Cleveland Clinic Journal of Medicine

In the late 19th century, breast cancer was considered a fatal disease. That began to change in the 1880s when W.S. Halsted described the radical mastectomy as the way to treat patients with breast cancer.¹ This aggressive surgical treatment—in which the breast, axillary lymph nodes, and chest muscles are all removed—remained the standard of care throughout much of the 20th century; as late as the early 1970s, nearly half (48%) of breast cancer patients were treated with radical mastectomy. During the 1970s, however, the Halsted radical mastectomy was largely abandoned for a less-disfiguring muscle-sparing technique called the modified radical mastectomy; by 1981, only 3% of patients underwent the Halsted mastectomy.²

The 1980s heralded even more minimally invasive techniques with the advent of breast conservation therapy, in which an incision is made over the tumor and the tumor is completely removed with negative margins, leaving behind normal breast tissue. (This procedure has been referred to by many different names, including definitive excision, lumpectomy, quadrantectomy, and partial mastectomy; since they all mean the same thing, for clarity and consistency this article will use “breast conservation therapy” throughout.) During the 1990s, surgical invasiveness was further minimized with the emergence of sentinel lymph node excision.

An important contributor to this evolution in the standard of breast cancer therapy since the 1970s has been the National Surgical Adjuvant Breast and Bowel Project (NSABP), a National Cancer Institute–funded clinical trials cooperative group. NSABP studies have been the driving force to show that the extent of surgery could be reduced without compromising outcome.³ These studies, along with several other trials, have resulted in a marked reduction in surgical aggressiveness and a multitude of adjuvant therapies for women with breast cancer. This article will briefly explore where this evolution has brought us in terms of the surgical options available for treatment of breast cancer today. We also discuss other key components in the management of women with newly diagnosed breast cancer, including cancer staging, patient counseling, and assessment of axillary lymph nodes.

BREAST CANCER CLASSIFICATION AND STAGING

Pathologic classification

Cancer staging

A simpler method relies on the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) summary staging system.⁵ This system classifies tumors as “localized” (contained in the breast, either in situ or invasive), “regional” (identified in regional lymph nodes), or “metastatic” (spread to distant organ systems).

Of course, patients cannot be told their stage until after surgery, when a final pathologic report detailing tumor size and nodal status is available. Some patients will never be definitively staged—for instance, those who undergo neoadjuvant chemotherapy for locally advanced disease prior to lymph node dissection, or those who do not have a metastatic work-up. The metastatic work-up involves ordering of additional tests to assess for metastasis, but only when prompted by specific patient symptoms. Thus, if the patient has shortness of breath, a chest radiograph or a chest computed tomograph (CT) needs to be ordered; for elevated liver enzymes, CTs of the abdomen and pelvis are ordered; for central nervous system symptoms, brain magnetic resonance imaging (MRI) is ordered; and for back pain or bone pain, a bone scan is ordered to rule out metastatic disease to bone.

INITIAL PATIENT ASSESSMENT AND COUNSELING

Relationship-building is fundamental

Following an initial diagnosis of breast cancer, the patient must undergo an assessment for local and systemic disease. The surgeon, as a member of a multi-disciplinary breast cancer treatment team, often spearheads this initial assessment. This first visit must go beyond mere clinical evaluation, however, and include thorough discussion and relationship-building with the patient, as this early meeting establishes a relationship with the patient that will carry through her entire process of cancer care. For a true understanding between patient and surgeon to occur, it is critical for patients to be comfortable in sharing their fears, expectations, and lifestyle needs. Following a diagnosis of breast cancer, the initial reactions women go through include both fear and realization of one’s own mortality. Although these responses may no longer be justified by the reality of patient outcomes in most cases, they are normal and fully understandable reactions. For this reason, clinicians must be sensitive to these reactions while being supportive about the efficacy of the treatment options available.

In addition to the establishment of communication and understanding, the vital components of this first meeting include a detailed medical history, a clinical breast examination, a review of imaging studies, and a discussion of treatment options.

The history should include all aspects of the patient’s reproductive history, her family history of breast cancer, and any comorbidities and medications being taken.

The clinical breast examination should give special attention to the shape (asymmetry), appearance (eg, dimpling, erythema, nipple inversion), and overall feel of the breasts. A palpable mass must be recorded in terms of its location in relation to the skin, the nipple-areola complex, and the chest wall, as well as the quadrant of the breast in which it lies. The regional lymph node basins need to be examined closely, including the axilla and supraclavicular nodes.

Imaging studies also need to be reviewed closely. Patients today frequently present with multiple types of imaging studies, including mammography, ultrasonography, and MRI. Occasionally patients also may present with nuclear medicine exam results, CTs, thermographic images, positron emission tomography studies, and bone scans. All radiology studies need to be reviewed closely and examined in the context of what they were ordered for and what utility they potentially provide.

Treatment options: Surgery is first step in most cases

Once the above components are addressed, the patient should be engaged in a discussion of treatment options. Most women with breast cancer will undergo some type of surgery in conjunction with radiation therapy, chemotherapy, or both. Generally, surgery takes place as the first part of a multiple-component therapy plan. The main goal of surgery is to remove the cancer and accurately define the stage of the disease.

Consider plastic surgery consultation

When indicated and available, consultation with a plastic surgery team may be appropriate at this stage to provide support and comfort to the patient so that she better understands her options for breast reconstruction along with those for breast cancer surgery. Recent data show that most general surgeons do not discuss reconstruction with their breast cancer patients before surgical breast cancer therapy, but that when such discussions do occur, they significantly influence patients’ treatment choices.⁶ Giving patients the chance to learn about reconstructive options through discussion with a plastic surgeon represents a good opportunity to provide complete patient care in a multidisciplinary way.

OVERVIEW OF SURGICAL OPTIONS

Two general approaches, no difference in survival

The two mainstays of surgical treatment today are (1) breast conservation therapy, generally followed by total or partial breast irradiation, and (2) mastectomy.

The prospective randomized trial data obtained from the NSABP trials have demonstrated no survival differences between patients with early-stage breast cancer based on whether they were treated with breast conservation therapy or mastectomy.² Beyond this fundamental issue of survival, there are a number of nuances, many of them logistical, related to the success of either operation that the clinician must keep in mind when presenting these surgical choices to patients. These considerations are reviewed below.

Breast conservation therapy

For breast conservation therapy, the ratio of tumor size to breast size must be small enough to ensure complete tumor removal with an acceptable cosmetic outcome. In general, it is estimated that up to 25% of the breast can be removed while still ensuring a “good” cosmetic outcome. Advances in closure techniques allowing for more tissue to be removed with even better cosmetic outcomes are known as oncoplastic closure. These techniques are mostly performed by breast oncologic surgeons, often in consultation or conjunction with plastic surgeons. (Reconstructive options following breast conservation therapy are reviewed in a subsequent article in this supplement.) Additionally, the patient must agree and be deemed a candidate for postoperative radiation therapy. The patient must be able to be followed clinically to enable early detection of a potential local recurrence.

A second surgical option for patients is mastectomy. Today “mastectomy” can refer to any of several subtypes of surgical procedures, which are outlined below and should be considered on a patient-by-patient basis. Mastectomy is appropriate when breast conservation therapy is not possible (due to a large or multicentric tumor) or would result in poor cosmetic outcome, or when the patient specifically chooses a mastectomy.

Simple mastectomy involves removal of the breast only, without removal of lymph nodes. Either of the incisions depicted in the left and center panels of Figure 3 can be used. Both modified radical mastectomy and simple mastectomy involve removal of the nipple and areola (nipple-areola complex).

Skin-sparing mastectomy (Figure 3, center) is performed when a patient is undergoing immediate breast reconstruction (using either a silicone or saline implant or autologous tissue). The goal is to remove all breast tissue, along with the nipple-areola complex, while preserving as much viable skin as possible to optimize the cosmetic outcome.^7,8

Nipple-areola–sparing mastectomy. There is increasing experience with attempts to preserve the nipple-areola complex. These procedures attempt to preserve either the whole complex, termed nipple-areola–sparing mastectomy (sometimes called simply nipple-sparing mastectomy) (Figure 3, right), or just the areola, with removal of the nipple (areola-sparing mastectomy). These procedures are also performed in a skin-sparing fashion.

There is some controversy surrounding these techniques to spare the nipple and/or areola, including debate over which technique.nipple-areola–sparing mastectomy or areola-sparing mastectomy.may be more oncologically safe. Currently the literature shows that both are probably safe oncologic alternatives for remote tumors that do not have an extensive intraductal component. Generally, frozen sections are performed intraoperatively on the retroareola tissue to document that there is no evidence of tumor.⁹

SURGICAL COMPLICATIONS

Breast procedures are fairly safe operations, but every operation has a risk of complications. Reported complications of breast surgery include the following:

• Bleeding
• Infection (including both cellulitis and abscess)
• Seroma
• Arm morbidity (including lymphedema)
• Phantom breast syndrome
• Injury to the motor nerves.

Seromas often occur in patients after mastectomy or lymph node surgery. Prolonged lymphatic drainage is usually exacerbated by extensive axillary node involvement and obesity.

Arm morbidity can present in different ways. Lymphedema is the most common manifestation, with reported incidences of approximately 15% to 20% when axillary lymph node dissection is performed versus 7% when sentinel lymph node biopsy is done.¹⁰ The risk of lymphedema can be reduced by avoiding blood pressure measurements, venipunctures, and intravenous insertions in the arm on the side of the operation, as well as by wearing a compression sleeve on the affected arm during airplane flights.

Phantom breast syndrome is rare but may manifest as pain that may also involve itching, nipple sensation, erotic sensations, or premenstrual-type soreness.

Many surgeons have historically removed the intercostobrachial nerves but are now trying to preserve these nerves, which when removed cause loss of sensation in the upper inner arm. Although rare, nerve injury during an axillary procedure has been reported. It may involve the long thoracic nerve (denervating the serratus anterior muscle and causing a winged scapula) or the thoracodorsal bundle (denervating the latissimus dorsi muscle and causing difficulty with arm/shoulder adduction).

LOCAL CANCER RECURRENCE

Among women undergoing mastectomy for breast cancer, 10% to 15% will have a recurrence of cancer in the chest wall or axillary lymph nodes within 10 years.¹¹ Similarly, among women undergoing breast conservation therapy plus radiation therapy, 10% to 15% will have in-breast cancer recurrence or recurrence in axillary lymph nodes within 10 years, although women who undergo breast conservation therapy without radiation have a much higher recurrence rate.¹¹Considerations for screening the surgically altered breast are discussed in the previous article in this supplement.

ASSESSMENT OF AXILLARY LYMPH NODES FOR METASTASIS

Even when patients have a known histologic diagnosis of breast cancer and have made a firm decision regarding the surgical option for removal of their cancer, the status of their axillary lymph nodes remains a great unanswered question until after the surgical procedure is completed. Lymph node status—ie, determining whether the cancer has spread to the axillary lymph nodes—still serves as the critical determinant for guiding adjuvant treatment, predicting survival, and assessing the risk of recurrence.

Axillary lymph node dissection

The standard approach for evaluating lymph node status has been a complete dissection of the axillary space, or axillary lymph node dissection. As briefly noted above, the axillary lymph nodes are anatomically classified into three levels as defined by their location relative to the pectoralis minor muscle. The extent of a nodal dissection can be defined by the number of nodes removed.

