, it should be easier to discover a local recurrence since the skin and subcutis are stretched over the mound of the reconstructed breast. The short time for follow-up in the present study and the fact that the two patient groups were not identical with respect to age or disease stage make comparisons between the patient groups difficult. With these limitations in mind, however, the current data indicate that immediate breast reconstruction does not increase the risk of local recurrence after mastectomy for cancer. A recent study by Johnson et al [13] supports the concept that the presence of a prosthesis does not inter-

fere with the detection and management of recurrent disease.

In summary, the present study suggests that immedi- ate breast reconstruction can be performed following mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or early local cancer recurrence. It is important to remem- ber, however, that breast reconstruction in this group of patients is not a completely benign procedure but has a substantial risk for specific complications, some of which may even lead to removal of a breast prosthesis. Patients need to be informed about these risks before they decide to have reconstruction after mastectomy. Other reports suggest, however, that psychologic advantages may well outweigh the risks for complications, and high patient satisfaction following immediate breast reconstruction is frequently reported [14,15].

This paper provides early and late outcome in forma- tion for both mastectomy and mastectomy with immedi- ate reconstruction. Good surgical judgment and careful technique seem to permit the safe use o f both options.

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13. Johnson CH, van Hecrden JA, Donohue JH, Martin JK, Jack- son IT, Ilstrup DM. Oncological aspects of immediate breast recon- struction following mastectomy for malignancy. Arch Surg 1989; 124: 819-24. 14. Noone RB, Frazier TG, Hayward CZ, Skilcs MS. Patient

acceptance of immediate reconstruction following maste~tomy. Plast Reconstr Surg 1982; 69: 632-40. 15. Dean C, Cherty U, Forrest APM. Effects of immediate breast reconstruction on psychosocial morbidity after maste~tomy. Lancet 1983; 1: 459-62.

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