Xrt After Reconstruction

RECONSTRUCTIVE OPTIONS

  • Implant-based techniques
    • Cadaveric or bovine dermis for lower pole coverage
    • Shaped saline implants
    • Semi-solid silicone gel implants
  • Autologous tissue reconstructions
    • Using tissue flaps that are transferred from adjoining or distant donor sites to the anterior chest wall.
    • TRAM(transverse rectus abdominis musculocutaneous)
    • Pedicle flaps
    • Free (microsurgical) flaps
    • Perforator flaps
      • Deep inferior epigastric perforator flap (DIEP)
      • Superficial inferior epigastric perforator flap (SIEP)
      • Superior gluteal artery perforator flap (SGAP)
      • Inferior gluteal artery flap (IGAP)

Timing of reconstruction

  • Immediate (at the time of the mastectomy)
  • Delayed (during a subsequent operation)

Advantages of immediate reconstruction:

  • Less overall cost
  • Psychosocial benefits
  • Normal breast landmarks (such as the inframammary fold) are preserved with immediate reconstruction. Particularly with skin-sparing mastectomies and autogenous tissue reconstructions
  • Remaining breast skin can be incorporated into the new breast==>yielding a more natural-appearing shape

Disadvantages of immediate reconstruction:

  • Prolongs operative time
  • Necrosis of the mastectomy skin flaps
  • Higher rate of complications
    • Particularly among those who had TRAM flaps

Relative contraindications to immediate reconstruction:

  • Advanced disease (stage III or higher)
  • Need for postoperative RT (although this is a controversial area)
  • Medical comorbidities such as active smoking, obesity, or cardiopulmonary disease

RADIATION THERAPY AND RECONSTRUCTION

Immediate Reconstruction:

  • May pose limitations on treatment planning for postmastectomy RT
  • Adversely affect the technical delivery of RT
    • Excessive dosage to the lung or inadequate dosage to the internal mammary lymph nodes
  • Rt also compromise the quality of the skin and underlying tissue

For patients who need postmastectomy RT, delayed autologous flap reconstruction provides the best cosmetic result with the fewest complications.

Impact of RT on implants

  • RT complication rates are highest among women undergoing expander/implant reconstruction
    • Scar formation at the implant/tissue interface
    • Capsular contracture
    • Impaired skin healing
    • May need replacement
  • That's irrespective of when RT is given in relation to surgery

Impact of RT on TRAM reconstruction

TRAM reconstruction=Transverse Rectus Abdominis Muscle

  • Fat necrosis
  • Fibrosis
  • Atrophy
  • Flap contracture
  • Early complications not more likely in RT patients vs non-RT
    • Vessel thrombosis
    • Partial or total flap loss
  • Late complications is higher in RT patients vs non-RT
    • Fat necrosis
    • Flap volume loss
    • Flap contracture

Immediate TRAM followed by RT would be more complex rather than RT followed by delayed flap.

Delayed reconstruction after RT

Autogenous tissue options preferred over implant-based techniques in previously irradiated patients.

Tissues severely damaged by RT can be resected and discarded at the time of the reconstruction, and the skin "paddle" of the designed flap can be tailored to replace the missing breast surface skin.

In general, prior RT increases the amount of tissue required for breast reconstruction, and this may limit flap selection.

AUTOGENOUS TISSUE RECONSTRUCTION — The development of musculocutaneous flaps and microsurgical tissue transplantation paved the way for modern autogenous tissue breast reconstruction. Musculocutaneous flaps consist of a segment of vascularized muscle with the overlying skin and fat which are perfused by perforating vessels from the underlying muscle. These flaps may be transposed into position with their vascular origin intact ("pedicled" flaps).

Alternatively, the flap and its vascular supply can be completely harvested and transferred to the mastectomy site, requiring anastomosis of the flap's artery and vein to local vessels at the recipient site, usually the internal mammary or thoracodorsal vessels ("free" flaps). Although these microvascular free flaps have traditionally included a segment of underlying muscle, a newer version, called a perforator free flap, harvests only the vascular supply (artery and vein) and the overlying skin and fat.

When reconstruction of the breast mound is accomplished using the patient's own tissues, the result is typically more natural in both appearance and feel than with expander/implant reconstruction. Autogenous tissue reconstruction also tends to provide a better match for a large, ptotic contralateral breast if alteration of the opposite breast is not desired. Furthermore, autogenous reconstruction may be the only available reconstructive option for patients who have large soft tissue deficits or chest wall skin that is unsuitable for tissue expansion due to scar tissue or radiation-induced changes.