Axillary lymph node dissection has been called into question over the last 15 years due to its invasiveness and the potential morbidity associated with it (including lymphedema and paresthesias). As a result, sen­tinel lymph node biopsy, a minimally invasive technique for identifying axillary metastasis, was developed to avoid the need for (and risk of complications from) axillary lymph node dissection in patients who have a low probability of axillary metastasis.

Reprinted from Contemporary Surgery (Pawlik TM, Gershenwald JE. Sentinel lymph node biopsy for melanoma. Contemp Surg 2005; 61:175–182.) with permission of Dowden Health Media.

Overall, however, it is now accepted that intraoperative lymph node mapping with sentinel lymphadenectomy is an effective and minimally invasive alternative to axillary lymph node dissection for identifying nodes containing metastases.

CONCLUSIONS

Decisions surrounding the choice of breast surgery procedure must be individualized to the patient and her desires and based on comprehensive patient evaluation and thorough patient counseling. Optimal results for the patient—oncologically, psychologically, and in terms of cosmetic outcomes—require consultation and collaboration among general surgeons, medical oncologists, genetic counselors, radiation oncologists, radiologists, and plastic surgeons to clarify the risks and benefits of various intervention options. Striving for this multidisciplinary collaboration will promote optimal patient management and the most favorable clinical outcomes.

In the late 19th century, breast cancer was considered a fatal disease. That began to change in the 1880s when W.S. Halsted described the radical mastectomy as the way to treat patients with breast cancer.¹ This aggressive surgical treatment—in which the breast, axillary lymph nodes, and chest muscles are all removed—remained the standard of care throughout much of the 20th century; as late as the early 1970s, nearly half (48%) of breast cancer patients were treated with radical mastectomy. During the 1970s, however, the Halsted radical mastectomy was largely abandoned for a less-disfiguring muscle-sparing technique called the modified radical mastectomy; by 1981, only 3% of patients underwent the Halsted mastectomy.²

The 1980s heralded even more minimally invasive techniques with the advent of breast conservation therapy, in which an incision is made over the tumor and the tumor is completely removed with negative margins, leaving behind normal breast tissue. (This procedure has been referred to by many different names, including definitive excision, lumpectomy, quadrantectomy, and partial mastectomy; since they all mean the same thing, for clarity and consistency this article will use “breast conservation therapy” throughout.) During the 1990s, surgical invasiveness was further minimized with the emergence of sentinel lymph node excision.

An important contributor to this evolution in the standard of breast cancer therapy since the 1970s has been the National Surgical Adjuvant Breast and Bowel Project (NSABP), a National Cancer Institute–funded clinical trials cooperative group. NSABP studies have been the driving force to show that the extent of surgery could be reduced without compromising outcome.³ These studies, along with several other trials, have resulted in a marked reduction in surgical aggressiveness and a multitude of adjuvant therapies for women with breast cancer. This article will briefly explore where this evolution has brought us in terms of the surgical options available for treatment of breast cancer today. We also discuss other key components in the management of women with newly diagnosed breast cancer, including cancer staging, patient counseling, and assessment of axillary lymph nodes.

BREAST CANCER CLASSIFICATION AND STAGING

Pathologic classification

Cancer staging

A simpler method relies on the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) summary staging system.⁵ This system classifies tumors as “localized” (contained in the breast, either in situ or invasive), “regional” (identified in regional lymph nodes), or “metastatic” (spread to distant organ systems).

Of course, patients cannot be told their stage until after surgery, when a final pathologic report detailing tumor size and nodal status is available. Some patients will never be definitively staged—for instance, those who undergo neoadjuvant chemotherapy for locally advanced disease prior to lymph node dissection, or those who do not have a metastatic work-up. The metastatic work-up involves ordering of additional tests to assess for metastasis, but only when prompted by specific patient symptoms. Thus, if the patient has shortness of breath, a chest radiograph or a chest computed tomograph (CT) needs to be ordered; for elevated liver enzymes, CTs of the abdomen and pelvis are ordered; for central nervous system symptoms, brain magnetic resonance imaging (MRI) is ordered; and for back pain or bone pain, a bone scan is ordered to rule out metastatic disease to bone.

INITIAL PATIENT ASSESSMENT AND COUNSELING

Relationship-building is fundamental

Following an initial diagnosis of breast cancer, the patient must undergo an assessment for local and systemic disease. The surgeon, as a member of a multi-disciplinary breast cancer treatment team, often spearheads this initial assessment. This first visit must go beyond mere clinical evaluation, however, and include thorough discussion and relationship-building with the patient, as this early meeting establishes a relationship with the patient that will carry through her entire process of cancer care. For a true understanding between patient and surgeon to occur, it is critical for patients to be comfortable in sharing their fears, expectations, and lifestyle needs. Following a diagnosis of breast cancer, the initial reactions women go through include both fear and realization of one’s own mortality. Although these responses may no longer be justified by the reality of patient outcomes in most cases, they are normal and fully understandable reactions. For this reason, clinicians must be sensitive to these reactions while being supportive about the efficacy of the treatment options available.

In addition to the establishment of communication and understanding, the vital components of this first meeting include a detailed medical history, a clinical breast examination, a review of imaging studies, and a discussion of treatment options.

The history should include all aspects of the patient’s reproductive history, her family history of breast cancer, and any comorbidities and medications being taken.

The clinical breast examination should give special attention to the shape (asymmetry), appearance (eg, dimpling, erythema, nipple inversion), and overall feel of the breasts. A palpable mass must be recorded in terms of its location in relation to the skin, the nipple-areola complex, and the chest wall, as well as the quadrant of the breast in which it lies. The regional lymph node basins need to be examined closely, including the axilla and supraclavicular nodes.

Imaging studies also need to be reviewed closely. Patients today frequently present with multiple types of imaging studies, including mammography, ultrasonography, and MRI. Occasionally patients also may present with nuclear medicine exam results, CTs, thermographic images, positron emission tomography studies, and bone scans. All radiology studies need to be reviewed closely and examined in the context of what they were ordered for and what utility they potentially provide.

Treatment options: Surgery is first step in most cases

Once the above components are addressed, the patient should be engaged in a discussion of treatment options. Most women with breast cancer will undergo some type of surgery in conjunction with radiation therapy, chemotherapy, or both. Generally, surgery takes place as the first part of a multiple-component therapy plan. The main goal of surgery is to remove the cancer and accurately define the stage of the disease.

Consider plastic surgery consultation

When indicated and available, consultation with a plastic surgery team may be appropriate at this stage to provide support and comfort to the patient so that she better understands her options for breast reconstruction along with those for breast cancer surgery. Recent data show that most general surgeons do not discuss reconstruction with their breast cancer patients before surgical breast cancer therapy, but that when such discussions do occur, they significantly influence patients’ treatment choices.⁶ Giving patients the chance to learn about reconstructive options through discussion with a plastic surgeon represents a good opportunity to provide complete patient care in a multidisciplinary way.

OVERVIEW OF SURGICAL OPTIONS

Two general approaches, no difference in survival

The two mainstays of surgical treatment today are (1) breast conservation therapy, generally followed by total or partial breast irradiation, and (2) mastectomy.

The prospective randomized trial data obtained from the NSABP trials have demonstrated no survival differences between patients with early-stage breast cancer based on whether they were treated with breast conservation therapy or mastectomy.² Beyond this fundamental issue of survival, there are a number of nuances, many of them logistical, related to the success of either operation that the clinician must keep in mind when presenting these surgical choices to patients. These considerations are reviewed below.

Breast conservation therapy

For breast conservation therapy, the ratio of tumor size to breast size must be small enough to ensure complete tumor removal with an acceptable cosmetic outcome. In general, it is estimated that up to 25% of the breast can be removed while still ensuring a “good” cosmetic outcome. Advances in closure techniques allowing for more tissue to be removed with even better cosmetic outcomes are known as oncoplastic closure. These techniques are mostly performed by breast oncologic surgeons, often in consultation or conjunction with plastic surgeons. (Reconstructive options following breast conservation therapy are reviewed in a subsequent article in this supplement.) Additionally, the patient must agree and be deemed a candidate for postoperative radiation therapy. The patient must be able to be followed clinically to enable early detection of a potential local recurrence.

A second surgical option for patients is mastectomy. Today “mastectomy” can refer to any of several subtypes of surgical procedures, which are outlined below and should be considered on a patient-by-patient basis. Mastectomy is appropriate when breast conservation therapy is not possible (due to a large or multicentric tumor) or would result in poor cosmetic outcome, or when the patient specifically chooses a mastectomy.

Simple mastectomy involves removal of the breast only, without removal of lymph nodes. Either of the incisions depicted in the left and center panels of Figure 3 can be used. Both modified radical mastectomy and simple mastectomy involve removal of the nipple and areola (nipple-areola complex).

Skin-sparing mastectomy (Figure 3, center) is performed when a patient is undergoing immediate breast reconstruction (using either a silicone or saline implant or autologous tissue). The goal is to remove all breast tissue, along with the nipple-areola complex, while preserving as much viable skin as possible to optimize the cosmetic outcome.^7,8

Nipple-areola–sparing mastectomy. There is increasing experience with attempts to preserve the nipple-areola complex. These procedures attempt to preserve either the whole complex, termed nipple-areola–sparing mastectomy (sometimes called simply nipple-sparing mastectomy) (Figure 3, right), or just the areola, with removal of the nipple (areola-sparing mastectomy). These procedures are also performed in a skin-sparing fashion.

There is some controversy surrounding these techniques to spare the nipple and/or areola, including debate over which technique.nipple-areola–sparing mastectomy or areola-sparing mastectomy.may be more oncologically safe. Currently the literature shows that both are probably safe oncologic alternatives for remote tumors that do not have an extensive intraductal component. Generally, frozen sections are performed intraoperatively on the retroareola tissue to document that there is no evidence of tumor.⁹

SURGICAL COMPLICATIONS

Breast procedures are fairly safe operations, but every operation has a risk of complications. Reported complications of breast surgery include the following:

• Bleeding
• Infection (including both cellulitis and abscess)
• Seroma
• Arm morbidity (including lymphedema)
• Phantom breast syndrome
• Injury to the motor nerves.

Seromas often occur in patients after mastectomy or lymph node surgery. Prolonged lymphatic drainage is usually exacerbated by extensive axillary node involvement and obesity.

Arm morbidity can present in different ways. Lymphedema is the most common manifestation, with reported incidences of approximately 15% to 20% when axillary lymph node dissection is performed versus 7% when sentinel lymph node biopsy is done.¹⁰ The risk of lymphedema can be reduced by avoiding blood pressure measurements, venipunctures, and intravenous insertions in the arm on the side of the operation, as well as by wearing a compression sleeve on the affected arm during airplane flights.

Phantom breast syndrome is rare but may manifest as pain that may also involve itching, nipple sensation, erotic sensations, or premenstrual-type soreness.

Many surgeons have historically removed the intercostobrachial nerves but are now trying to preserve these nerves, which when removed cause loss of sensation in the upper inner arm. Although rare, nerve injury during an axillary procedure has been reported. It may involve the long thoracic nerve (denervating the serratus anterior muscle and causing a winged scapula) or the thoracodorsal bundle (denervating the latissimus dorsi muscle and causing difficulty with arm/shoulder adduction).

