Mastectomy With and Without Immediate Breast Reconstruction Using a Musculocutaneous Flap
Masakuni Noguchi, MD, Mitsuharu Earashi, MD, Nagayoshi Ohta, MI), Hirohisa Kitagawa, MD, Kazuo Kinoshita, MI), Michael Thomas, PhO, Takao Taniya, MD, Itsuo Miyazaki, Mo,
Tetsuji Yamada, ME), Masaaki Nakagawa, MI), Kanazawa, Japan
We compared surgical cosmetic results in 83 pa- tients who underwent mastectomy with immediate breast reconstruction (MIBR) using a myocuta- neous flap with those of 153 patients with breast cancer who underwent mastectomy without breast reconstruction. Cosmetic results were significantly better in patients who underwent MIBR than radi- cal mastectomy or extended MIBR, although no in- tergruup difference existed in the reconstructive technique. Neither did any difference exist in the incidence of complications between patients under- going MIBR and mastectomy without breast recon- struction, or between patients undergoing modified mastectomy and radical or extended mastectomy. Finally, MIBR did not appear to adversely effect recurrence or overall survival. We conclude that MIBR using a myocutaneous flap is an acceptable treatment option for patients with breast cancer.
From the Operation Center (M Noguchi), Department of Surgery (II) (M Noguchi, ME, NO, HK, KK, MT, TT, IM), Kanazawa University Hospital, the Department of Surgery (TY, M Nakagawa), Ishikawa Prefectural Central Hospital, and the Hokuriku Breast Cancer Society (MN, ME, NO, HK, KK, MT, TT, IM, TY, MN), Kanazawa, Japan.
Requests for reprints should be addressed to Masakuni Noguchi, MD, The Operation Center, Kanazawa University Hospital, Takara- machi, 13-1, Kanazawa, 920, Japan.
Manuscript submitted February 18, 1992, and accepted in revised form July 30, 1992.
I mprovements in adjuvant therapy for breast cancer have allowed surgeons to focus more attention on min-
imizing the cosmetic deformity of mastectomy. The three primary treatment options available for patients with breast cancer are as follows: (1) modified radical mastec- tomy (MRM); (2) modified radical mastectomy with immediate breast reconstruction (MIBR); and (3) breast-conserving procedure, consisting of partial mas- tectomy, axillary dissection, and breast irradiation. Al- though breast-conserving treatment has recently gained acceptance as an alternative to mastectomy in patients with early breast cancer [1,2], we believe that MIBR offers another acceptable option for these patients . Furthermore, MIBR offers other advantages over other techniques, such as single anesthesia and operation, im- mediate reconstruction of breast form, and decreased psychologic trauma. Reconstructive options for MIBR include submuscular implants, such as a silicone prosthe- sis or tissue expander, and the use of a myocutaneous flap, such as a latissimus dorsi myocutaneous flap (LDM) [4,5], or a transverse rectus abdominis myocutaneous flap (TRAM) [4,6,7]. The use of implants for MIBR is technically simple, but implants are unsuitable for pa- tients who have undergone either a Halsted mastectomy or a MRM in which a large tissue deficit was created. For these patients, MIBR commonly is performed using a TRAM flap. Concerns regarding the safety of using a myocutaneous flap for immediate breast reconstruction remain, especially in regard to its effect on cancer treat- ment.
We have evaluated the cosmetic results of MIBR using a myocutaneous flap in 83 patients with breast cancer. Rates of complication, patterns of recurrence, and survival were compared with those of a control popu- lation not undergoing breast reconstruction.
PATIENTS AND METHODS From April 1982 through March 1991, 83 patients
with breast cancer (group A) underwent MIBR using a myocutaneous flap. The mastectomy was a MRM in 62 patients and radical or extended mastectomy in 21 (group A in Table I). During the same period, 153 patients un- derwent mastectomy without breast reconstruction (group B). The procedure was a MRM in 62 patients and radical or extended mastectomy in 91 (group B in Table I). Histologic types were classified according to the His- tological Classification of Breast Cancer proposed by the Japan Breast Cancer Society , a modification of the Histological Typing of the World Health Organization .
THE AMERICAN JOURNAL OF SURGERY VOLUME 166 SEPTEMBER 1993 279
TABLE I. Demographics of Patients with Breast Cancer
Group A Group B (n = 83) (n = 153) pValue
Age < 35 years 10 7 36-50 years 58 64 >51 years 15 82
3 15 29
NS = not significant.
*Noninvasive carcinoma includes noninvasive ductal carcinoma, in situ Iobular
carcinoma, and Paget's disease.