Pedicled TRAM flap — One of the most commonly used autogenous tissue reconstructions is the TRAM (transverse rectus abdominus myocutaneous) flap. The flap is comprised of an ellipse of lower abdominal skin, subcutaneous fat, and muscle. The skin and subcutaneous fat of the lower abdomen receive their blood supply from the underlying muscle via perforating vessels from the superior and inferior epigastric arteries, which arborize through the rectus abdominus muscle. The pedicled TRAM flap is based on the superior epigastric artery and vein, and is rotated into the breast pocket with the superior portion of the muscle still attached to the costal margin (figure 4).

TRAM flaps use a transversely oriented skin island from the lower abdomen [102]. This design incorporates an abdominoplasty ("tummy tuck") as part of the donor site closure. Using a single rectus muscle, up to 75 percent of the infraumbilical skin and fat can be harvested for the pedicled TRAM flap (figure 5).

Some women have a greater tissue volume requirement than can be provided by a single rectus muscle. In these cases, both rectus muscles may be raised with the TRAM flap (a bipedicled TRAM). By using both rectus muscles to feed the flap, a larger portion of the abdominal skin and fat can be carried, and the likelihood of fat necrosis or flap loss is reduced [103].

Other methods are commonly used to augment the sometimes tenuous arterial blood supply or venous drainage of a pedicled TRAM flap. With a preliminary delay procedure, the inferior epigastric vessels are ligated at least one week prior to the reconstruction. The superior epigastric vessels dilate in response to the relative hypoperfusion of the tissue in their vascular territory, an effect that appears to permanently augment the vascular supply [104]. This procedure can be used for both unipedicled and bipedicled flaps, and is most often used in patients who are at higher risk for fat necrosis and flap loss.

A second technique, called "supercharging" the flap, involves anastomosing the deep inferior artery and vein microsurgically into the thoracodorsal or internal mammary vessels to augment the vascular supply of the pedicled TRAM flap.

Advantages and disadvantages — Like other autogenous tissue reconstructions, pedicled TRAM flaps produce a natural appearance and texture in the new breast. The aesthetic results tend to age well, seldom requiring revision in later life to maintain symmetry with the contralateral breast. Unlike expander/implant techniques, pedicled TRAM reconstructions are essentially one-staged procedures: patients do not require multiple operations or weekly tissue expansions.

Disadvantages of this type of reconstruction include long operative times (four to six hours), relatively long hospitalizations (three to five days), and long postoperative recovery. It may take women two to four months to return to their preoperative physical functioning. Other outcomes associated with TRAM flap reconstruction, including patient satisfaction and postreconstruction physical functioning, are discussed below. (See 'Outcomes associated with breast reconstruction' below.)
Patient selection — Although TRAM reconstruction is a safe, reliable procedure, patient selection is critical in order to avoid flap loss and donor site morbidity. The ideal candidate for a pedicled TRAM flap is a nonsmoking, nondiabetic patient of normal weight with adequate soft tissue in the lower abdomen to match the volume of the contralateral breast.

Absolute contraindications include a previous TRAM flap, abdominoplasty, or an open cholecystectomy scar that violates the blood supply of the pedicle. Active smoking, obesity, diabetes, collagen vascular disease, postmastectomy radiation therapy (RT), and the presence of certain abdominal scars all increase the risk of complications with the flap and wound healing problems at the lower abdominal donor site.
Outcomes — Major complications from TRAM flap reconstruction are rare. These include total flap loss (1 percent or less) [35,105], which necessitates surgery to both remove necrotic tissue and perform an additional procedure to reconstruct the breast. Rarely, patients can also experience bleeding, infection, deep venous thrombosis, or pulmonary embolism.

Lesser complications are relatively common, including fat necrosis, acute partial flap loss, seroma, and lower abdominal laxity or hernias. Fat necrosis and/or partial flap loss occur when a fatty region of the flap within the flap does not receive enough blood supply. The resulting tissue fibrosis and/or calcification can simulate a mass in the reconstructed breast on postoperative physical examinations.

Acute partial flap loss, usually manifest by small areas of skin loss, is usually treated nonoperatively, with dressing changes to promote secondary healing. Seromas most commonly occur in the donor site and may require percutaneous aspiration or reinsertion of a surgical drain.

The incidence of long-term complications such as abdominal wall laxity, bulge, or hernia was 8 percent in one series [35] and 3 percent on a second [105]. These complications generally require surgical repair.

