Mastectomy with and without immediate breast reconstruction using a musculocutaneous flap

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 patients who underwent mastectomy with immediate breast reconstruction (MIBR) using a myocutaneous flap with those of 153 patients with breast cancer who underwent mastectomy without breast reconstruction. Cosmetic results were significantly bet ter in patients who underwent MIBR than radical 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 undergoing MIBR and mastectomy without breast reconstruction, 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 mastectomy (MRM); (2) modified radical mastectomy with immediate breast reconstruction (MIBR); and (3) breast-conserving procedure, consisting of partial mastectomy, 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 [3]. Furthermore, MIBR offers other advantages over other techniques, such as single anesthesia and operation, immediate reconstruction of breast form, and decreased psychologic trauma. Reconstructive options for MIBR include submuscular implants, such as a silicone prosthesis 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 patients 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 treatment.

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 underwent 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 [8], a modification of the Histological Typing of the World Health Organization [9].

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NOGUCHIET AL

T A B L E I. Demographics of Patients with Breast Cancer

Undergoing Mastectomy

Group A Group B (n = 83) (n = 153) pValue

Age < 35 years 10 7 36-50 years 58 64 >51 years 15 82

<0.01

Menopausal status Premenopausal 67 66 Postmenopausal 16 87

<0.01

Clinical stage Tumor in situ 3 8 Stage 1 18 38 Stage 2 48 74 Stage 3 14 33

NS

Histology Noninvasive cancer* 3 8 Invasive ductal cancer 75 127 Special type of invasive cancer 5 18

NS

Tumor size _< 2.0 cm 30 68 NS 2.1-5.0 cm 44 75 >5.1 cm 9 10

No. of axillary lymph node metastases

0 48 85 NS 1-3 20 39 >3 15 29

NS = not significant.

*Noninvasive carcinoma includes noninvasive ductal carcinoma, in situ Iobular

carcinoma, and Paget's disease.

I ~ - Pectoralis major musc le

TR_AM - flap

�9 S'~!.L

,K'~"

Figure 1. The pectoral is major muscle is sutured onto the upper part of the transverse rectus abdominis myocutaneous (TRAM) flap. The pectoral is 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 sutured 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 abdominal 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 exist for evaluating the cosmetic results of breast reconstruction, 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 conducted 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 reconstruction to other women who have breast cancer?"

Retrospective comparison of postoperative complications 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 subcutaneous 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-conserving treatment were excluded.

280 T H E A M E R I C A N J O U R N A L OF S U R G E R Y V O L U M E 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 recurrence, 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 relevant prognostic factors, including age, menopausal status, 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 <0.01). However, the intergroup difference in length of hospital stay was not different, 30 4- 11 days in group A and 29 4- 10 days in group B. The cost of surgery was approximate- ly $1,500 for MRM, $1,350 for radical mastectomy, and $1,900 for extended radical mastectomy. An additional $1,400 was charged for creating a myocutaneous flap.

Cosmetic appearance and patient serf-assessment: The cosmetic appearance in patients undergoing MIBR was rated as excellent or good in 47 of 67 patients (70%). Results in patients undergoing modified MIBR were significantly better than in patients undergoing radical or extended MIBR, but no difference was noted between patients whose breast was reconstructed using a TRAM flap or a LDM flap (Table H). Forty-five of 78 respondents (58%) answered "Yes," to the question, "Did your breast reconstruction achieve the goals you desired?" Six- ty-eight of 78 respondents (87%) answered "Yes," to the

TABLE III Complications Associated With the Types of Mastectomy

and the Methods of Reconstruction for Breast Cancer

Mastectomy Radical or GroupA/Group B Modified Extended Total (No. of patients) (62/62) (21/91) (83/153)

Epidermolysis (%) 26/30 29/34 27/28 Hematoma (%) 11/8 10/12 11/11 Seroma (%) 3/30* 5/18 4/19" Infection (%) 5/10 0/9 4/9 Others (%) 13 / - - 2 4 / - - 1 6 / - No complicaton (%) 47/50 48/48 47/49

Reconstruction method TRAM LDM Total (No. of patients) (60) (23) (83)

Infection on donor side (%) 5 9 5 Dehiscence on donor side (%) 0 9 t 2 Myocutaneous flap failure (%) 2 4 2 Abdominal hernia (%) 3 - - - -

Group A = mastectomy with immediate reconstruction; Group B = mastectomy

without immediate breast reconstruction; TRAM = transverse rectus abdominis

myocutaneous flap; LDM = latissimus dorsi myocutaneous flap.