LOCAL CANCER RECURRENCE

Among women undergoing mastectomy for breast cancer, 10% to 15% will have a recurrence of cancer in the chest wall or axillary lymph nodes within 10 years.¹¹ Similarly, among women undergoing breast conservation therapy plus radiation therapy, 10% to 15% will have in-breast cancer recurrence or recurrence in axillary lymph nodes within 10 years, although women who undergo breast conservation therapy without radiation have a much higher recurrence rate.¹¹Considerations for screening the surgically altered breast are discussed in the previous article in this supplement.

ASSESSMENT OF AXILLARY LYMPH NODES FOR METASTASIS

Even when patients have a known histologic diagnosis of breast cancer and have made a firm decision regarding the surgical option for removal of their cancer, the status of their axillary lymph nodes remains a great unanswered question until after the surgical procedure is completed. Lymph node status—ie, determining whether the cancer has spread to the axillary lymph nodes—still serves as the critical determinant for guiding adjuvant treatment, predicting survival, and assessing the risk of recurrence.

Axillary lymph node dissection

The standard approach for evaluating lymph node status has been a complete dissection of the axillary space, or axillary lymph node dissection. As briefly noted above, the axillary lymph nodes are anatomically classified into three levels as defined by their location relative to the pectoralis minor muscle. The extent of a nodal dissection can be defined by the number of nodes removed.

Axillary lymph node dissection has been called into question over the last 15 years due to its invasiveness and the potential morbidity associated with it (including lymphedema and paresthesias). As a result, sen­tinel lymph node biopsy, a minimally invasive technique for identifying axillary metastasis, was developed to avoid the need for (and risk of complications from) axillary lymph node dissection in patients who have a low probability of axillary metastasis.

Reprinted from Contemporary Surgery (Pawlik TM, Gershenwald JE. Sentinel lymph node biopsy for melanoma. Contemp Surg 2005; 61:175–182.) with permission of Dowden Health Media.

Overall, however, it is now accepted that intraoperative lymph node mapping with sentinel lymphadenectomy is an effective and minimally invasive alternative to axillary lymph node dissection for identifying nodes containing metastases.

CONCLUSIONS

Decisions surrounding the choice of breast surgery procedure must be individualized to the patient and her desires and based on comprehensive patient evaluation and thorough patient counseling. Optimal results for the patient—oncologically, psychologically, and in terms of cosmetic outcomes—require consultation and collaboration among general surgeons, medical oncologists, genetic counselors, radiation oncologists, radiologists, and plastic surgeons to clarify the risks and benefits of various intervention options. Striving for this multidisciplinary collaboration will promote optimal patient management and the most favorable clinical outcomes.

In the late 19th century, breast cancer was considered a fatal disease. That began to change in the 1880s when W.S. Halsted described the radical mastectomy as the way to treat patients with breast cancer.¹ This aggressive surgical treatment—in which the breast, axillary lymph nodes, and chest muscles are all removed—remained the standard of care throughout much of the 20th century; as late as the early 1970s, nearly half (48%) of breast cancer patients were treated with radical mastectomy. During the 1970s, however, the Halsted radical mastectomy was largely abandoned for a less-disfiguring muscle-sparing technique called the modified radical mastectomy; by 1981, only 3% of patients underwent the Halsted mastectomy.²

The 1980s heralded even more minimally invasive techniques with the advent of breast conservation therapy, in which an incision is made over the tumor and the tumor is completely removed with negative margins, leaving behind normal breast tissue. (This procedure has been referred to by many different names, including definitive excision, lumpectomy, quadrantectomy, and partial mastectomy; since they all mean the same thing, for clarity and consistency this article will use “breast conservation therapy” throughout.) During the 1990s, surgical invasiveness was further minimized with the emergence of sentinel lymph node excision.

An important contributor to this evolution in the standard of breast cancer therapy since the 1970s has been the National Surgical Adjuvant Breast and Bowel Project (NSABP), a National Cancer Institute–funded clinical trials cooperative group. NSABP studies have been the driving force to show that the extent of surgery could be reduced without compromising outcome.³ These studies, along with several other trials, have resulted in a marked reduction in surgical aggressiveness and a multitude of adjuvant therapies for women with breast cancer. This article will briefly explore where this evolution has brought us in terms of the surgical options available for treatment of breast cancer today. We also discuss other key components in the management of women with newly diagnosed breast cancer, including cancer staging, patient counseling, and assessment of axillary lymph nodes.

BREAST CANCER CLASSIFICATION AND STAGING

Pathologic classification

Cancer staging

A simpler method relies on the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) summary staging system.⁵ This system classifies tumors as “localized” (contained in the breast, either in situ or invasive), “regional” (identified in regional lymph nodes), or “metastatic” (spread to distant organ systems).

Of course, patients cannot be told their stage until after surgery, when a final pathologic report detailing tumor size and nodal status is available. Some patients will never be definitively staged—for instance, those who undergo neoadjuvant chemotherapy for locally advanced disease prior to lymph node dissection, or those who do not have a metastatic work-up. The metastatic work-up involves ordering of additional tests to assess for metastasis, but only when prompted by specific patient symptoms. Thus, if the patient has shortness of breath, a chest radiograph or a chest computed tomograph (CT) needs to be ordered; for elevated liver enzymes, CTs of the abdomen and pelvis are ordered; for central nervous system symptoms, brain magnetic resonance imaging (MRI) is ordered; and for back pain or bone pain, a bone scan is ordered to rule out metastatic disease to bone.

INITIAL PATIENT ASSESSMENT AND COUNSELING

Relationship-building is fundamental

Following an initial diagnosis of breast cancer, the patient must undergo an assessment for local and systemic disease. The surgeon, as a member of a multi-disciplinary breast cancer treatment team, often spearheads this initial assessment. This first visit must go beyond mere clinical evaluation, however, and include thorough discussion and relationship-building with the patient, as this early meeting establishes a relationship with the patient that will carry through her entire process of cancer care. For a true understanding between patient and surgeon to occur, it is critical for patients to be comfortable in sharing their fears, expectations, and lifestyle needs. Following a diagnosis of breast cancer, the initial reactions women go through include both fear and realization of one’s own mortality. Although these responses may no longer be justified by the reality of patient outcomes in most cases, they are normal and fully understandable reactions. For this reason, clinicians must be sensitive to these reactions while being supportive about the efficacy of the treatment options available.

In addition to the establishment of communication and understanding, the vital components of this first meeting include a detailed medical history, a clinical breast examination, a review of imaging studies, and a discussion of treatment options.

The history should include all aspects of the patient’s reproductive history, her family history of breast cancer, and any comorbidities and medications being taken.

The clinical breast examination should give special attention to the shape (asymmetry), appearance (eg, dimpling, erythema, nipple inversion), and overall feel of the breasts. A palpable mass must be recorded in terms of its location in relation to the skin, the nipple-areola complex, and the chest wall, as well as the quadrant of the breast in which it lies. The regional lymph node basins need to be examined closely, including the axilla and supraclavicular nodes.

Imaging studies also need to be reviewed closely. Patients today frequently present with multiple types of imaging studies, including mammography, ultrasonography, and MRI. Occasionally patients also may present with nuclear medicine exam results, CTs, thermographic images, positron emission tomography studies, and bone scans. All radiology studies need to be reviewed closely and examined in the context of what they were ordered for and what utility they potentially provide.

Treatment options: Surgery is first step in most cases

Once the above components are addressed, the patient should be engaged in a discussion of treatment options. Most women with breast cancer will undergo some type of surgery in conjunction with radiation therapy, chemotherapy, or both. Generally, surgery takes place as the first part of a multiple-component therapy plan. The main goal of surgery is to remove the cancer and accurately define the stage of the disease.

Consider plastic surgery consultation

When indicated and available, consultation with a plastic surgery team may be appropriate at this stage to provide support and comfort to the patient so that she better understands her options for breast reconstruction along with those for breast cancer surgery. Recent data show that most general surgeons do not discuss reconstruction with their breast cancer patients before surgical breast cancer therapy, but that when such discussions do occur, they significantly influence patients’ treatment choices.⁶ Giving patients the chance to learn about reconstructive options through discussion with a plastic surgeon represents a good opportunity to provide complete patient care in a multidisciplinary way.

OVERVIEW OF SURGICAL OPTIONS

Two general approaches, no difference in survival

The two mainstays of surgical treatment today are (1) breast conservation therapy, generally followed by total or partial breast irradiation, and (2) mastectomy.

The prospective randomized trial data obtained from the NSABP trials have demonstrated no survival differences between patients with early-stage breast cancer based on whether they were treated with breast conservation therapy or mastectomy.² Beyond this fundamental issue of survival, there are a number of nuances, many of them logistical, related to the success of either operation that the clinician must keep in mind when presenting these surgical choices to patients. These considerations are reviewed below.

Breast conservation therapy

For breast conservation therapy, the ratio of tumor size to breast size must be small enough to ensure complete tumor removal with an acceptable cosmetic outcome. In general, it is estimated that up to 25% of the breast can be removed while still ensuring a “good” cosmetic outcome. Advances in closure techniques allowing for more tissue to be removed with even better cosmetic outcomes are known as oncoplastic closure. These techniques are mostly performed by breast oncologic surgeons, often in consultation or conjunction with plastic surgeons. (Reconstructive options following breast conservation therapy are reviewed in a subsequent article in this supplement.) Additionally, the patient must agree and be deemed a candidate for postoperative radiation therapy. The patient must be able to be followed clinically to enable early detection of a potential local recurrence.

A second surgical option for patients is mastectomy. Today “mastectomy” can refer to any of several subtypes of surgical procedures, which are outlined below and should be considered on a patient-by-patient basis. Mastectomy is appropriate when breast conservation therapy is not possible (due to a large or multicentric tumor) or would result in poor cosmetic outcome, or when the patient specifically chooses a mastectomy.

Simple mastectomy involves removal of the breast only, without removal of lymph nodes. Either of the incisions depicted in the left and center panels of Figure 3 can be used. Both modified radical mastectomy and simple mastectomy involve removal of the nipple and areola (nipple-areola complex).

Skin-sparing mastectomy (Figure 3, center) is performed when a patient is undergoing immediate breast reconstruction (using either a silicone or saline implant or autologous tissue). The goal is to remove all breast tissue, along with the nipple-areola complex, while preserving as much viable skin as possible to optimize the cosmetic outcome.^7,8

Nipple-areola–sparing mastectomy. There is increasing experience with attempts to preserve the nipple-areola complex. These procedures attempt to preserve either the whole complex, termed nipple-areola–sparing mastectomy (sometimes called simply nipple-sparing mastectomy) (Figure 3, right), or just the areola, with removal of the nipple (areola-sparing mastectomy). These procedures are also performed in a skin-sparing fashion.