Free TRAM flap — Unlike the pedicled TRAM flap, which leaves the rectus abdominis muscle attached to the costal margin and tunnels the lower abdominal skin and fat in to the mastectomy site, the free TRAM flap completely detaches and directly transfers the lower abdominal tissue to the mastectomy site. The deep inferior epigastric artery and vein, which provide the vascular supply for the free flap, are anastomosed to local recipient vessels, using either the internal mammary or thoracodorsal arteries and veins. Thereafter, the free TRAM flap is contoured and inset in a fashion similar to that of the pedicled TRAM. Donor site closure is the same with both types of TRAM flaps (figure 6). (See 'Pedicled TRAM flap' above.)

Advantages and disadvantages — Free TRAM flaps may provide a more robust blood flow, particularly to the perforators, making the flaps more reliable than pedicled TRAM flaps. Disadvantages of this technique include potentially longer operating times and the need for microsurgical expertise. Furthermore, a trained nursing staff is required in the early post-operative period for flap monitoring in order to detect vessel thrombosis and resulting flap compromise. The rate of total flap loss is also somewhat higher than that for pedicled TRAM flaps (2 to 5 versus less than 1 percent).
Patient selection — Because the free TRAM flap may provide a more robust blood supply than the pedicled TRAM flap, the free TRAM may be preferred when the mastectomy defect requires large amounts of skin and soft tissue coverage, or when large unilateral or bilateral reconstructions (figure 7) require the use of peripheral portions of the flap. In addition, the more generous blood supply can improve flap survival in patients who have risk factors such as smoking, diabetes, or obesity. In addition, some women who are not candidates for pedicled TRAM flaps due to previous subcostal incisions and resultant interruption of the superior epigastric vessels can undergo free TRAM flap reconstruction without difficulty.
Outcomes — Complications in the early postoperative period include infection, hematoma, seroma, donor site necrosis, and partial or total flap loss. As noted above, the rate of total flap failure is somewhat higher for free TRAM than for pedicled flaps (2 to 5 versus less than 1 percent, respectively) [106], although the free flap is more resistant to partial loss than is the pedicled TRAM flap. As with pedicled TRAM reconstructions, long-term complications for the free TRAM flap include abdominal wall laxity or hernia.

Latissimus dorsi reconstruction — Another reliable option for autologous tissue reconstruction is the latissimus dorsi (LD) flap (figure 8). Usually transferred to the mastectomy site as a pedicled flap, the LD flap is tunneled through the axilla, leaving its vascular pedicle, the thoracodorsal artery and vein, intact. Because the LD is not a bulky flap, it usually is used in combination with a saline or silicone implant to provide sufficient breast volume and projection. Alternatively, some surgeons inset the LD flap over a tissue expander, relying on the subsequent expansions to create the needed breast contour. As described above, the expander is later replaced with a saline or silicone reconstructive implant (figure 9). (See 'Implant-based techniques' above.)

Patient selection — LD flaps are useful in patients who are not candidates for expander/implant or TRAM reconstruction [107,108]. In some individuals, the skin at the mastectomy site may be compromised from previous RT or surgical trauma, thus eliminating expander-implant reconstruction as a viable option.

LD flaps also represent an acceptable alternative for patients who require autogenous tissue reconstruction but are not appropriate candidates for TRAM flaps because of obesity, active smoking, or significant medical comorbidity. LD flaps also are commonly used for reconstruction of contour defects following lumpectomy and RT in breast cancer patients. Finally, LD flaps can work well for salvage of breast reconstruction in cases of partial or total loss of other types of autogenous tissue reconstruction, provided that the thoracodorsal vessels or the LD muscle have not been sacrificed in previous operations.
Advantages and disadvantages — The advantages of LD reconstruction include flap reliability and suitability in patients who may be marginal candidates for more complicated flap techniques.

Disadvantages of the LD flap include significant donor site scarring and the frequent need for an implant and/or tissue expander placement due to insufficient flap volume. The latissimus dorsi muscle may also atrophy over time, making the underlying implant more prominent and causing contour irregularities in the reconstructed breast. In a report of 68 women undergoing reconstruction with combined LD flaps and implants followed for at least 10 years, one-half needed additional surgeries for exchange or removal of the prosthesis [109].
Outcomes — Complications from LD flaps include hematoma, infection, fat necrosis, and partial or total flap loss. Because the blood supply to the latissimus is extremely reliable, the incidence of flap loss is relatively low, compared to other autogenous tissue options for breast reconstruction.

