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Outcomes Differ with Type of Post-Mastectomy Breast Reconstruction

2008-11-24T09:00:00-04:00
Todd Neale

What breastcancer.org says about this article…

Outcomes Differ with Type of Post-Mastectomy Breast Reconstruction

Deciding whether to have a breast reconstructed after surgery to remove breast cancer is a very personal choice. Researchers are studying how different reconstruction techniques, as well as the timing of reconstruction, affect reconstruction outcomes, both emotionally and physically.

There are three ways to time reconstruction after mastectomy:

Right after mastectomy, before any other treatments such as chemotherapy and/or radiation therapy. This approach is called immediate reconstruction.
After surgery and after any chemotherapy and radiation therapy are done. This approach is called delayed reconstruction.
A two-step approach involving some reconstructive surgery during mastectomy and more reconstructive surgery after any additional treatments. This is called delayed-immediate reconstruction.

There are two main techniques for reconstructing the breast:

Inserting an implant that's filled with salt water, silicone gel, or a combination of the two. In many cases, your plastic surgeon places a tissue expander between the skin and chest muscle after your breast surgeon has removed the breast tissue. A tissue expander is a balloon-type device that stretches the skin to make room for the implant. The expander has a port (a metal or plastic plug, valve, or coil) that allows the surgeon to add increasing amounts of liquid (a salt water solution) over time (between 2 to 6 months) until the skin is gradually stretched enough to accommodate the implant.
Using tissue transplanted from another part of your body (such as your belly or back). This is called autologous reconstruction.

The small study reviewed here found that poor outcomes or severe complications were more likely with immediate implant reconstruction followed by radiation therapy than with immediate autologous reconstruction followed by radiation therapy. Most of the women in the study who choose autologous reconstruction had a TRAM flap. TRAM stands for the transverse rectus abdominis muscle, which is in the lower abdomen, between the waist and the pubic bone. With the TRAM procedure a "flap" of this abdominal tissue is moved to the chest area to reconstruct the breast.

33% of the women who had immediate tissue expander/implant reconstruction followed by radiation had a severe complication that required more surgery or antibiotic treatment. None of the women who had immediate autologous reconstruction followed by radiation had these severe complications.
55% of the women who had immediate tissue expander/implant reconstruction followed by radiation had problems moving their arm or couldn't lift an object (this is called a poor functional result). Only 9% of the women who had immediate autologous reconstruction followed by radiation had these problems.
Only 51% of the women who had immediate tissue expander/implant reconstruction followed by radiation said the breast reconstruction was cosmetically acceptable. More than 82% of the women who had immediate autologous reconstruction followed by radiation said the reconstruction was cosmetically acceptable.

If you're considering breast reconstruction, talk to your doctor about the options that make the most sense for you. Here are some sample questions you might want to ask:

Which reconstruction timing choice is best for me? Immediate reconstruction can be a good option, but if your treatment plan includes radiation and chemotherapy, your doctor may recommend delayed or immediate-delayed reconstruction.
Which type of reconstruction is best for me? Each type of implant and autologous reconstruction has its own benefits and potential side effects. The best approach for you will depend on your individual circumstances and your preferences.
Who should do the reconstruction? Most plastic surgeons who do breast reconstruction have experience with the different breast reconstruction options, but that experience may be stronger with some approaches. If you choose immediate reconstruction, it's important to choose a plastic surgeon who can work well with your breast surgeon.

Visit the Breastcancer.org Reconstruction section to learn much more about reconstruction options you and your doctor can consider.

More Research News on Reconstruction (9 Articles)

GARDEN CITY, N.Y., Nov. 21 (MedPage Today) -- For women who've had breast reconstruction immediately after mastectomy, the type of procedure may determine outcomes following radiation, researchers found.

The rate of severe complications requiring surgical intervention or IV antibiotics was significantly higher for women who had tissue expander and implant reconstruction than for those whose new breast was constructed using autologous tissue (33.3% versus 0%, P=0.001), according to Jigna Jhaveri, M.D., of Long Island Radiation Therapy here, and colleagues.

Women undergoing tissue expander and implant reconstruction were also significantly more likely to have poor functional results (55% versus 8.7%, P<0.001), they reported in the Nov. 1 issue of the International Journal of Radiation Oncology Biology Physics.

And patients who had autologous tissue reconstruction were more likely to rate the cosmetic result as acceptable (82.5% versus 51%, P=0.007), the researchers said.

"We believe that this report provides important information to help patients in choosing a reconstructive technique that may suit them best," they said.

Undergoing immediate reconstruction can complicate planning for radiation therapy and, alternately, radiation can negatively affect clinical outcomes of the reconstruction, the researchers said.

Most previous studies evaluating outcomes following post-mastectomy breast reconstruction and radiation therapy have been subject to various limitations, they said.

So they retrospectively analyzed data from 92 patients who had had a radical mastectomy, immediate reconstruction, and radiation therapy at their practice from 1998 through 2005.

Three-quarters of the patients underwent tissue expander and implant reconstruction, and the rest had autologous tissue reconstruction, mostly using a tissue flap from the transverse rectus abdominus muscle.

All patients received 50.4 Gy of radiation to the reconstructed breast and chest wall and 45 Gy to the supraclavicular region; 18% received a boost greater than 50.4 Gy.

Patients who had the autologous tissue procedure were significantly younger (median age 46 versus 54, P=0.04), but received similar treatment.

Most of the patients (95%) received primarily doxorubicin-based chemotherapy, and 76% received hormonal therapy after radiation therapy was completed.

Through a median follow-up of 38 months, the overall rates of poor functional results and severe complications were 43.4% and 25%, respectively, although both were significantly higher in patients who had the tissue expander procedure.

Severe complications found in the patients who underwent the tissue expander procedure included severe capsular contracture requiring revision and infection requiring IV antibiotics.

Fourteen patients, all in the tissue expander group, had their implants removed because of unacceptable cosmetic result (six), infection (seven), or cancer recurrence (one).

Aside from type of reconstruction, no treatment- or patient-related factors were significantly associated with clinical outcome.

The authors acknowledged that the study was limited by the retrospective design and by the lack of information regarding the timing of the exchange of the tissue expander for a permanent implant.

The authors reported no conflicts of interest.

Primary source: International Journal of Radiation Oncology Biology Physics Source reference: Jhaveri J, et al "Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction" Int J Radiation Oncology Biol Phys 2008; 72: 859-865.

Research News on Reconstruction (9 Articles)

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