There is some controversy surrounding these techniques to spare the nipple and/or areola, including debate over which technique.nipple-areola–sparing mastectomy or areola-sparing mastectomy.may be more oncologically safe. Currently the literature shows that both are probably safe oncologic alternatives for remote tumors that do not have an extensive intraductal component. Generally, frozen sections are performed intraoperatively on the retroareola tissue to document that there is no evidence of tumor.⁹

SURGICAL COMPLICATIONS

Breast procedures are fairly safe operations, but every operation has a risk of complications. Reported complications of breast surgery include the following:

• Bleeding
• Infection (including both cellulitis and abscess)
• Seroma
• Arm morbidity (including lymphedema)
• Phantom breast syndrome
• Injury to the motor nerves.

Seromas often occur in patients after mastectomy or lymph node surgery. Prolonged lymphatic drainage is usually exacerbated by extensive axillary node involvement and obesity.

Arm morbidity can present in different ways. Lymphedema is the most common manifestation, with reported incidences of approximately 15% to 20% when axillary lymph node dissection is performed versus 7% when sentinel lymph node biopsy is done.¹⁰ The risk of lymphedema can be reduced by avoiding blood pressure measurements, venipunctures, and intravenous insertions in the arm on the side of the operation, as well as by wearing a compression sleeve on the affected arm during airplane flights.

Phantom breast syndrome is rare but may manifest as pain that may also involve itching, nipple sensation, erotic sensations, or premenstrual-type soreness.

Many surgeons have historically removed the intercostobrachial nerves but are now trying to preserve these nerves, which when removed cause loss of sensation in the upper inner arm. Although rare, nerve injury during an axillary procedure has been reported. It may involve the long thoracic nerve (denervating the serratus anterior muscle and causing a winged scapula) or the thoracodorsal bundle (denervating the latissimus dorsi muscle and causing difficulty with arm/shoulder adduction).

LOCAL CANCER RECURRENCE

Among women undergoing mastectomy for breast cancer, 10% to 15% will have a recurrence of cancer in the chest wall or axillary lymph nodes within 10 years.¹¹ Similarly, among women undergoing breast conservation therapy plus radiation therapy, 10% to 15% will have in-breast cancer recurrence or recurrence in axillary lymph nodes within 10 years, although women who undergo breast conservation therapy without radiation have a much higher recurrence rate.¹¹Considerations for screening the surgically altered breast are discussed in the previous article in this supplement.

ASSESSMENT OF AXILLARY LYMPH NODES FOR METASTASIS

Even when patients have a known histologic diagnosis of breast cancer and have made a firm decision regarding the surgical option for removal of their cancer, the status of their axillary lymph nodes remains a great unanswered question until after the surgical procedure is completed. Lymph node status—ie, determining whether the cancer has spread to the axillary lymph nodes—still serves as the critical determinant for guiding adjuvant treatment, predicting survival, and assessing the risk of recurrence.

Axillary lymph node dissection

The standard approach for evaluating lymph node status has been a complete dissection of the axillary space, or axillary lymph node dissection. As briefly noted above, the axillary lymph nodes are anatomically classified into three levels as defined by their location relative to the pectoralis minor muscle. The extent of a nodal dissection can be defined by the number of nodes removed.

Axillary lymph node dissection has been called into question over the last 15 years due to its invasiveness and the potential morbidity associated with it (including lymphedema and paresthesias). As a result, sen­tinel lymph node biopsy, a minimally invasive technique for identifying axillary metastasis, was developed to avoid the need for (and risk of complications from) axillary lymph node dissection in patients who have a low probability of axillary metastasis.

Reprinted from Contemporary Surgery (Pawlik TM, Gershenwald JE. Sentinel lymph node biopsy for melanoma. Contemp Surg 2005; 61:175–182.) with permission of Dowden Health Media.

Overall, however, it is now accepted that intraoperative lymph node mapping with sentinel lymphadenectomy is an effective and minimally invasive alternative to axillary lymph node dissection for identifying nodes containing metastases.

CONCLUSIONS

Decisions surrounding the choice of breast surgery procedure must be individualized to the patient and her desires and based on comprehensive patient evaluation and thorough patient counseling. Optimal results for the patient—oncologically, psychologically, and in terms of cosmetic outcomes—require consultation and collaboration among general surgeons, medical oncologists, genetic counselors, radiation oncologists, radiologists, and plastic surgeons to clarify the risks and benefits of various intervention options. Striving for this multidisciplinary collaboration will promote optimal patient management and the most favorable clinical outcomes.

Patients recently diagnosed with breast cancer are distraught with concerns not only about surviving their disease but also about how its treatment will affect their body image and self-image. Although the risk of breast cancer increases with age, it is not a disease limited to the elderly. With advances in screening and awareness, breast cancers are now detected at earlier stages and in younger women. Approximately 5% of breast cancer patients are age 40 years or younger, which explains the recommendation that women be told about the benefits (and limits) of regular breast self-examinations beginning in their 20s.¹ Additionally, breast cancer is the most common cancer in pregnant and postpartum women, occurring in about 1 in 3,000 pregnant women.2 Although breast conservation therapy is an attractive option, for many patients mastectomy is still the recommended surgical treatment. When mastectomy is required, it is understandable that many women are very concerned about losing their breast.

REASONS FOR RECONSTRUCTION

Mastectomies are commonly performed for women with ductal carcinoma in situ or with early or locally advanced invasive breast cancer (infiltrating ductal carcinoma) and sometimes for recurrent disease or for prophylaxis in high-risk women such as those with BRCA gene mutations or lobular carcinoma in situ. As reviewed in the preceding article in this supplement, mastectomy can be performed in various ways, using modified radical, skin-sparing, or nipple-sparing mastectomy techniques.

An emotional ‘double hit’

Following mastectomy, women are often left with what may be regarded as an emotional “double hit.” First, of course, is the anxiety from having a cancer diagnosis. Second, and perhaps equally devastating for some, is the emotional impact of losing a breast and the accompanying perception of disfigurement or loss of femininity and sexuality. These latter feelings often lead women who have undergone or will undergo mastectomy to explore the possibility of breast reconstruction.^3–5

Both a medical and an emotional decision

While the reasons that women may seek breast reconstruction are many and varied (eg, to restore their self-esteem and social functioning, to help put their cancer experience behind them), it is important for primary care providers and other referring physicians to recognize that this decision is both a medical and an emotional one. Most women healthy enough to undergo extirpative surgical procedures are, in fact, healthy enough to undergo breast reconstruction if desired. Since choosing a reconstructive strategy is a complex process that takes into account many therapeutic and individual patient factors, plastic surgery consultation plays a major role in the comprehensive treatment of breast cancer.

TIMING AND TYPE OF RECONSTRUCTION

The timing of breast reconstruction can vary. In cases where the patient knows she will want reconstruction and the cancer surgery is performed at a site where a reconstructive surgery team is available, reconstruction can be performed immediately following mastectomy during a single trip to the operating room. When a reconstructive surgeon is not available locally or when systemic or local cancer therapies need to be completed first, reconstruction may need to be delayed.

Immediate reconstruction has the advantage of improved aesthetics while mitigating the sense of loss that can accompany mastectomy. Delayed reconstruction will give the patient more time for her decisions. An additional option, called “delayed-immediate” reconstruction, involves placing a tissue expander at the time of mastectomy (to preserve the breast skin envelope) and awaiting pathology results to determine whether radiation therapy is needed. If radiation is not needed, the patient undergoes reconstruction right away; if radiation is needed, the patient undergoes delayed reconstruction after radiation therapy is completed, with the breast skin envelope preserved for better aesthetic results. (The timing of reconstruction and these various timing options are discussed in detail in the final article in this supplement.) Selecting the correct timing and method of reconstruction requires good communication and coordination between the patient, her oncologist, and her multidisciplinary surgical team comprising both breast and plastic surgery specialists.

The patient and her surgeon will also discuss which reconstructive technique is best for her. Choosing a reconstructive strategy is a highly individualized process that takes into account the patient’s body characteristics, overall health, breast cancer treatment plan, and personal preferences. Consequently, a strategy offered to one patient is not necessarily valid for another. In general, options for reconstruction include use of the patient’s own tissue (autologous tissue), use of implant material (nonautologous), or a combination of an implant and autologous tissue.

IMPLANT-BASED RECONSTRUCTION

What the procedure involves

Nonautologous breast reconstruction usually involves a two-step procedure: placement of a tissue expander followed by later placement of a permanent implant.

Choice of permanent implant

Permanent implants vary by shape, texture of the implant shell, and filler material. They are typically filled with either silicone gel or saline.

Breast implants have been available for many years for use in both reconstructive breast surgery and cosmetic augmentation. A great deal of bad press and misinformation had surrounded the use of silicone gel-filled implants, with the result that they ceased to be marketed in the United States beginning in the early 1990s while the US Food and Drug Administration (FDA) reviewed additional safety information on their use. During this period when the use of silicone implants was limited, saline-filled implants became the preferred choice until the FDA approved the reintroduction of silicone implants to the market in November 2006, after what the agency described as years of rigorous scientific review of multiple clinical studies and other data.6 The FDA concluded that silicone implants are safe and effective for general use in breast reconstruction, correction of congenital breast anomalies, and breast augmentation.⁶ There is no evidence that silicone implants pose a significant systemic risk to women undergoing breast reconstruction.

Potential complications

Capsular contracture is another potential and more frequent complication of implant-based reconstruction. In all cases, the body forms a protective coverage, or fibrous capsule, around the implant. This process is called encapsulation. Most of the time, the capsule is relatively thin and pliable. Infrequently, however, the capsule can become thickened, hardened, and contracted, which constitutes capsular con-tracture. Although rare, severe contractures cause deformation of the reconstructed breast as well as pain. Severe contractures often require an operation to replace or remove the implant and treat the excessively thickened capsule. This can be done by exchanging the implant and either opening the capsule (capsulotomy) or removing the capsule (capsulectomy). If the contracture is significant enough or if the contracture recurs, then reconstruction using autologous tissue might be needed.

Although nonautologous implant-based reconstruction can have some limitations, this procedure attracts many patients as a result of its advantages and good aesthetic results. The mastectomy procedure is prolonged by only about 1 hour, and most patients require only an overnight stay after the procedure. The recovery period is approximately 2 to 3 weeks, at which point tissue expansion is started.

What if radiation therapy is needed?

When treatment of the breast cancer is expected to involve radiation therapy right from the beginning, implant-based reconstruction is not an optimal choice. Radiation can affect the reconstruction in several negative ways. By design, radiation treats cancer by destroying dividing cells. Dividing cells are also required for wound healing and tissue remodeling. Without this remodeling ability, surgical scars are more susceptible to breakdown, which leads to tissue loss. In addition, because the effects of radiation are long-term, over time the thin tissue over the implant might respond poorly to the excessive stress of the implant, raising the possibility that tissue thinning could eventually lead to implant loss.⁷

Certainly there are instances when radiation therapy is not anticipated prior to the extirpative operation but then becomes necessary to complete the cancer treatment, based on final pathology results. Some patients in these circumstances may have had implants placed prior to the decision to give radiation. This does not doom the implant reconstruction to failure, however. Depending on the effect of the radiation and the patient’s body, there might be only a limited impact on the implant and the overall reconstruction result. We recommended close follow-up in these patients to monitor for any long-term complications such as skin discoloration, implant extrusion, or capsular contracture, which can be addressed as they arise.