The most common complication is seroma formation in the LD donor site; rates as high as 12 to 21 percent are reported [110,111]. Although it has not been systematically studied, the impact of LD harvest on shoulder function appears to be minimal [112].

Perforator flaps — In an effort to conserve muscle, "perforator" flaps harvest only the skin and fat overlying the muscle along with the perforating vessels and dominant artery and vein supplying the flap. The free flap is then transferred as described above for free TRAM flaps. Although the underlying muscle must be split to dissect out the perforating vessels, the muscle itself is not included in the transfer. (See 'Free TRAM flap' above.)

DIEP perforator flaps — The most commonly used perforator flap for breast reconstruction is the deep inferior epigastric perforator (DIEP) flap (figure 10). The DIEP uses the same lower abdominal island of skin and fat as TRAM techniques but spares the rectus abdominis muscle. Also as with TRAM flaps, the DIEP donor site is closed as a modified abdominoplasty.

Patient selection — Similar to TRAM flaps, patient selection for DIEP flaps should be made on the basis of body weight, medical comorbidities, quantity of abdominal fat, and breast volume. Patients who are very concerned about abdominal wall morbidity or bulging after a TRAM reconstruction may also be candidates.

Contraindications to DIEP reconstruction are similar to those for TRAM flaps and include prior history of abdominoplasty or abdominal liposuction, obesity, and active smoking (within one month of surgery). Relative contraindications include large transverse or oblique abdominal incisions [113]. Pfannenstiel scars do not appear to influence complication rates [114].

Successful transplantation of perforator flaps requires blood vessels of suitable caliber and location. Accordingly, some surgeons employ preoperative evaluation of perforator vessels using modalities such as computerized tomographic angiography (CTA) or magnetic resonance angiography [115-117].

Advantages and disadvantages ─ The DIEP flap has all of the advantages of the free TRAM flap and a similar aesthetic outcome, but may be associated with a lower incidence of abdominal wall laxity, and weakness, less postoperative pain, and shorter recovery [113,118-124]. In appropriately selected patients, some microsurgeons prefer DIEP flaps over free TRAM reconstruction.

Significant microsurgical expertise is required for the meticulous dissection and anastomosis of perforators as small as one millimeter in diameter. The complexity of the procedure contributes to long operative times.
Outcomes ─ Patients should be counseled preoperatively that consideration of a DIEP flap as a reconstructive option depends upon the number, caliber, and location of the perforating vessels. If the inferior epigastric perforators are noted intraoperatively to be insufficient to support the entire flap, the procedure may need to be converted to a standard free TRAM reconstruction, in which case a portion of the rectus muscle would be harvested with the flap.

Complications of the DIEP flap include fat necrosis, partial flap loss, total flap loss, and abdominal wall laxity or hernia. In a series of 758 DIEP flaps performed for breast reconstruction, 6 percent of patients were returned to the operating room for flap-related problems [118]. Partial flap loss occurred in 2.5 percent and total flap loss in less than 1 percent. Other problems included fat necrosis in 13 percent (risk factors were smoking and post reconstruction RT), seroma formation at the abdominal donor site in 5 percent, and abdominal hernia in 0.7 percent.

Whether the incidence of partial and total flap loss is higher than with traditional TRAM procedures is unclear. Some studies show that DIEP flaps have a less robust blood supply than TRAM flaps, and therefore an increased risk of fat necrosis [125,126]. One study, for example, compared 105 women who underwent bilateral pedicled TRAM flaps with 58 women who had bilateral DIEP flap reconstructions; there were significantly higher rates of partial skin loss, wound dehiscence, and fat necrosis with the DIEP flap [126]. There were no significant differences in the incidence of seromas or hematomas, back pain, abdominal hernias or bulges between the two groups. Other studies suggest that rates of partial flap loss and fat necrosis are no higher with perforator flaps than with pedicled TRAM procedures [127].

SEIA perforator flaps — The superficial inferior epigastric artery (SIEA) perforator flap, provides the same abdominal tissue for breast reconstruction as the DIEP flap [128]. While not all patients have superficial inferior epigastric vessels of sufficient caliber to support transfer of the associated lower abdominal skin and fat, basing the flap on the inferior epigastric vessels can provide a reliable, less invasive free flap option for breast reconstruction in appropriately selected patients.

Careful intraoperative evaluation of the superficial inferior epigastric vessels is mandatory with this procedure [113]. If the vessels are undersized or otherwise not suitable, the flap can be converted into a DIEP or free TRAM for a more reliable vascular supply.

