Aitsr. N . Z . J. Surg (1996) 66, 452-456

ORIGINAL ARTICLE

IMMEDIATE BREAST RECONSTRUCTION IN CHINESE WOMEN USING THE TRANSVERSE RECTUS ABDOMlNlS MYOCUTANEOUS

(TRAM) FLAP

K. W. FUNG, Y. LAU, K. NYUNT, C. M. CHAN AND C. M. Ho Breast and Plastic Surger?, Team, Deppcirtment of Sitrger?,, K w n g Wah Hospitd, Hong Kong

Background: Total mastectomy remains the mainstay of operative treatment for breast cancer mainly because i t is preferred by surgeons. The techniques and benefits of reconstructing the amputated breast have been well documented in the medical literature but there have been very few reports on this issue in Chinese women. Immediate breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap in Chinese women suffering from early breast cancer who require mastectomy is summarized. Methods: Since September 1991, the option of immediate breast reconstruction was offered to all patients less than 60 years of age suffering from early cancer (Tis, TI or T2) who were not suitable for breast-conserving treatment or who preferred to have a mastectomy. The single-pedicled TRAM flap was used. Results: From September I99 I to September 1994, 27 reconstructions were performed. Partial flap loss occurred in four patients (15%). fat necrosis in three patients ( I 1%) and abdominal bulging in one patient (4%). Operations performed by two teams simultaneously reduced operating time by 1.5 h without increasing the risk of complications. Twenty-one patients (78%) were satisfied or very satisfied with the outcome of reconstruction. Conclusions: The TRAM flap is a safisfactory method of breast reconstruction i n Chinese women. A two-team approach can be employed safely to shorten operative time. Overall patient satisfaction was high.

Key words: breast carcinoma, breast reconstruction, mastectomy, myocutaneous flap.

INTRODUCTION Breast cancer is the commonest malignancy in women in most Western countries.' Its incidence in the East is increasing. In Hong Kong, in the decade from I98 I to 1990, a steady increase in the incidence of breast cancer by 25% has been observed (Fig. This increase cannot be explained by the introduction of population screening for breast cancer as i n some Western countries because no screening programme was available in Hong Kong before 1990.

The treatment of breast cancer has undergone major changes, the most significant being a reduction in the size of surgical resections and an increase i n the use of systemic treatment. Breast reconstruction after mastectomy has also become an important development, contributing to the patients' quality of life. A search i n the medical literature of the past 5 years yielded 334 publications relating to breast reconstruction. Among these, only 18 papers were from the Orient and most of these were from Japan. Only two papers were written by Chinese authors and in both of them breast reconstruction was only mentioned in the course of discussion. In Hong Kong, mastectomy is still the most popular surgical treatment for breast cancer, but post-mastectomy reconstruction is not rou- tinely offered.

The technique of reconstructing the amputated breast has been developed for more than three decades and has gained widespread acceptance i n the West. Why is the same trend not

Correspondence: Dr K. W. Fung, Breast and Plastic Surgery Team, Department of Surgery. Kwong Wah Hospital. Waterloo Road, Hong Kong.

Accepted for publication 2 2 February 1996. Fig. 1. Age-adjusted incidence of breast cancer in women in Hong Kong from 198 I to 1990 (per 100 000 population).

BREAST RECONSTRUCTION IN CHINESE WOMEN

Breast-conserving treatment 24 (22%)

453

Mastectomy Others

75 (69%) 9 (8%)

Mastectomy and reconstruction

11 (33%)

observed among Chinese women? This paper summarizes our experience of breast reconstruction in Chinese women in the 3 year period from I99 I to 1994.

Mastectomy alone

22 (67%)

METHOD Since September 1991, the option of immediate breast recon- struction was offered to all patients less than 60 years of age suffering from early cancers (Tis, TI or T2) who were not suit- able for breast-conserving treatment or who preferred to have a mastectomy. The transverse rectus abdominis myocutaneous (TRAM) flap reconstruction method was used unless there were contra-indications to the procedure.