AUTOLOGOUS RECONSTRUCTION

Techniques using abdominal tissue

As noted above, autologous breast reconstruction uses the patient’s own tissue. If the patient has adequate abdominal fat, the skin and fatty tissue of the lower abdomen may be used to reconstruct the missing breast. Historically, this type of reconstruction has included a portion of the abdominal muscles.

TRAM flap technique. The transverse rectus abdominis muscle (TRAM) flap technique takes advantage of the blood supply within the rectus abdominis muscle and its overlying skin and soft tissue. The muscle serves as the conduit for the blood supply of the skin and fatty tissue used in this method of reconstruction. The distal insertion of the muscle close to the pubic symphysis is cut, and the tissue receives its blood via the superior epigastric artery, which passes through the rectus muscle. This skin and soft tissue is then brought into the defect on the chest beneath the skin by tunneling it through the undermined skin flap between the abdomen and chest.

While the reconstructive results with the TRAM flap are good, this technique has been associated with increased risk of hernias or bulges in the abdominal wall. In sacrificing the rectus abdominis muscle, one of the major contributors to posture and the dynamic abdominal contour of the ventral abdomen is lost and the abdominal wall is weakened. This risk becomes even more significant when both rectus abdominis muscles are used to reconstruct both breasts.

Limitations of techniques using abdominal tissue. Although autologous reconstruction is most commonly performed using tissue from the lower abdomen, flaps from the lower abdomen can be used only when there is sufficient fatty tissue to provide bulk for reconstructing the breast. In thin patients, using flaps from the abdomen may not be a good option. Contraindications to autologous reconstruction using the abdomen include previous abdominal surgery such as abdominoplasty, liposuction, open cholecystectomy, or other major abdominal operations that would compromise circulation to the skin and tissue over the flap. Other relative contraindications to autologous tissue reconstruction using the abdomen are obesity, smoking, a history of blood clots, and other major systemic medical conditions.

Options when abdominal tissue cannot be used

For patients who have insufficient tissue on the abdomen or have had previous abdominal surgery that compromises perfusion to the abdominal tissue, other options for autologous breast reconstruction are available. The gluteal tissue can be used, based on its superior or inferior blood supply, known as the superior gluteal artery perforator (SGAP) flap or the inferior gluteal artery perforator (IGAP) flap. Like the DIEP free flap technique, reconstruction using these flaps also requires a microsurgical procedure.

Another common option involves using skin and muscle from the back, or the latissimus dorsi myocutaneous flap. This flap does not require microsurgery; however, often the amount of tissue available to reconstruct the breast is inadequate to create a breast mound, requiring that the reconstruction be supplemented with an implant beneath the flap.⁸

Pros and cons of autologous reconstruction

Unlike implant-based reconstruction, autologous reconstruction obviously eliminates the need for implant replacement in the future. It also generally results in a more natural-feeling and natural-looking breast. Another advantage is that the breast reconstructed with autologous tissue will grow and decrease in size with weight fluctuations, just as a nonreconstructed breast would. Finally, in many cases the patient also essentially undergoes an abdominoplasty, or “tummy tuck” procedure, by virtue of how the tissue is harvested for reconstruction, which is likely to be welcomed by many patients.

Nipple reconstruction

Reconstruction of the nipple and areola is important in that many patients feel that the nipple is what makes a breast. With the increased use of nipple-sparing mastectomy and improved reconstructive techniques, the aesthetic outcomes of reconstruction are often regarded as superior to many breast conservation procedures. A recent study by Cocquyt et al suggests that skin-sparing mastectomy with immediate DIEP flap reconstruction or TRAM flap reconstruction appears to yield a better cosmetic outcome than breast conservation therapy.⁹

Reconstruction of the nipple and areola restores the shape of the nipple, the shape of the areola, and the color of both with tattoos. Closing the autologous flap in a circular manner creates the shape of the areola, and the nipple is formed by local bilobed or trilobed skin flaps wrapped around each other to create a cone. Although nipple reconstruction can be performed at the time of immediate reconstruction, it is usually performed at a later time in the outpatient setting when the shape of the reconstructed breast is more definite after healing has occurred.

Revisional procedures

In many cases reconstructive breast surgery is not able to provide a breast that is shaped or sized exactly as desired or that perfectly matches the contralateral breast. Revisional procedures are sometimes performed to improve breast appearance and symmetry. Most revisional breast surgeries are performed on an outpatient basis and at times can be completed at the time of nipple reconstruction.

Modifying the contralateral breast

Modification of the contralateral breast is often necessary, and either a mastopexy (breast lift), reduction, or augmentation of the contralateral side may be needed for symmetry.

Mastopexy and reduction mammaplasty. Mastopexy, a skin-tightening and nipple-repositioning procedure, is performed to correct soft tissue descent without removing much breast tissue (see Figure 2), while reduction mammaplasty involves removing 400 to 2,000 grams of breast tissue (see Figure 4). A patient who has had a unilateral mastectomy without reconstruction may be a candidate for reduction mammaplasty of the contralateral breast. A unilateral large breast can cause marked neck and back pain due to the asymmetry of the weight on the chest.

Augmentation. Patients with smaller breasts often will undergo a matching augmentation procedure on the contralateral breast following completion of mastectomy and reconstruction on the other side.

Prophylactic mastectomy. For some women with a very high lifetime risk of breast cancer, such as those with BRCA1 or BRCA2 gene mutations, prophylactic mastectomy of the contralateral breast or even bilateral prophylactic mastectomy may be recommended by the oncologic surgeon. In some of these selected patients with sufficient abdominal tissue, bilateral DIEP flaps may be suitable; otherwise, the reconstruction can be completed with tissue expanders and implants.

WHAT ABOUT INSURANCE COVERAGE?

As the result of a federal law enacted 10 years ago, insurance coverage should not be a concern for women who are considering breast reconstruction following mastectomy. The Women’s Health and Cancer Rights Act of 1998 requires all medical insurers that provide coverage for mastectomy to also cover all stages of reconstruction of the affected breast as well as surgery and reconstruction of the contralateral breast to produce a symmetrical appearance.¹⁰

CONCLUSION

Although breast cancer remains a significant health risk to women and can result in significant disfigurement, breast reconstruction strategies continue to improve. These strategies offer women who have undergone mastectomy some excellent options for creating a near-normal-appearing breast. Women interested in pursuing reconstruction should meet with a plastic surgeon early in the course of their breast cancer treatment planning in order to better understand the options available and make an informed and individualized choice.

Patients recently diagnosed with breast cancer are distraught with concerns not only about surviving their disease but also about how its treatment will affect their body image and self-image. Although the risk of breast cancer increases with age, it is not a disease limited to the elderly. With advances in screening and awareness, breast cancers are now detected at earlier stages and in younger women. Approximately 5% of breast cancer patients are age 40 years or younger, which explains the recommendation that women be told about the benefits (and limits) of regular breast self-examinations beginning in their 20s.¹ Additionally, breast cancer is the most common cancer in pregnant and postpartum women, occurring in about 1 in 3,000 pregnant women.2 Although breast conservation therapy is an attractive option, for many patients mastectomy is still the recommended surgical treatment. When mastectomy is required, it is understandable that many women are very concerned about losing their breast.

REASONS FOR RECONSTRUCTION

Mastectomies are commonly performed for women with ductal carcinoma in situ or with early or locally advanced invasive breast cancer (infiltrating ductal carcinoma) and sometimes for recurrent disease or for prophylaxis in high-risk women such as those with BRCA gene mutations or lobular carcinoma in situ. As reviewed in the preceding article in this supplement, mastectomy can be performed in various ways, using modified radical, skin-sparing, or nipple-sparing mastectomy techniques.

An emotional ‘double hit’

Following mastectomy, women are often left with what may be regarded as an emotional “double hit.” First, of course, is the anxiety from having a cancer diagnosis. Second, and perhaps equally devastating for some, is the emotional impact of losing a breast and the accompanying perception of disfigurement or loss of femininity and sexuality. These latter feelings often lead women who have undergone or will undergo mastectomy to explore the possibility of breast reconstruction.^3–5

Both a medical and an emotional decision

While the reasons that women may seek breast reconstruction are many and varied (eg, to restore their self-esteem and social functioning, to help put their cancer experience behind them), it is important for primary care providers and other referring physicians to recognize that this decision is both a medical and an emotional one. Most women healthy enough to undergo extirpative surgical procedures are, in fact, healthy enough to undergo breast reconstruction if desired. Since choosing a reconstructive strategy is a complex process that takes into account many therapeutic and individual patient factors, plastic surgery consultation plays a major role in the comprehensive treatment of breast cancer.

TIMING AND TYPE OF RECONSTRUCTION

The timing of breast reconstruction can vary. In cases where the patient knows she will want reconstruction and the cancer surgery is performed at a site where a reconstructive surgery team is available, reconstruction can be performed immediately following mastectomy during a single trip to the operating room. When a reconstructive surgeon is not available locally or when systemic or local cancer therapies need to be completed first, reconstruction may need to be delayed.

Immediate reconstruction has the advantage of improved aesthetics while mitigating the sense of loss that can accompany mastectomy. Delayed reconstruction will give the patient more time for her decisions. An additional option, called “delayed-immediate” reconstruction, involves placing a tissue expander at the time of mastectomy (to preserve the breast skin envelope) and awaiting pathology results to determine whether radiation therapy is needed. If radiation is not needed, the patient undergoes reconstruction right away; if radiation is needed, the patient undergoes delayed reconstruction after radiation therapy is completed, with the breast skin envelope preserved for better aesthetic results. (The timing of reconstruction and these various timing options are discussed in detail in the final article in this supplement.) Selecting the correct timing and method of reconstruction requires good communication and coordination between the patient, her oncologist, and her multidisciplinary surgical team comprising both breast and plastic surgery specialists.

The patient and her surgeon will also discuss which reconstructive technique is best for her. Choosing a reconstructive strategy is a highly individualized process that takes into account the patient’s body characteristics, overall health, breast cancer treatment plan, and personal preferences. Consequently, a strategy offered to one patient is not necessarily valid for another. In general, options for reconstruction include use of the patient’s own tissue (autologous tissue), use of implant material (nonautologous), or a combination of an implant and autologous tissue.

IMPLANT-BASED RECONSTRUCTION

What the procedure involves

Nonautologous breast reconstruction usually involves a two-step procedure: placement of a tissue expander followed by later placement of a permanent implant.

Choice of permanent implant

Permanent implants vary by shape, texture of the implant shell, and filler material. They are typically filled with either silicone gel or saline.

Breast implants have been available for many years for use in both reconstructive breast surgery and cosmetic augmentation. A great deal of bad press and misinformation had surrounded the use of silicone gel-filled implants, with the result that they ceased to be marketed in the United States beginning in the early 1990s while the US Food and Drug Administration (FDA) reviewed additional safety information on their use. During this period when the use of silicone implants was limited, saline-filled implants became the preferred choice until the FDA approved the reintroduction of silicone implants to the market in November 2006, after what the agency described as years of rigorous scientific review of multiple clinical studies and other data.6 The FDA concluded that silicone implants are safe and effective for general use in breast reconstruction, correction of congenital breast anomalies, and breast augmentation.⁶ There is no evidence that silicone implants pose a significant systemic risk to women undergoing breast reconstruction.