The indications for an SIEA flap are the same as for a DIEP flap [128]. However, the SIEA flap is associated with even less donor site morbidity than the DIEP flap as no fascial incisions or muscle dissection are required. The SIEA flap is limited by variable anatomy, particularly with regard to the presence and size of the superficial inferior epigastric arteries. SIEA flaps are not anatomically and technically possible in most patients and the available volume of tissue is limited.

As with the DIEP flap procedures, significant microsurgical expertise is required for the meticulous dissection and anastomosis of SIEA perforators as small as one millimeter in diameter. The complexity of the procedure contributes to long operative times. In a retrospective review of over 200 SIEA flap breast reconstructions, there were no flap losses and the rate of return to the operating room was similar to that with DIEP flap reconstructions [129].

GAP perforator flaps — For patients who do not have sufficient lower abdominal fat for TRAM, DIEP or SIEA flaps, but who prefer the use of autologous tissue, a more viable donor site may be the buttock area [129,130] (figure 11). For this free flap, perforating vessels from either the superior gluteal artery (SGAP flap) or the inferior gluteal artery (IGAP flap) can be used as the vascular supply for the transferred tissue. For the SGAP flap, upper buttock tissue is used, resulting in a donor site scar that is concealable under most swimwear. If an IGAP flap is performed, the donor site scar lies within the lower buttock crease.

Advantages of GAP flaps include the ready availability of sufficient soft tissue for breast reconstruction in most patients. Furthermore, these flaps do not require the sacrifice of the gluteus maximus muscle and thus do not appear to have any adverse impact on postoperative functioning.

Disadvantages of GAP flaps include the technical challenges of flap harvest and transfer, and the associated risk of sciatic nerve injury. In general, the caliber and length of the vascular pedicle associated with gluteal perforator flaps is less than its abdominal counterpart (DIEP flap). Some patients report postoperative pain due to insufficient padding of the sciatic nerve.

In a retrospective review of 170 GAP flaps, 8 percent of patients required a return to the operating room with a 6 percent rate of vascular complications and total flap failure rate of 2 percent [129].

TUG flaps — The transverse upper gracilis (TUG) flap is based on the proximal gracilis muscle and its vascular pedicle, the ascending branch of the medial circumflex femoral artery [131,132] (figure 12). This flap utilizes tissue from the posterior upper thigh/lower buttock and provides another choice for women with insufficient lower abdominal fat for breast reconstruction. The advantage of the TUG flap is avoidance of scars on the abdomen, back, or gluteal region. The TUG flap is appropriate for small to moderate volume breast reconstruction because there is usually not a large quantity of fat in the upper thigh.

As with the DIEP flap procedure, significant microsurgical expertise is required for the meticulous dissection and anastomosis of TUG perforators, which are as small as one mm in diameter. The complexity of the procedure contributes to long operative times.

OPTIONS FOR THE CONTRALATERAL NORMAL BREAST (SYMMETRY PROCEDURES) — Once reconstruction of the affected breast has begun, the challenge of creating symmetry with the contralateral breast is undertaken. Contralateral breast surgery can be performed at the time of the initial reconstruction or during the second stage [133]. Mastopexy, reduction, augmentation or a combination of procedures can be used both for aesthetic improvement and improved symmetry (figure 13). As an example, in a woman with very large breasts who undergoes a mastectomy with reconstruction, a contralateral reduction will decrease the size discrepancy, resulting in improved patient comfort and increased symmetry.

RECONSTRUCTION OF THE NIPPLE/AREOLAR COMPLEX — The final component of breast reconstruction is the creation of the nipple and areola. This is typically performed during the second stage of breast reconstruction, but can also be performed in an office setting. The goal of nipple and areolar reconstruction is to achieve symmetry of position of the nipple-areolar complex in the contralateral breast with comparable appearance and color.

There are multiple techniques of local tissue rearrangement for creation of a new nipple. Some are based on skin grafts, while others utilize donor sites that are closed primarily. Nipple projection varies among the different techniques, but adequate results can be achieved with most. Symmetry of position on the breast mound is the most important goal of nipple reconstruction, as even small discrepancies are obvious. Once the projecting papilla has been created, the appearance of the entire nipple-areola complex can be enhanced by the use of tattooing (figure 14).

OUTCOMES ASSOCIATED WITH BREAST RECONSTRUCTION — For women undergoing mastectomy, breast reconstruction offers significant quality of life (QOL) benefits and is a vital option to enhance breast cancer recovery. With the variety of reconstructive techniques available, choosing the "right" option can sometimes be a daunting task, even for highly educated consumers. Considerations include patient preference, body habitus, and prior surgical procedures.