Pre-operatively the positions of the infra-mammary folds were carefully marked with the patient in the erect position. The laxity of the abdominal wall and the amount of excess skin and subcutaneous fat were also assessed. Prophylactic anti- biotics were given before the operation and continued post- operatively for two doses. For the first 17 patients, mastectomy and breast reconstruction were carried out sequentially by the same team of surgeons. Later, a synchronous approach by two teams of surgeons was adopted. Mastectomy was performed with careful preservation of the infra-mammary folds. The TRAM flap was raised as a pedicled flap based on the contra- lateral rectus abdominis muscle. The flap was tunnelled and brought over the chest-wall defect with a rotation of 180 degrees. The subcutaneous tunnel was made as close to the midline as possible to avoid disruption of the infra-mammary folds. The two poorly vascularized lateral flanges of tissue (Hartrampf's zones 111 and IV) were largely discarded. Sculpt- ing of the flap was carried out to match the contour of the opposite breast. For closure of the abdominal fascia1 defect, direct suturing was used in the first three patients. Later, poly- propylene mesh was used to avoid excessive tension. Suction

Fig. 2. Treatment of all patients diagnosed with breast cancers in 1994.

drains were placed in both wounds. Postoperatively the patients were nursed in the semi-upright position in bed for 3-4 days. Adjuvant chemotherapy, hormonal therapy and radiotherapy were given according to oncological indications when the wounds had healed.

RESULTS From September 1991 to September 1994, 250 new cases of breast cancer were diagnosed and treated in our hospital. Not all of these were candidates for breast reconstruction. In 1994, out of 108 patients with breast cancer, only 33 patients who required or requested mastectomy satisfied our criteria ( S 60 years with tumour stage < T3) and were offered breast recon- struction (Fig. 2). Eleven of these patients (33%) accepted the option of immediate reconstruction.

A total of 27 immediate breast reconstructions were per- formed in Chinese who had undergone mastectomy for early breast cancer (Table I ) . The age of the patients ranged from 29 to 57 years with a mean of 47.8 2 7.2 years. The average body- weight of the patients was 55.7 ? 8.6 kg. Seven patients had significant past medical illness: two patients had hypertension, and five patients had suffered from hypothyroidism, Grave's disease, ischaemic heart disease, poliomyelitis and pulmonary tuberculosis. None of the patients had diabetes mellitus. Two patients were chronic smokers. Three patients had previous abdominal operations. Two of these were lower transverse scars for the excision of uterine fibroid and Caesarean section, respectively, and one was a low midline scar for Caesarean section. In these three patients the TRAM flaps were fashioned slightly more cephalad to avoid the scars. All patients had early breast cancers. Two patients had ductal carcinoma in situ, eight had TI tumours and 17 had T2 tumours. The mean tumour size was 2.6 f I .O cm.

454 FUNG ETAL.

Table 1. Summary of patient statistics

Patient details n

Age (years) Bodyweight (kg) Risk factors

Previous abdominal surgery Chronic smoker

Tumour staging Ductal carcinoma in situ TI tumour T2 tumour

Tumour size (cm)

29-57 (mean 47.8) 41-77 (mean 55.7)

3 2

2 8

17 0.9-4.5 (mean 2.6)

Table 2. Summary of complications (n = 9)

Complication n (%)

Abdominal wound Minor healing problems Infected mesh Bulging or weakness

Partial flap loss Minor healing problems Fat necrosis

Flap

2/27 7 I I24 4 I 127 4

4/21 15 2/27 I 3/27 I 1

Total 9/27 33

The average operation time was 5.1 f 0.5 h for the single- team method and 3.5 f 0.3 h for the two-team method ( P < 0.001 ), Eighteen patients (67%) recovered without any com- plications. Among those who developed complications, four patients had delayed healing of the chest or the abdominal wound, and were managed successfully with wound dressing alone (Table 2). One patient had infection of the polypropylene mesh secondary to wound infection and the mesh had to be removed. One patient developed a small abdominal bulge which was subsequently repaired. Partial flap necrosis was observed in four patients involving 15% of the flap in the most severe case. There was no total flap loss. Three patients developed firm nodules under the flap and these were con- firmed on excisional biopsy to be fat necrosis.