I ~ - Pectoralis major muscle
TR_AM - flap
Figure 1. The pectoralis major muscle is sutured onto the upper part of the transverse rectus abdominis myocutaneous (TRAM) flap. The pectoralis major muscle is positioned just under a thin skin flap.
Reconstructive technique: Breast reconstruction was performed at the patient's request. A myocutaneous flap was used to repair large chest wall defects following extended radical mastectomy. The choice of method for breast reconstruction depended on the patient's prefer- ence and the patient's clinical condition. The LDM flap was preferred in thin, young patients and in patients who had undergone lower abdominal surgery that may have interrupted the deep superior epigastric pedicle. The TRAM flap was recommended in patients with large breasts and in patients without prior lower abdominal surgery. In MIBR, the pectoralis major muscle was su- tured to the upper part of the LDM or TRAM flap to reconstruct the breast. Since the pectoralis major muscle is placed beneath a thin skin flap, it does not obscure local recurrence (Figure 1). Marlex mesh was used for abdom- inal closure when a TRAM flap was created. A LDM flap was used in 23 patients, and a TRAM flap in 60 patients. In a few patients, the nipple-areola complex of the involved breast was implanted immediately on the reconstructed breast. In other patients, a new nipple- areola complex was constructed secondarily from other pigmented skin several months later.
Cosmetic evaluations: Since no objective criteria ex- ist for evaluating the cosmetic results of breast recon- struction, we compared the reconstructed breast with the contralateral breast. Results were rated as poor, fair, good, or excellent. The rate of good cosmesis (GC), a rating of excellent or good, was calculated as follows: GC(%) = (E + G)/(E + G + F + P) 100, in which E is excellent, G is good, F is fair, and P is poor. Patient satisfaction was determined by a telephone interview con- ducted by surgical nurses. The interviewers asked two questions: (1) "Did your breast reconstruction achieve your desired goals?" and (2) "Would you recommend modified mastectomy with immediate breast reconstruc- tion to other women who have breast cancer?"
Retrospective comparison of postoperative com- plications and survival: Postoperatively, all patients in groups A and B received adjuvant chemotherapy under a number of protocols. Patient follow-up was conducted through March 1991. Postoperative complications were assessed by chart review. The incidence of complications, including epidermolysis, hematoma, fluid collection, and infection, was determined for each group and compared. Epidermolysis was defined as any degree of skin flap necrosis. Hematomas were classified as any subcutane- ous collection of blood or a bloody fluid. A seroma was defined as any subcutaneous fluid collection not contain- ing blood. Any patient treated with antibiotics based on wound appearance was assumed to have an infection, regardless of the culture results. Complications specifi- cally related to breast reconstruction were also recorded. Flap failure was defined as any area of necrosis of a TRAM or LDM flap. We also compared the rates of recurrence and length of survival. Data were corrected for known prognostic factors of primary breast cancer. Patients with stage 4 breast cancer or bilateral breast cancer, men, and patients who underwent breast-conserv- ing treatment were excluded.
280 THE AMERICAN JOURNAL OF SURGERY VOLUME 166 SEPTEMBER 1993
BREAST RECONSTRUCTION AFTER MASTECTOMY
TABLE I1 Cosmetic Results and Patient Satisfaction Following Breast Reconstruction as a Function of the Type of Mastectomy and
the Method of Reconstruction in Patients with Breast Cancer*
Radical or Modified Extended Total
Mastectomy % (No. of Patients) % (No, of Patients) % (No. of Patients)
E+G/E+G+F+P 80 (41/51) 1 38 (6/16) 70 (47/67) Did MIBR achieve the goals you desired? Yes 62 (38/61) 41 (7/17) 58 (45/78) Would you recommend MIBR to the other patients? Yes 90 (55/61)$ 76 (13/17) 87 (68/78)
Reconstructive method TRAM (%) LDM (%) Total (%)
E+G/E+G+F+P 74 (34/46) 62 (13/21) 70 (47/67) Did MIBR achieve the goals you desired? Yes 55 (31/56) 64 (14/22) 58 (45/78) Would you recommend MIBR to the other patients? Yes 91 (51/56) 77 (17/22) 87 (67/78)
Cosmetic results were rated as E: Excellent; G: Good; F: Fair; P: Poor.
TRAM - transverse rectus abdominis myocutaneous flap; LDM - latissimus dorsi myocutaneous flap; MIBR = mastectomy with immediate breast reconstruction.
*Five patients who died and all patients who refused evaluation were excluded.
tp < 0.01 modified mastectomy versus radical or extended mastectomy.
*p < 0.05 modified mastectomy versus radical or extended mastectomy.
Statistical methods: Comparisons between qualita- tive parameters in each group were made using the x 2 test. The duration of overall and disease-free survival was calculated as the interval from t