Outcomes data on surgical complications, physical function, and quality of life and patient satisfaction provide both the surgeon and patient with useful information when choosing the most appropriate reconstructive technique and timing. Surgical complications associated with the individual reconstructive options are discussed above.

The following sections emphasize data on post reconstruction outcomes that are relevant to psychosocial issues, patient satisfaction, and physical functioning, as derived from the Michigan Breast Reconstruction Outcomes Study (MBROS), a multicenter prospective cohort that included women undergoing first-time immediate or delayed breast reconstructions recruited from 12 centers and 23 plastic surgeons [40]. The procedures evaluated were expander/implant, pedicled TRAM, and free TRAM reconstructions. Data were collected preoperatively and at one and two years postoperatively.

Psychosocial function and quality of life — Among women undergoing mastectomy for breast cancer, well-documented psychological sequelae include disturbances of body image, loss of femininity, severe depression and mood disturbance, feelings of diminished self-worth, and interpersonal, sexual, and marital dysfunction [2-4,43,134-137]. The psychological impact of postmastectomy reconstructive procedures has become a focus of considerable outcomes research.

Several studies have documented the psychological, social, emotional, and functional benefits of breast reconstruction, including improved psychological health, self-esteem [7-9], sexuality, body image [5,6,10-12,43,137,138], quality of life (QOL) [139], and reduced concerns of cancer recurrence [13-15]. However, most studies do not focus on the impact of the type of breast reconstruction on psychosocial outcomes. Understanding the impact of specific procedure type on outcomes is important because expander/implant and autogenous tissue techniques are associated with different surgical risks, recovery periods and long-term aging processes.

The Michigan Breast Reconstruction Outcomes Study (MBROS) study evaluated psychosocial measures such as emotional, functional and social wellbeing, vitality, general mental health, social functioning, and body image preoperatively and postoperatively among 273 women undergoing tissue expander/implant and TRAM procedures; year 2 surveys were available for 173 [40,140]. For those women who had immediate reconstruction, significant improvements were observed in all psychosocial domains except body image. Procedure type had no significant effect on these outcomes.

At postoperative year 1, significant improvement was observed within the delayed reconstruction population in emotional wellbeing, vitality, general mental health, functional wellbeing and body image [40]. At two years, patients continued to have significantly better body image [140]. Procedure type had a limited effect on most psychosocial outcomes except body image. At both years 1 and 2, patients who underwent delayed TRAM reconstruction had significantly greater gains in body image compared to women with delayed tissue expander/implant reconstructions, a result that supports the predominant view among plastic surgeons that autogenous tissue techniques produce aesthetically superior results. The findings from this large series are supported by those of other investigators [7,10,43,138,141-143].

There are no randomized trials examining quality of life (QOL) issues in TRAM-reconstructed versus non-reconstructed patients. Improved QOL after TRAM reconstruction was observed in two retrospective analyses:

One analysis included 25 women who had a delayed pedicled TRAM flap reconstruction and who underwent formal assessment of health-related QOL (HRQOL) at three, six, and 12 months after reconstruction [144]. Scores were compared to those of a historical but not concurrently randomized group of 20 women undergoing mastectomy without breast reconstruction. The control group's scores were significantly lower in all dimensions when compared to reconstructed patients at postoperative month 12, except on physical function. The level of patient satisfaction with the TRAM flap reconstruction was high.
In the second report, QOL, as measured by the SF-36 Health Survey questionnaire, was assessed preoperatively and 12 months after immediate breast reconstruction in 76 women who underwent mastectomy for breast cancer [139]. The results were compared to those of 920 age-matched women from the general population. Preoperative scores for emotional wellbeing and physical functioning were significantly lower in the women with breast cancer but had improved and were comparable to the normal population at 12 months after immediate reconstruction.

Few trials have directly compared QOL among TRAM versus other types of autogenous reconstruction. In a Swedish trial, 75 women were randomly assigned to delayed reconstruction using a lateral thoracodorsal flap, the latissimus dorsi flap, or the pedicled TRAM flap [16]. Questionnaires assessing patient perception of cosmetic result and impact on HRQOL were completed at six and 12 months postoperatively. The majority of women in all three groups were very satisfied with the cosmetic result. Social functioning and mental health improved significantly after the reconstruction. Both the latissimus dorsi and TRAM flap cohorts scored higher than the lateral thoracodorsal flap patients for breast symmetry and for reduced problems in social situations. All methods were considered to produce good cosmetic results and improvements in patient-defined problem areas of life and quality of life. No negative effects were recorded.