Potential complications

Capsular contracture is another potential and more frequent complication of implant-based reconstruction. In all cases, the body forms a protective coverage, or fibrous capsule, around the implant. This process is called encapsulation. Most of the time, the capsule is relatively thin and pliable. Infrequently, however, the capsule can become thickened, hardened, and contracted, which constitutes capsular con-tracture. Although rare, severe contractures cause deformation of the reconstructed breast as well as pain. Severe contractures often require an operation to replace or remove the implant and treat the excessively thickened capsule. This can be done by exchanging the implant and either opening the capsule (capsulotomy) or removing the capsule (capsulectomy). If the contracture is significant enough or if the contracture recurs, then reconstruction using autologous tissue might be needed.

Although nonautologous implant-based reconstruction can have some limitations, this procedure attracts many patients as a result of its advantages and good aesthetic results. The mastectomy procedure is prolonged by only about 1 hour, and most patients require only an overnight stay after the procedure. The recovery period is approximately 2 to 3 weeks, at which point tissue expansion is started.

What if radiation therapy is needed?

When treatment of the breast cancer is expected to involve radiation therapy right from the beginning, implant-based reconstruction is not an optimal choice. Radiation can affect the reconstruction in several negative ways. By design, radiation treats cancer by destroying dividing cells. Dividing cells are also required for wound healing and tissue remodeling. Without this remodeling ability, surgical scars are more susceptible to breakdown, which leads to tissue loss. In addition, because the effects of radiation are long-term, over time the thin tissue over the implant might respond poorly to the excessive stress of the implant, raising the possibility that tissue thinning could eventually lead to implant loss.⁷

Certainly there are instances when radiation therapy is not anticipated prior to the extirpative operation but then becomes necessary to complete the cancer treatment, based on final pathology results. Some patients in these circumstances may have had implants placed prior to the decision to give radiation. This does not doom the implant reconstruction to failure, however. Depending on the effect of the radiation and the patient’s body, there might be only a limited impact on the implant and the overall reconstruction result. We recommended close follow-up in these patients to monitor for any long-term complications such as skin discoloration, implant extrusion, or capsular contracture, which can be addressed as they arise.

AUTOLOGOUS RECONSTRUCTION

Techniques using abdominal tissue

As noted above, autologous breast reconstruction uses the patient’s own tissue. If the patient has adequate abdominal fat, the skin and fatty tissue of the lower abdomen may be used to reconstruct the missing breast. Historically, this type of reconstruction has included a portion of the abdominal muscles.

TRAM flap technique. The transverse rectus abdominis muscle (TRAM) flap technique takes advantage of the blood supply within the rectus abdominis muscle and its overlying skin and soft tissue. The muscle serves as the conduit for the blood supply of the skin and fatty tissue used in this method of reconstruction. The distal insertion of the muscle close to the pubic symphysis is cut, and the tissue receives its blood via the superior epigastric artery, which passes through the rectus muscle. This skin and soft tissue is then brought into the defect on the chest beneath the skin by tunneling it through the undermined skin flap between the abdomen and chest.

While the reconstructive results with the TRAM flap are good, this technique has been associated with increased risk of hernias or bulges in the abdominal wall. In sacrificing the rectus abdominis muscle, one of the major contributors to posture and the dynamic abdominal contour of the ventral abdomen is lost and the abdominal wall is weakened. This risk becomes even more significant when both rectus abdominis muscles are used to reconstruct both breasts.

Limitations of techniques using abdominal tissue. Although autologous reconstruction is most commonly performed using tissue from the lower abdomen, flaps from the lower abdomen can be used only when there is sufficient fatty tissue to provide bulk for reconstructing the breast. In thin patients, using flaps from the abdomen may not be a good option. Contraindications to autologous reconstruction using the abdomen include previous abdominal surgery such as abdominoplasty, liposuction, open cholecystectomy, or other major abdominal operations that would compromise circulation to the skin and tissue over the flap. Other relative contraindications to autologous tissue reconstruction using the abdomen are obesity, smoking, a history of blood clots, and other major systemic medical conditions.

Options when abdominal tissue cannot be used

For patients who have insufficient tissue on the abdomen or have had previous abdominal surgery that compromises perfusion to the abdominal tissue, other options for autologous breast reconstruction are available. The gluteal tissue can be used, based on its superior or inferior blood supply, known as the superior gluteal artery perforator (SGAP) flap or the inferior gluteal artery perforator (IGAP) flap. Like the DIEP free flap technique, reconstruction using these flaps also requires a microsurgical procedure.

Another common option involves using skin and muscle from the back, or the latissimus dorsi myocutaneous flap. This flap does not require microsurgery; however, often the amount of tissue available to reconstruct the breast is inadequate to create a breast mound, requiring that the reconstruction be supplemented with an implant beneath the flap.⁸

Pros and cons of autologous reconstruction

Unlike implant-based reconstruction, autologous reconstruction obviously eliminates the need for implant replacement in the future. It also generally results in a more natural-feeling and natural-looking breast. Another advantage is that the breast reconstructed with autologous tissue will grow and decrease in size with weight fluctuations, just as a nonreconstructed breast would. Finally, in many cases the patient also essentially undergoes an abdominoplasty, or “tummy tuck” procedure, by virtue of how the tissue is harvested for reconstruction, which is likely to be welcomed by many patients.

Nipple reconstruction

Reconstruction of the nipple and areola is important in that many patients feel that the nipple is what makes a breast. With the increased use of nipple-sparing mastectomy and improved reconstructive techniques, the aesthetic outcomes of reconstruction are often regarded as superior to many breast conservation procedures. A recent study by Cocquyt et al suggests that skin-sparing mastectomy with immediate DIEP flap reconstruction or TRAM flap reconstruction appears to yield a better cosmetic outcome than breast conservation therapy.⁹

Reconstruction of the nipple and areola restores the shape of the nipple, the shape of the areola, and the color of both with tattoos. Closing the autologous flap in a circular manner creates the shape of the areola, and the nipple is formed by local bilobed or trilobed skin flaps wrapped around each other to create a cone. Although nipple reconstruction can be performed at the time of immediate reconstruction, it is usually performed at a later time in the outpatient setting when the shape of the reconstructed breast is more definite after healing has occurred.

Revisional procedures

In many cases reconstructive breast surgery is not able to provide a breast that is shaped or sized exactly as desired or that perfectly matches the contralateral breast. Revisional procedures are sometimes performed to improve breast appearance and symmetry. Most revisional breast surgeries are performed on an outpatient basis and at times can be completed at the time of nipple reconstruction.

Modifying the contralateral breast

Modification of the contralateral breast is often necessary, and either a mastopexy (breast lift), reduction, or augmentation of the contralateral side may be needed for symmetry.

Mastopexy and reduction mammaplasty. Mastopexy, a skin-tightening and nipple-repositioning procedure, is performed to correct soft tissue descent without removing much breast tissue (see Figure 2), while reduction mammaplasty involves removing 400 to 2,000 grams of breast tissue (see Figure 4). A patient who has had a unilateral mastectomy without reconstruction may be a candidate for reduction mammaplasty of the contralateral breast. A unilateral large breast can cause marked neck and back pain due to the asymmetry of the weight on the chest.

Augmentation. Patients with smaller breasts often will undergo a matching augmentation procedure on the contralateral breast following completion of mastectomy and reconstruction on the other side.

Prophylactic mastectomy. For some women with a very high lifetime risk of breast cancer, such as those with BRCA1 or BRCA2 gene mutations, prophylactic mastectomy of the contralateral breast or even bilateral prophylactic mastectomy may be recommended by the oncologic surgeon. In some of these selected patients with sufficient abdominal tissue, bilateral DIEP flaps may be suitable; otherwise, the reconstruction can be completed with tissue expanders and implants.

WHAT ABOUT INSURANCE COVERAGE?

As the result of a federal law enacted 10 years ago, insurance coverage should not be a concern for women who are considering breast reconstruction following mastectomy. The Women’s Health and Cancer Rights Act of 1998 requires all medical insurers that provide coverage for mastectomy to also cover all stages of reconstruction of the affected breast as well as surgery and reconstruction of the contralateral breast to produce a symmetrical appearance.¹⁰

CONCLUSION

Although breast cancer remains a significant health risk to women and can result in significant disfigurement, breast reconstruction strategies continue to improve. These strategies offer women who have undergone mastectomy some excellent options for creating a near-normal-appearing breast. Women interested in pursuing reconstruction should meet with a plastic surgeon early in the course of their breast cancer treatment planning in order to better understand the options available and make an informed and individualized choice.

Patients recently diagnosed with breast cancer are distraught with concerns not only about surviving their disease but also about how its treatment will affect their body image and self-image. Although the risk of breast cancer increases with age, it is not a disease limited to the elderly. With advances in screening and awareness, breast cancers are now detected at earlier stages and in younger women. Approximately 5% of breast cancer patients are age 40 years or younger, which explains the recommendation that women be told about the benefits (and limits) of regular breast self-examinations beginning in their 20s.¹ Additionally, breast cancer is the most common cancer in pregnant and postpartum women, occurring in about 1 in 3,000 pregnant women.2 Although breast conservation therapy is an attractive option, for many patients mastectomy is still the recommended surgical treatment. When mastectomy is required, it is understandable that many women are very concerned about losing their breast.

REASONS FOR RECONSTRUCTION

Mastectomies are commonly performed for women with ductal carcinoma in situ or with early or locally advanced invasive breast cancer (infiltrating ductal carcinoma) and sometimes for recurrent disease or for prophylaxis in high-risk women such as those with BRCA gene mutations or lobular carcinoma in situ. As reviewed in the preceding article in this supplement, mastectomy can be performed in various ways, using modified radical, skin-sparing, or nipple-sparing mastectomy techniques.

An emotional ‘double hit’

Following mastectomy, women are often left with what may be regarded as an emotional “double hit.” First, of course, is the anxiety from having a cancer diagnosis. Second, and perhaps equally devastating for some, is the emotional impact of losing a breast and the accompanying perception of disfigurement or loss of femininity and sexuality. These latter feelings often lead women who have undergone or will undergo mastectomy to explore the possibility of breast reconstruction.^3–5

Both a medical and an emotional decision

While the reasons that women may seek breast reconstruction are many and varied (eg, to restore their self-esteem and social functioning, to help put their cancer experience behind them), it is important for primary care providers and other referring physicians to recognize that this decision is both a medical and an emotional one. Most women healthy enough to undergo extirpative surgical procedures are, in fact, healthy enough to undergo breast reconstruction if desired. Since choosing a reconstructive strategy is a complex process that takes into account many therapeutic and individual patient factors, plastic surgery consultation plays a major role in the comprehensive treatment of breast cancer.

TIMING AND TYPE OF RECONSTRUCTION

The timing of breast reconstruction can vary. In cases where the patient knows she will want reconstruction and the cancer surgery is performed at a site where a reconstructive surgery team is available, reconstruction can be performed immediately following mastectomy during a single trip to the operating room. When a reconstructive surgeon is not available locally or when systemic or local cancer therapies need to be completed first, reconstruction may need to be delayed.