The incidence of complications was 43% for patients weigh- ing more than 55 kg. This was much higher than the incidence of 23% i n patients weighing less than 55 kg. However, this difference did not reach statistical significance (P = 0.42; Fish- er’s exact test). The incidence of complications was the same regardless of whether the operation was performed by one or two teams of surgeons. Among the three patients who had pre- vious abdominal surgery, one suffered from delayed healing of the abdominal wound while the other two recovered unevent- fully. Of the two patients that were smokers in the series, one had partial flap necrosis which required debridement and the other patient did not have any complicatons.

Twenty-one patients (78%) required some form of adjuvant therapy (two received radiotherapy, 17 received chemotherapy and 10 received tamoxifen). In two of these patients adjuvant chemotherapy had to be delayed for more than 6 weeks post- operatively because of operative complications. Over an average length of follow up of 18 months (range 8-3 1 months), one patient developed local recurrence of tumour while another

Fig. 4. In women with larger than average breasts, size match is not usually a problem.

patient developed both local recurrence and distant metastasis. The remaining patients were alive and free of disease. Overall, 21 patients (78%) were satisfied or very satisfied with the reconstruction. Four patients were not satisfied because they developed partial flap necrosis which required debridement and secondary wound closure and the final aesthetic outcome was compromised. Two patients were not satisfied because they thought that the donor site scar was too conspicuous.

DISCUSSION Despite the increasing acceptance of breast conserving treatment internationally, modified radical mastectomy remains the main- stay of operative treatment for early breast cancer in Hong Kong. This is largely due to the surgeons’ preference rather than the patients’ choice. When given the choice of breast-conserving treatment or mastectomy, a significant proportion of patients will opt for the former. In 1994, among I08 new cases of breast cancer

BREAST RECONSTRUCTION IN CHINESE WOMEN 455

treated in our department, 48 patients were considered to be suit- able for breast conservation and 24 patients (50%) chose breast conservation instead of mastectomy (Fig. 2).

While the loss of the breast may be perceived differently by different individuals, studies have shown that mastectomy is associated with a significant degree of psychological morbid- ity.3,4 Nowadays, more emphasis is being placed on improving the quality of life of cancer patients. It is worthwhile to consider ways of reducing the psychological trauma caused by mastec- tomy. The psychosocial benefits of immediate breast recon- struction have been documented by several studies.s-n In a prospective randomized study Dean et al. allocated women with early breast cancer at the time of mastectomy to a group receiv- ing immediate breast reconstruction or to a control group to whom breast reconstruction was offered I2 months later. It was shown that women who had had immediate reconstruction had less psychiatric morbidity, more freedom of dress and were less likely to be repulsed by their own naked appearance.5 Several other studies also demonstrated a positive psychological impact following immediate breast reconstruction which included a more positive body image and decreased post-mastectomy

Immediate breast reconstruction has been shown to be safe and well tolerated in patients with early breast cancer requiring mastectomy without adversely affecting disease outcome. Johnson et al. reviewed more than 100 patients with mastectomy and immediate breast reconstruction for breast cancer and found no difference in disease-free and overall sur- vival compared with patients with mastectomy alone.' Indeed, mastectomy with immediate reconstruction is a good alternative for patients in whom breast-conserving treatment is either not suitable or not desirable.