Summary — Taken together, the available data indicate that regardless of procedure choice, breast reconstruction is a valuable tool to improve psychosocial wellbeing and QOL for the breast cancer patient following mastectomy.

Patient satisfaction — Clinicians and researchers evaluate health care not just by assessing objective outcomes (complication rates and length of hospitalization, for example) but also from the consumers' point of view in terms of patient satisfaction. As a key measure of quality of care and outcomes, patient satisfaction is being used as a basis for policy formulation, quality improvement programs, and to help direct the patient-clinician decision making process. Patient satisfaction surveys provide consumer feedback about the structure, process, and outcomes of care.

It is well established that breast reconstruction is associated with high levels of patient satisfaction [83,84]. The type of reconstructive procedure appears to affect postoperative patient satisfaction. This was illustrated in the Michigan Breast Reconstruction Outcomes Study (MBROS) project described above, which measured patient satisfaction with regard to aesthetic result (softness, symmetry) and general satisfaction with the process and outcome of care [40,84].

At one year following surgery, women with pedicled TRAM flaps, free TRAM flaps, and expander/implants had similar levels of general satisfaction [40], but autogenous tissue reconstructions (TRAM procedures) were associated with greater aesthetic satisfaction than expander/implant techniques. At year 2, these procedural differences had diminished, but patients continued to be more aesthetically satisfied with autogenous tissue compared to expander/implant reconstructions [84]. At postoperative year 2, the percentages of patients aesthetically satisfied in the expander/implant, pedicled TRAM, and free TRAM groups were 43, 69, and 70 percent, respectively. With regard to general satisfaction, the percentages of patients who were satisfied with their procedure were 64, 79, and 78 percent, respectively.

Even after controlling for possible confounding factors such as preoperative physical function and timing of surgery, patients with TRAM flaps (both free and pedicle) had higher levels of aesthetic satisfaction at year 2 as compared to expander/implant patients (odds ratio [OR] 2.8, p<.01). When controlling for the same confounding factors, the type of reconstruction (expander/implant, pedicle TRAM and free TRAM) had no statistically significant effect on general satisfaction.

There were no significant differences in aesthetic satisfaction between women with free and pedicle TRAM flaps, a finding which has been noted by other investigators [126,145].

Physical functioning — The variability in the degree of muscle that is sacrificed, denervated, or injured in creating abdominal wall flaps for breast reconstruction makes the comparison of abdominal wall function after abdominal flaps challenging. Several studies have evaluated abdominal function using basic physical functioning tests such as getting out of bed and the ability to perform sit-ups, although more sensitive testing of muscle function, such as isokinetic dynamometry, which measure the maximum strength a muscle can reach, may be necessary for accurate comparison [119,146,147].

Physical functioning following free pedicled flap reconstructive surgery depends on whether the reconstruction was unilateral or bilateral, whether the motor innervation to the rectus abdominis muscles was sacrificed or preserved, and the degree of postoperative fibrosis occurring within the remaining muscle. In general, for most women who require unilateral reconstruction, breast reconstruction with a perforator pedicle TRAM flap will not make a significant impact on the activities of daily living. However, for women who need bilateral reconstruction, perforator or muscle sparing flaps may confer an advantage in physical function.

TRAM procedures — Many patients and surgeons are concerned about potential abdominal wall morbidity with TRAM procedures. Functional outcomes studies have shown mixed results, with between 6 to 23 percent of patients demonstrating deficits in trunk function following TRAM reconstruction [148,149]. However, these are largely single center studies without long-term follow-up. Physical function outcomes data are especially important as more technically complex procedures, such as perforator flaps, are being increasingly performed to limit the surgical "insult" to the abdominal wall.

In the Michigan Breast Reconstruction Outcomes Study (MBROS), data on trunk peak torque and range of motion were collected preoperatively and at postoperative years 1 and 2 in the expander/implant, free TRAM, and pedicled TRAM groups [150]. At two years postoperatively, procedure type, timing and laterality (unilateral versus bilateral) did not significantly affect the range of motion for trunk flexion or extension. Peak torque for trunk flexion at year 2 was significantly lower (by 11 to 18 percent) in patients with TRAM flaps compared to those undergoing expander/implant reconstructions. However, no significant difference in flexion peak torque was found between patients who had free and pedicle TRAM reconstructions.

