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 the initial operation until death due to breast cancer-related causes and to recur- rence, respectively. Patients dying without recurrence were censored at death. In univariate analysis, the overall and disease-free survival in both groups was evaluated by the Kaplan-Meier method. A log-rank test was employed to assess statistical significance. In multivariate analysis, the Cox regression test was used to determine whether MIBR compromised patient survival, adjusting for rele- vant prognostic factors, including age, menopausal sta- tus, clinical stage, tumor size, histologic type, and the presence of axillary lymph node metastases.
RESULTS Operative data: The average length of surgery was
4.45 hours in group A patients and 2.3 hours in group B patients. The average loss of blood was 425 4- 223 mL in group A and 206 4- 107 mL in group B (p
suction catheters, an axillary collection of blood, serum, or lymph was a frequent postoperative complication. Ser- oma was more frequent in patients undergoing modified mastectomy without breast reconstruction compared with those with breast reconstruction. However, the over- all incidence of complications was not higher in patients who underwent MIBR (Table IH). Complications related to breast reconstruction included one partial failure of a TRAM flap and one total failure of a LDM flap. Dehis- cence of the posterior wound occurred in two patients with LDM flaps, and an abdominal hernia occurred in two patients with TRAM flaps (Table III).
Outcome: As of March 1991, 5 patients (6%) in group A had died of disease recurrence, 3 (4%) were alive with recurrence, and 75 (90%) were alive without recur- rence. No patient died of an unrelated course in group A. Ten patients (7%) in group B had died of disease recur- rence, 7 (5%) were alive with recurrence, and 129 (84%) were alive without recurrence. Seven others (5%) had died of unrelated causes. In group A, distant metastases developed in four patients, and regional lymph node re- currence followed by distant metastases developed in four other patients. In group B, isolated distant metastases developed in nine patients, and regional lymph node re- currence with subsequent distant metastases developed in eight patients.
Disease-free interval and overall survival: The 5- year disease-free and overall survival rates were 90% and 92% in group A and 86% and 92% in group B, respective- ly. These rates were not significantly different, although a number of differences in the prevalence of prognostic factors existed between the groups (Table I). To correct for the differences, prognostic variables were analyzed by Cox's multivariate analysis to determine their relative importance and independence. Only the presence of axil- lary lymph node metastases affected the disease-free in- terval and overall survival. Age, menopausal status, clini- cal stage, tumor size, histologic type, and breast reconstruction were not independent variables affecting survival in this series. After adjustment for the relevant prognostic factors, MIBR did not appear to affect patient survival.
COMMENTS The loss of a breast has significant psychologic, social,
and sexual impact [10,11]. MIBR has become an accept- ed procedure for the treatment of breast cancer, although concern related to compromised ablation and long-term survival continues to be expressed. The presence of a bulky implant or autogenous tissue may prevent early detection of local recurrence. However, the detection of local recurrence is not impaired by implants placed be- neath the pectoralis major muscle because most local recurrences develop in the skin, subcutaneous tissue, or regional nodal basins, rather than deep in the chest wall musculature . Georgiade et al  and Johnson et al  have demonstrated that MIBR using silicone im- plants does not adversely effect the natural history of surgically treated breast cancer. The recurrence of cancer in MIBR seems to be a function of the disease itself, not
the timing of reconstruction . To our knowledge, no report has documented a negative effect of MIBR using a myocutaneous flap on survival. Another major concern regarding MIBR has been that extensive surgery may compromise survival by delaying adjuvant therapy or by inhibiting the immune response. Our series included pa- tients with advanced breast cancer, in whom a myocuta- neous flap was used to repair a chest wall defect rather than for breast reconstruction. However, univariate and multivariate analyses did not show any effect of recon- struction on patient survival. Therefore, we believe we are justified in encouraging women undergoing mastectomy for breast cancer to accept immediate reconstruction us- ing a myocutaneous flap.
Furthermore, immediate reconstruction does not in- crease the rate of complications. Vinton et al  have reported that more wound complications occurred follow- ing MRM than MIBR with submuscular prosthetic im- plant (48% versus 31%, respectively). No other study has compared the wound complication rate for MIBR and mastectomy alone. Feller et al  have reported on 100 patients who underwent MIBR using a submuscular im- plant or a myocutaneous flap and found a 2% infection rate and a 2% incidence of hematomas in patients wit...