There are a few possible reasons why breast reconstruction is not performed as often in Chinese women as in women in the West. First of all, the expertise of breast reconstruction is not widely available in Hong Kong, and as a result breast recon- struction is not routinely offered in some hospitals. Secondly, general knowledge of breast cancer and its treatment options is limited in Hong Kong. According to a recent survey conducted on 300 female patients attending our breast clinic, only 3 1 % of the respondents knew that breast cancer most commonly pres- ents as a painless lump, 52% never performed breast self- examination and only 35% knew that the best time to examine their breasts is after menses (unpubl. data). Most women do not know that breast reconstruction after mastectomy is an option. Therefore, requests for reconstruction are rarely made. Thirdly, i t has been suggested that Oriental women do not consider the loss of a breast to be as mutilating as Western women consider it, and so the benefits from and demand for breast reconstruc- tion are not as great. However, there is no evidence to support this hypothesis. Among the patients we encountered, a signifi- cant proportion (33%) elected to have breast reconstruction and most of them (78%) were satisfied with the outcome. A study in Japanese women showed that breast reconstruction improved quality of life. Breast reconstruction gave patients more freedom in the choice of clothing and allowed them to enjoy sports and travelling more.'" These findings are very similar to results of comparable studies in Caucasians. In Chinese women, however, data on the benefits of breast reconstruction are not available. This gap needs to be filled by appropriate quality-of- life studies.

There are many methods used to reconstruct the breast. Broadly speaking, these can be divided into those that involve the use of artificial implants and those that use the patient's own tissues alone. The introduction of the TRAM flap in 1982 by Hartrampf revolutionized the scene of breast reconstruction." The TRAM flap (or 'transverse abdominal island flap' as originally described by Hartrampf) is near-ideal among available The use of autologous tissues alone avoids problems such as capsular contracture, leakage and possible autoimmune diseases associ- ated with the use of implants. The final result is usually good and lasting. The donor site scar is well hidden and the added abdominoplasty is a bonus. However, the operation itself is tech- nically demanding and should be taken with caution. The latis- simus dorsi myocutaneous flap is another popular flap used for breast reconstruction. This flap is technically easier to raise, and is probably safer than the TRAM flap. However, the latissimus dorsi flap alone is seldom sufficient in providing volume for the new breast and the addition of an internal prosthesis is often required. This is a major drawback and most of our patients would refuse to have breast reconstruction if implantation of prosthesis was involved.

The reported incidence of partial and total flap loss ranges from 6 to 3 I %.ls- ly The incidence of flap loss in our series was 15%. The main cause of flap failure is the use of tissue beyond the vascular limits of the flap.!" In women with big breasts surgeons are often tempted to use larger portions of the flap, including areas with dubious blood supply (zones I11 and IV), thus increasing the flap failure rate. In Chinese women with average breast size, more than sufficient tissue is usually av'ail- able and only the areas with the best blood supply should be used (Figs 3, 4). In fact, in the later half of our present series, we almost completely discarded zones 111 and IV and we did not encounter any flap loss in our last 10 reconstructions. This also shows that there is a significant learning curve inherent in this complex operation.'".?"

Another major problem is abdominal-wall weakness. The reconstruction of a strong abdominal wall is of the utmost importance, otherwise the mutilation of mastectomy will be replaced with another handicap which may be equally unac- ceptable. Whether synthetic mesh should be used in abdominal- wall closure is still controversial. Lejour and Dome reported the lowest rate of abdominal weakness and synthetic mesh was routinely used.?' Kroll and Marchi also suggested that synthetic mesh reinforcement was useful in lowering the incidence of abdominal-wall weakness in tight closures.2o

Concerning the patient factors for development of compli- cations, several risk factors have been suggested. These are smoking history, diabetes mellitus, autoimmune disease, pre- vious abdominal surgery and obesity.'".'' It has been recom- mended that smoking should be discontinued at least 6 weeks before operation.'" But this is only feasible in patients under- going delayed breast reconstruction. In our small series we observed an almost two-fold increase in the incidence of com- plications in patients with greater bodyweight, although the dif- ference was not statistically significant. Only two of our patients smoked and no useful conclusions could be made. In patients with more than one risk factor, or in patients with a large contralateral breast to match, modifications of technique such as the use of a bi-pedicled flap or even a free flap may be considered.IX.??

4.56 FUNG ETAL.

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