These data are consistent with other contemporary breast reconstruction functional outcomes studies [151-153]. In a review of 20 studies of abdominal wall function following breast reconstruction, bilateral reconstruction was associated with the greatest difficulty in performing some daily activities [154]. However, unilateral reconstruction did not affect the performance of activities of daily living.

Perforator flaps — The available outcomes data on perforator flaps are limited to retrospective reviews. One study evaluated sit-up ability three and six months following perforator flap reconstruction [155]. At three months, 95 percent of women were able to return to their preoperative sit-up activity; this was 100 percent by six months postoperatively. Another retrospective series of 18 patients evaluated abdominal wall function in patients with DIEP flaps compared to free TRAM reconstructions [156]. The TRAM group appeared to have significantly lower trunk flexion torque compared to the DIEP group.

POSTTREATMENT SURVEILLANCE OF THE RECONSTRUCTED BREAST — Following mastectomy, the reconstructed breast is at risk for a chest wall recurrence and less often, a second primary breast cancer. Even after the most aggressive mastectomies, some small amount of normal residual breast tissue remains and presents a risk for a subsequent new primary breast cancer. Thus, several authors have suggested that screening might be of value [157].

Guidelines from expert groups for the follow-up of breast cancer patients recommend annual mammography, but these recommendations do not apply to women who have undergone breast reconstruction [158]. Postmastectomy surveillance for reconstructed breasts has usually been performed by physical examination. Routine mammographic imaging is technically limited in patients who have prosthetic implants and has generally not been advocated. However, mammography is technically feasible following autogenous myocutaneous flap reconstruction, particularly following TRAM or perforator flap reconstruction, because abdominal adipose tissue forms the bulk of the reconstructed breast. (See 'Autogenous tissue reconstruction' above.)

Although the data are sparse and there is no consensus on this issue, some institutions image TRAM-reconstructed breasts mammographically (sometimes referred to as a "TRAMogram"). While "tramograms" are possible, they are generally not recommended as recurrent breast cancer cannot occur in TRAM tissue. In addition, fat necrosis can appear radiographically as calcifications in reconstructed breast tissue, leading to unnecessary biopsy procedures. Because of the low detection rate for nonpalpable recurrent breast cancer, mammography on reconstructed breasts is not routinely recommended [159].

The only place where cancer can occur is either right below the skin in the subcutaneous tissue or just over the pectoralis muscle. Given that most surgeons remove the pectoralis fascia with the mastectomy specimen, recurrence on the chest wall is less common than subcutaneous tissue recurrence [160]. Physical examination remains the cornerstone of detection of recurrent breast cancer after reconstruction and other modalities such as mammogram, ultrasound, or MRI are used as adjuncts to clarify any physical findings [161]. Detection rates of chest wall recurrence and outcomes are not significantly affected by reconstruction [161]. (See "Management of locoregional recurrence of breast cancer after mastectomy", section on 'Findings on imaging' and "Follow-up for breast cancer survivors: Recommendations for surveillance after therapy", section on 'Surveillance of reconstructed breasts'.)

SUMMARY AND RECOMMENDATIONS

All women undergoing mastectomy for breast cancer should be counseled regarding their reconstructive options before surgery. (See 'Introduction' above.)
There are two general types of reconstructive procedures: implants (saline or silicone) and autogenous tissue reconstruction, which involves the transfer of a flap of tissue from a donor site to the anterior chest wall. The choice of the reconstructive option is dependent on a variety of factors including body habitus, associated comorbidity (eg, obesity, history of diabetes, smoking), the size and configuration of the contralateral breast, prior surgical procedures, the quality of the chest wall skin, and patient choice. (See 'Reconstructive options' above.)
Breast reconstruction is usually performed immediately after mastectomy. The advantages of immediate reconstruction include streamlined care, reduced cost, superior cosmetic results, and psychosocial benefits. We suggest immediate reconstruction for patients who are undergoing mastectomy for prophylaxis, ductal carcinoma in situ, or for invasive breast cancers less than 5 cm in size that are clinically axillary node-negative, with negative premastectomy sentinel node biopsy) (Grade 2C). (See 'Immediate versus delayed reconstruction' above.)
For women who are likely to need postmastectomy RT (breast tumor size ≥5 cm, positive lymph nodes), we suggest delayed reconstruction using autologous tissue since this approach provides the best cosmetic result with the fewest complications (Grade 2C). (See 'Selecting patients likely to need postmastectomy RT' above.)