Immediate reconstruction has the advantage of improved aesthetics while mitigating the sense of loss that can accompany mastectomy. Delayed reconstruction will give the patient more time for her decisions. An additional option, called “delayed-immediate” reconstruction, involves placing a tissue expander at the time of mastectomy (to preserve the breast skin envelope) and awaiting pathology results to determine whether radiation therapy is needed. If radiation is not needed, the patient undergoes reconstruction right away; if radiation is needed, the patient undergoes delayed reconstruction after radiation therapy is completed, with the breast skin envelope preserved for better aesthetic results. (The timing of reconstruction and these various timing options are discussed in detail in the final article in this supplement.) Selecting the correct timing and method of reconstruction requires good communication and coordination between the patient, her oncologist, and her multidisciplinary surgical team comprising both breast and plastic surgery specialists.

The patient and her surgeon will also discuss which reconstructive technique is best for her. Choosing a reconstructive strategy is a highly individualized process that takes into account the patient’s body characteristics, overall health, breast cancer treatment plan, and personal preferences. Consequently, a strategy offered to one patient is not necessarily valid for another. In general, options for reconstruction include use of the patient’s own tissue (autologous tissue), use of implant material (nonautologous), or a combination of an implant and autologous tissue.

IMPLANT-BASED RECONSTRUCTION

What the procedure involves

Nonautologous breast reconstruction usually involves a two-step procedure: placement of a tissue expander followed by later placement of a permanent implant.

Choice of permanent implant

Permanent implants vary by shape, texture of the implant shell, and filler material. They are typically filled with either silicone gel or saline.

Breast implants have been available for many years for use in both reconstructive breast surgery and cosmetic augmentation. A great deal of bad press and misinformation had surrounded the use of silicone gel-filled implants, with the result that they ceased to be marketed in the United States beginning in the early 1990s while the US Food and Drug Administration (FDA) reviewed additional safety information on their use. During this period when the use of silicone implants was limited, saline-filled implants became the preferred choice until the FDA approved the reintroduction of silicone implants to the market in November 2006, after what the agency described as years of rigorous scientific review of multiple clinical studies and other data.6 The FDA concluded that silicone implants are safe and effective for general use in breast reconstruction, correction of congenital breast anomalies, and breast augmentation.⁶ There is no evidence that silicone implants pose a significant systemic risk to women undergoing breast reconstruction.

Potential complications

Capsular contracture is another potential and more frequent complication of implant-based reconstruction. In all cases, the body forms a protective coverage, or fibrous capsule, around the implant. This process is called encapsulation. Most of the time, the capsule is relatively thin and pliable. Infrequently, however, the capsule can become thickened, hardened, and contracted, which constitutes capsular con-tracture. Although rare, severe contractures cause deformation of the reconstructed breast as well as pain. Severe contractures often require an operation to replace or remove the implant and treat the excessively thickened capsule. This can be done by exchanging the implant and either opening the capsule (capsulotomy) or removing the capsule (capsulectomy). If the contracture is significant enough or if the contracture recurs, then reconstruction using autologous tissue might be needed.

Although nonautologous implant-based reconstruction can have some limitations, this procedure attracts many patients as a result of its advantages and good aesthetic results. The mastectomy procedure is prolonged by only about 1 hour, and most patients require only an overnight stay after the procedure. The recovery period is approximately 2 to 3 weeks, at which point tissue expansion is started.

What if radiation therapy is needed?

When treatment of the breast cancer is expected to involve radiation therapy right from the beginning, implant-based reconstruction is not an optimal choice. Radiation can affect the reconstruction in several negative ways. By design, radiation treats cancer by destroying dividing cells. Dividing cells are also required for wound healing and tissue remodeling. Without this remodeling ability, surgical scars are more susceptible to breakdown, which leads to tissue loss. In addition, because the effects of radiation are long-term, over time the thin tissue over the implant might respond poorly to the excessive stress of the implant, raising the possibility that tissue thinning could eventually lead to implant loss.⁷

Certainly there are instances when radiation therapy is not anticipated prior to the extirpative operation but then becomes necessary to complete the cancer treatment, based on final pathology results. Some patients in these circumstances may have had implants placed prior to the decision to give radiation. This does not doom the implant reconstruction to failure, however. Depending on the effect of the radiation and the patient’s body, there might be only a limited impact on the implant and the overall reconstruction result. We recommended close follow-up in these patients to monitor for any long-term complications such as skin discoloration, implant extrusion, or capsular contracture, which can be addressed as they arise.

AUTOLOGOUS RECONSTRUCTION

Techniques using abdominal tissue

As noted above, autologous breast reconstruction uses the patient’s own tissue. If the patient has adequate abdominal fat, the skin and fatty tissue of the lower abdomen may be used to reconstruct the missing breast. Historically, this type of reconstruction has included a portion of the abdominal muscles.

TRAM flap technique. The transverse rectus abdominis muscle (TRAM) flap technique takes advantage of the blood supply within the rectus abdominis muscle and its overlying skin and soft tissue. The muscle serves as the conduit for the blood supply of the skin and fatty tissue used in this method of reconstruction. The distal insertion of the muscle close to the pubic symphysis is cut, and the tissue receives its blood via the superior epigastric artery, which passes through the rectus muscle. This skin and soft tissue is then brought into the defect on the chest beneath the skin by tunneling it through the undermined skin flap between the abdomen and chest.

While the reconstructive results with the TRAM flap are good, this technique has been associated with increased risk of hernias or bulges in the abdominal wall. In sacrificing the rectus abdominis muscle, one of the major contributors to posture and the dynamic abdominal contour of the ventral abdomen is lost and the abdominal wall is weakened. This risk becomes even more significant when both rectus abdominis muscles are used to reconstruct both breasts.

Limitations of techniques using abdominal tissue. Although autologous reconstruction is most commonly performed using tissue from the lower abdomen, flaps from the lower abdomen can be used only when there is sufficient fatty tissue to provide bulk for reconstructing the breast. In thin patients, using flaps from the abdomen may not be a good option. Contraindications to autologous reconstruction using the abdomen include previous abdominal surgery such as abdominoplasty, liposuction, open cholecystectomy, or other major abdominal operations that would compromise circulation to the skin and tissue over the flap. Other relative contraindications to autologous tissue reconstruction using the abdomen are obesity, smoking, a history of blood clots, and other major systemic medical conditions.

Options when abdominal tissue cannot be used

For patients who have insufficient tissue on the abdomen or have had previous abdominal surgery that compromises perfusion to the abdominal tissue, other options for autologous breast reconstruction are available. The gluteal tissue can be used, based on its superior or inferior blood supply, known as the superior gluteal artery perforator (SGAP) flap or the inferior gluteal artery perforator (IGAP) flap. Like the DIEP free flap technique, reconstruction using these flaps also requires a microsurgical procedure.

Another common option involves using skin and muscle from the back, or the latissimus dorsi myocutaneous flap. This flap does not require microsurgery; however, often the amount of tissue available to reconstruct the breast is inadequate to create a breast mound, requiring that the reconstruction be supplemented with an implant beneath the flap.⁸

Pros and cons of autologous reconstruction

Unlike implant-based reconstruction, autologous reconstruction obviously eliminates the need for implant replacement in the future. It also generally results in a more natural-feeling and natural-looking breast. Another advantage is that the breast reconstructed with autologous tissue will grow and decrease in size with weight fluctuations, just as a nonreconstructed breast would. Finally, in many cases the patient also essentially undergoes an abdominoplasty, or “tummy tuck” procedure, by virtue of how the tissue is harvested for reconstruction, which is likely to be welcomed by many patients.

Nipple reconstruction

Reconstruction of the nipple and areola is important in that many patients feel that the nipple is what makes a breast. With the increased use of nipple-sparing mastectomy and improved reconstructive techniques, the aesthetic outcomes of reconstruction are often regarded as superior to many breast conservation procedures. A recent study by Cocquyt et al suggests that skin-sparing mastectomy with immediate DIEP flap reconstruction or TRAM flap reconstruction appears to yield a better cosmetic outcome than breast conservation therapy.⁹

Reconstruction of the nipple and areola restores the shape of the nipple, the shape of the areola, and the color of both with tattoos. Closing the autologous flap in a circular manner creates the shape of the areola, and the nipple is formed by local bilobed or trilobed skin flaps wrapped around each other to create a cone. Although nipple reconstruction can be performed at the time of immediate reconstruction, it is usually performed at a later time in the outpatient setting when the shape of the reconstructed breast is more definite after healing has occurred.

Revisional procedures

In many cases reconstructive breast surgery is not able to provide a breast that is shaped or sized exactly as desired or that perfectly matches the contralateral breast. Revisional procedures are sometimes performed to improve breast appearance and symmetry. Most revisional breast surgeries are performed on an outpatient basis and at times can be completed at the time of nipple reconstruction.

Modifying the contralateral breast

Modification of the contralateral breast is often necessary, and either a mastopexy (breast lift), reduction, or augmentation of the contralateral side may be needed for symmetry.

Mastopexy and reduction mammaplasty. Mastopexy, a skin-tightening and nipple-repositioning procedure, is performed to correct soft tissue descent without removing much breast tissue (see Figure 2), while reduction mammaplasty involves removing 400 to 2,000 grams of breast tissue (see Figure 4). A patient who has had a unilateral mastectomy without reconstruction may be a candidate for reduction mammaplasty of the contralateral breast. A unilateral large breast can cause marked neck and back pain due to the asymmetry of the weight on the chest.

Augmentation. Patients with smaller breasts often will undergo a matching augmentation procedure on the contralateral breast following completion of mastectomy and reconstruction on the other side.

Prophylactic mastectomy. For some women with a very high lifetime risk of breast cancer, such as those with BRCA1 or BRCA2 gene mutations, prophylactic mastectomy of the contralateral breast or even bilateral prophylactic mastectomy may be recommended by the oncologic surgeon. In some of these selected patients with sufficient abdominal tissue, bilateral DIEP flaps may be suitable; otherwise, the reconstruction can be completed with tissue expanders and implants.

WHAT ABOUT INSURANCE COVERAGE?

As the result of a federal law enacted 10 years ago, insurance coverage should not be a concern for women who are considering breast reconstruction following mastectomy. The Women’s Health and Cancer Rights Act of 1998 requires all medical insurers that provide coverage for mastectomy to also cover all stages of reconstruction of the affected breast as well as surgery and reconstruction of the contralateral breast to produce a symmetrical appearance.¹⁰

CONCLUSION

Although breast cancer remains a significant health risk to women and can result in significant disfigurement, breast reconstruction strategies continue to improve. These strategies offer women who have undergone mastectomy some excellent options for creating a near-normal-appearing breast. Women interested in pursuing reconstruction should meet with a plastic surgeon early in the course of their breast cancer treatment planning in order to better understand the options available and make an informed and individualized choice.

Oncoplastic surgery refers to immediate or delayed breast reconstruction following partial mastectomy, also known as breast conservation therapy. The term was coined by Audretsch et al in 1998¹ and is now often referred to as oncoplasty. It involves four integral components:²

• Oncologically sound techniques of tumor removal
• Partial reconstruction of the breast to correct small defects
• Immediate reconstruction for larger defects using various principles of plastic surgery
• Creation of symmetry with the contralateral breast.

This article provides a brief overview of various procedures used for reconstruction following breast conservation therapy and the factors that guide selection among these procedures for individual patients. It concludes with a discussion of complications of oncoplastic procedures, patient counseling, and other general considerations in patient management.