*p < 0.05, group A versus group B.

tp < 0.05 TRAM versus LDM.

question, "Would you recommend modified radical mastectomy with immediate breast reconstruction to other women with breast cancer?" There was a discrepancy between patients' self-assessed satisfaction and the cosmetic appearance as judged by physicians. Patient satisfaction was significantly higher in the group undergoing modified MIBR than radical or extended MIBR. Satis- faction was not different between patients undergoing different types of reconstruction (Table II).

Postoperative eonlplieations: Epidermolysis occurred frequently and was not related to the type of mastectomy or reconstruction. Despite the routine use of

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NOGUCHIET AL

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 overall 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 recurrence. No patient died of an unrelated course in group A. Ten patients (7%) in group B had died of disease recurrence, 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 recurrence followed by distant metastases developed in four other patients. In group B, isolated distant metastases developed in nine patients, and regional lymph node recurrence 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, respectively. 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 axillary lymph node metastases affected the disease-free interval and overall survival. Age, menopausal status, clinical 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 accepted 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 beneath 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 [12]. Georgiade et al [13] and Johnson et al [14] have demonstrated that MIBR using silicone implants 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 [15]. 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 patients with advanced breast cancer, in whom a myocutaneous 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 reconstruction on patient survival. Therefore, we believe we are justified in encouraging women undergoing mastectomy for breast cancer to accept immediate reconstruction using a myocutaneous flap.

Furthermore, immediate reconstruction does not in- crease the rate of complications. Vinton et al [16] have reported that more wound complications occurred following MRM than MIBR with submuscular prosthetic implant (48% versus 31%, respectively). No other study has compared the wound complication rate for MIBR and mastectomy alone. Feller et al [17] have reported on 100 patients who underwent MIBR using a submuscular implant or a myocutaneous flap and found a 2% infection rate and a 2% incidence of hematomas in patients with both types of surgery. Webster et al [18] have evaluated 85 patients who underwent MIBR using either an implant or myocutaneous flap and found a 41% complication rate, a 14% infection rate, a 5% epidermolysis rate, and an 11% incidence of prosthesis loss. Frazier and Noone [19] have studied 70 patients undergoing MIBR with submuscular prosthetic implants and found a complication rate of 8% and an infection rate of 4%. Noone et al [20] have reported a wound complication rate of 24% in 185 patients undergoing MIBR with either submuscular implants or myocutaneous flap. Cellulitis occurred in 2%, seromas in 12%, epidermolysis in 15%, and prosthesis loss in 4%. This series of reports demonstrates that MIBR is a safe and acceptable alternative in the treatment of patients with breast cancer. Thin skin flaps were developed, as in a Halsted mastectomy in our series, to prevent local recurrence. This accounts for the increased incidence of epidermolysis in patients undergoing either MIBR or mastectomy alone. Myocutaneous flap failure occurred with both TRAM and LDM flaps. Among 300 patients with delayed breast reconstruction, Hartrampf and Bennett [7] have reported 1 total TRAM flap failure (0.3%) and 18 partial TRAM flap failures (6%). The leading cause of TRAM flap failure was the use of tissue beyond the vascular pedicle. We believe that results improve as a direct function of the surgeon's experience.

Other concerns regarding MIBR involve psychologic theories of loss and bereavement [21]. It has been sug- gested that patient satisfaction with breast reconstruction may be enhanced by mourning the deformity of a mastectomy [22-25]. These theories have been challenged. It has been demonstrated that women who undergo MIBR are more likely to incorporate their new breast into their body image and achieve a higher level of comfort and satisfaction from the onset [26-29]. Goin and Goin [27] have compared immediate and delayed reconstruction in

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women undergoing synchronous procedures and conclud- ed that no psychologic benefits accrue from delayed re. construction. These and numerous other investigations attest to the psychologic benefit of MIBR [26-31]. Cos- metic appearance and patient satisfaction were inversely correlated with the extent of mastectomy in this series, and the reconstructive technique did not influence either of these parameters. Ordinarily, patients require multiple procedures to achieve optimal results in both delayed and immediate breast reconstruction; however, no patient in this series desired further surgery to improve the cosmetic appearance of the reconstructed breast. Patient prefer- ence for a single operation should be respected and suggests yet another advantage to MIBR. To accomplish this goal, cooperation of the plastic and general surgeons must be encouraged [20].

Longer follow-up is necessary for conclusive results regarding long-term survival. This short-term study, however, strongly suggests that MIBR using a myocutaneous flap does not adversely affect patient survival, while offering acceptable cosmetic results for patients undergoing MRM.

REFERENCES 1. Fisher B, Redmond C, Poisson R, et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpec- tomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989; 320: 822-8. 2. Veronesi U, Banff A, dcl Becchio M, et al. Comparison of Halsted mastcctomy with quadrantectomy, axillary dissection and radiotherapy in early breast cancer: long-term results. Eur J Cancer Clln Oncol 1986; 22: 1085-9. 3. Nognchi M, Miyazaki I. The surgical management of breast cancer. Int Surg 1990; 75: 8-14. 4. Bostwick JIII. Breast reconstruction after mastectomy. Cancer 1990; 66: 1402-11. 5. Marshall DR, Anstee EJ, Stapleton MJ. Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap. Br J Plast Surg 1984; 37: 361-8. 6. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69: 216-24. 7. Hartrampf CR, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient. Ann Surg 1987; 205: 508-19. 8. Japan Breast Cancer Society. General rules for clinical and pathological recording of breast cancer, 9th ed. Tokyo: Kinbara, 1988. 9. The World Health Organization. The World Health Organiza- tion histological typing of breast tumors--second Edition. Am J Clin Pathol 1982; 78: 806-16. 10. Schain WS. Sexual functioning in cancer patients. In: deVita VT, Hellmann S, Rosenbcrg SA, editors. Practices in oncology. Philadelphia: Lippincott, 1982.

11. Jamison KR, Wellisch DK, Pasnau Re. Psychosocial aspects of mastcctomy: the woman's perspective. Am J Psychiatry 1978; 135: 432-6. 12. Georgiadr GS, Georgiade NG, McCarty KS, Ferguson BJ, Seigler HF. Modified radical mastectomy with immediate reconstruction for carcinoma of the breast. Ann Surg 1981; 193: 565-73. 13. Georgiade GS, Riefkohl R, Cox E, et al. Long-term clinical outcome of immediate reconstruction after mastectomy. Plast Re. constr Surg 1985; 76: 415-20. 14. Johnson CH, van Hecrden JA, Donohue JH, Martin JK Jr, Jackson IT, Ilstrup DM. Oncological aspects of immediate breast reconstruction following mastcctomy for malignancy. Arch Surg 1989; 124: 819-24. 15. Gilliland MD, Larsen DL, Copcland EM. Appropriate timing for breast reconstruction. Plast Rcconstr Surg 1983; 72: 335-40. 16. Vinton AL, Traverse LW, Zchring RD. Immediate breast reconstruction following mastectomy is as safe as mastectomy alone. Arch Surg 1990; I25: 1303-8. 17. Feller WF, Holt R, Spear S, Little JW. Modified radical mastectomy with immediate breast reconstruction. Am Surg 1986; 52: 129-33. 18. Webster D J, Mansel RE, Hughes LE. Immediate reconstruction of the breast after mastectomy: is it safe? Cancer 1984; 53: 1416-9. 19. Frazier TG, Noone RB. An objective analysis of immediate simultaneous reconstruction in the treatment of primary carcinoma of the breast. Cancer 1985; 55: 1202-5. 20. Noone RB, Murphy JB, Spear SL, Little JW. A 6-year experience with immediate reconstruction after mastectomy for cancer. Plast Reeonstr Surg 1985; 76: 258-69. 21. Parkes MC. Bereavement studies of grief in adult life. London: Pelican Books, 1972. 22. Klein R. A crisis to grow on. Cancer 1971; 28: 1660-5. 23. Luce EA. Breast reconstruction after mastectomy. South Med J 1983; 76: 190-3. 24. Teimourian B, Adham MN. Survey of patients' responses to breast reconstruction. Ann Plast Surg 1982; 9: 321-5. 25. Rosato FE, Horton CE, Maxwell GP. Postmastcctomy reconstruction. Curt Probl Surg 1980; 17: 585-629. 26. Stevens LA, McGrath MH, Druss RG, et al. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg 1984; 73: 619-26. 27. Goin MK, Goin JM. Psychological reactions to prophylactic mastcctomy synchronous with contralateral breast reconstruction. Plast Reconstr Surg 1982; 70: 355-9. 28. Clifford E. The reconstruction experience: the search for resti- tution. In: Georgiade NG, editor. Breast reconstruction following maste~tomy. St. Louis: Mosby, 1979. 29. Dean C, Chetty U, Fortest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastaztomy. Lancet 1983; 1: 459-62. 30. Wilkinson LH. Modified radical mastectomy with immediate breast reconstruction. Arch Surg 1982; 117: 579-82. 31. Wdlisch DK, Schain WS, Ncone RB, Little JW III. Psychoso- cial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg 1985; 76: 713-8.

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Mastectomy with and without immediate breast reconstruction using a musculocutaneous flap