THE RATIONALE FOR RECONSTRUCTION

Effects of radiation argue for immediate reconstruction

Although radiation therapy is integral to the comprehensive treatment of breast cancer after breast conservation therapy, radiation-induced changes to the breast are one of the greatest obstacles faced when delayed reconstruction is performed. Radiation results in deformation of the parenchyma, leading to retraction, fibrosis, vasculitis, and skin breakdown. The effects of radiation on breast tissue may possibly be a larger problem when reconstruction is delayed, as wound healing is inhibited and vascular supply is impaired. Therefore, immediate reconstruction should be undertaken whenever possible.⁷ (The timing of reconstruction is discussed in greater detail in the final article in this supplement, although mainly in the context of mastectomy.)

OPTIONS FOR RECONSTRUCTION

Various techniques of partial breast reconstruction can be used to achieve an aesthetically acceptable result. They can be thought of as volume-displacement procedures, such as local tissue rearrangement and reduction mammaplasty, or as volume-replacement procedures using flap reconstruction.⁸ Additionally, simple wound closure (primary closure) may be performed if small amounts of tissue can be removed without creating a noticeable defect, but simple closure is an option only for large breasts. The decision among techniques depends on a variety of factors, as delineated below.

Local tissue rearrangement

Local tissue rearrangement is defined as the use of local tissue (skin and subcutaneous and/or breast tissue) from either the breast or the axilla. This technique involves the transfer of adjacent breast parenchyma and skin to the area of the defect. It is dependent on a random blood supply and does not involve creating a parenchymal tissue pedicle.^4,5 It does rely, however, on a balance between the amount of tissue resected and the available residual breast size and volume. This procedure is not suitable for patients who require large-volume resection with a small breast or limited breast tissue.

When local tissue rearrangement is to be performed, the surgical incision needs to be planned by both the oncologic surgeon and the plastic surgeon to ensure an appropriate cosmetic outcome and prevent displacement or distortion of the nipple-areola complex. If such planning is not done, the cosmetic outcome may be compromised, thereby undermining one of the reasons for breast conservation in the first place. When full-thickness excisions of tissue are removed from a certain area of the breast—termed “no man’s land” by Grisotti and Calabrese⁷—the nipple-areola complex shifts to an unnatural position. Therefore, resections in this area, located superiomedial to the nipple, should include little or no skin.

Other techniques of tissue transposition include circumareolar incisions for tumors located adjacent to the nipple-areola complex, radially designed resections for lateral tumors, and donut-shaped resections for superior or lateral tumors.⁸

Reduction mammaplasty

Standard breast reduction techniques are used on the contralateral (uninvolved) breast. This matching procedure can be performed at the same time as the initial cancer operation or as a delayed procedure. The matching procedure is usually performed at a later date for those who need to undergo radiation therapy, allowing time for healing and for final breast volume and shape to be achieved. Reduction of the contralateral breast does not increase its risk for cancer; in fact, reduction may improve body image and make breast self-examinations and follow-up mammography easier.

Therapeutic reduction mammaplasty is highly versatile and gives a better aesthetic result in the immediate setting when compared with flap reconstruction. However, it is usually limited to patients with a brassiere cup size of D or larger.⁴

An advantage of reduction mammaplasty is that reducing the size of the affected breast facilitates postoperative radiation therapy. Some radiation oncologists are reluctant to administer radiation to a large breast because of increased toxicity to the skin and the likelihood of a poor aesthetic outcome. With reduction mammaplasty, lower radiation doses are required and the delivery of radiation is more uniform.⁴

Reduction mammaplasty is ideal for women with moderate-sized or large breasts with ptosis (sagging), for whom a reduction in size would be considered a positive outcome.¹⁰ Patients with symptomatic macromastia likewise benefit from reduction in breast volume. An additional advantage is that the reduction procedure on the contralateral breast affords the opportunity for tissue sampling from this presumedly uninvolved breast; occult carcinomas in the contralateral breast have been identified in a small percentage of patients.¹¹

At the same time, the exposure of the contralateral breast to surgery also constitutes the main disadvantage of this procedure, as both breasts are placed at risk for wound or nipple complications and the discomfort of surgery.⁹ Moreover, surgery time is also increased. Lastly, reduction mammaplasty can be offered only to patients who possess enough breast tissue to undergo reduction.¹²

Flap reconstruction is indicated in patients who have significant breast volume deficit after resection and have insufficient adjacent tissue for local tissue recruitment and rearrangement. This method of reconstruction is based on an axial blood supply, which means that a specific vascular pedicle is responsible for a given distribution of tissue. For this purpose, flaps can be either myocutaneous (muscle-skin flaps), fasciocutaneous (fascia, subcutaneous tissue, and skin) or adipocutaneous (containing fat and skin). Examples include the latissimus dorsi myocutaneous flap, the transverse thoracoepigastric skin flap, and the lateral thoracic adipocutaneous flap.^4–6

The latissimus dorsi myocutaneous flap is used most often, especially when more than 25% of the breast volume has been resected. Since a large volume of tissue is removed, either the tumor and a margin can be resected or a nipple-sparing subcutaneous mastectomy may be performed¹⁰ (nipple-sparing mastectomy would not be breast-conserving and has been discussed earlier in this supplement). This myocutaneous flap is based on the thoracodorsal vessels and was first described for volume replacement after breast-conserving surgery by Noguchi et al.¹³ A benefit of this flap is that most patients do not need reduction of the contralateral breast for symmetry, as the flap usually provides adequate tissue volume.⁴ This is beneficial for the patient, as she is not exposed to the potential complications of an operation on the contralateral breast.

The lateral thoracic adipocutaneous flap is another option. This flap has the benefit of sparing the muscle while using skin and fat from the axillary region. It can be based on one of three vascular pedicles that have been shown to be reliable as a sole blood supply. The most common pedicle for this technique is the thoracodorsal artery, as the main blood supply for the thoracodorsal artery perforator flap. This flap provides a potentially large amount of tissue for use and affords patients the chance to have a redundant roll of axillary tissue removed. This tissue can be used alone for reconstruction or in conjunction with a breast implant.⁶

One drawback of the latissimus dorsi flap is the potential for mismatch of skin color and texture when there is a need to address a significant skin deficit on the breast. Replacing a whole aesthetic unit, as opposed to only a small skin paddle, can minimize this potential; thus, using a larger amount of skin may provide a better aesthetic result. Rarely, if there is no skin defect, the muscle alone can be used, with no skin component.⁵ The lateral thoracic flap, on the other hand, may be more similar in skin color and texture to the native breast and may allow the scar to be better hidden in the axilla than is the case with the latissimus dorsi flap.⁶ Any type of flap presents potential donor site problems as well as breast complications (discussed below).

Flap reconstruction broadens the application of breast conservation therapy to women who would not otherwise be candidates because of the large volume of tissue they need to have removed.² Oncoplasty reconstruction also allows the oncologic surgeon to be more aggressive with tissue removal without concerns about compromising the aesthetic outcome. Patients with small to moderate breasts are therefore candidates for flap reconstruction, as even modest resections in such patients result in a large volume of tissue loss and the need for additional tissue to reconstruct the breast.¹⁴ Any of the aforementioned flaps are advantageous, as they are in close proximity to the breast and can readily be used for reconstruction.⁶

CHOICE OF TECHNIQUE

Many factors contribute to the choice among reconstructive methods for a particular patient after breast conservation therapy.

Tumor location plays a significant role. Kronowitz et al described using breast reduction as their primary reconstructive modality, particularly for tumors of the upper inner, upper outer, and lower inner quadrants of the breast.⁴ They used flap reconstruction only for outer-quadrant tumors, and they found that tumors of the lower outer quadrant were the largest and lent themselves to local tissue rearrangement, often with axillary tissue.⁴ Centrally located tumors usually require removal of the nipple-areola complex and can be challenging to reconstruct. The techniques include either (1) direct closure with some degree of local tissue remodeling, or (2) reduction mammaplasty. The majority of patients with centrally located tumors will need contralateral breast reduction for symmetry¹⁴ and nipple-areola reconstruction at a later date.

The size of the defect created by the tumor resection also significantly affects the choice of technique, as does the patient’s preoperative brassiere size. In the analysis by Kronowitz et al, defects smaller than 20% of the overall breast size were found to be amenable to breast reduction, whereas larger defects were reconstructed with flaps or local tissue rearrangement.⁴ Also, women with a brassiere cup size of D or larger tended to undergo breast reduction, whereas those with a size smaller than D underwent local tissue rearrangement or flap reconstruction.⁴

COMPLICATIONS

Complications of breast surgery include seromas (of the breast as well as the donor site when a flap is used), nipple necrosis, wound dehiscence, infection, hematoma, fat necrosis, and mastectomy flap necrosis. Postoperative hematomas and superficial wound infections tend to occur in the immediate postoperative period (usually within the first few days), whereas the other complications mentioned may take 1 to 2 weeks to develop. These complications are common to all breast operations and are not specific to reconstruction after breast conservation therapy.

Postoperative complications vary in frequency but are more common when reconstruction is delayed.^4,7 They also vary depending on the reconstructive technique. Donor-site seromas and fat necrosis are most common with immediate reconstruction using a flap; wound dehiscence is most common with delayed local tissue rearrangement; and breast seroma is most common with delayed reduction mammaplasty.⁴

Other issues to consider include the possible delay in adjuvant therapy in patients who experience wound healing problems, especially in those who are obese, who smoke, or who undergo therapeutic mammaplasty.^15,16 Moreover, operative time is increased with oncoplasty as compared with simple wide local excision, which increases patients’ exposure to anesthesia and thereby raises the risk of complications, particularly in older patients with comorbidities.¹⁶

Certain patient characteristics carry an increased risk for postoperative complications. These include tobacco smoking, previous breast surgeries, comorbidities that impair wound healing, and obesity.^4,15–17

The vasoconstrictive, thrombotic, and hypoxic effects of tobacco place patients who smoke at an increased risk for necrosis of the nipple-areola complex, as well as for pulmonary complications, when breast reduction is performed. The standard recommendation is cessation of smoking for 6 to 8 weeks preoperatively to reduce pulmonary risks, although rigorous scientific validation is lacking.¹⁷

Breasts that have been previously operated on have scarring of the skin and subcutaneous tissues, which may affect the surgical incision and technique. Additionally, vascular compromise of the underlying breast tissue and nipple-areola complex is a possibility in patients who have had previous breast operations.⁴ For these reasons, it is of utmost importance to obtain a full history of any previous breast procedures a patient has had.

Obesity is a risk factor for impaired wound healing, as delayed wound healing has been correlated with increased body mass index in patients undergoing breast reduction.¹⁵

What about positive margins?

Addressing positive margins can be problematic after breast conservation therapy with immediate reconstruction, as it is difficult to locate the resection margin after the breast tissue has been rearranged.^4,5,12,14 Patients who have positive margins will usually need to undergo completion mastectomy and opt for immediate reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi flap with an implant. Therefore, use of a TRAM flap for initial reconstruction after breast conservation therapy is discouraged.^4,14 If a TRAM flap is needed to restore the shape and contour of the breast after breast conservation, it is usually better to perform a mastectomy, as it provides a superior aesthetic result and reduces the risk of a subsequent malignancy since the breast tissue is removed.⁵

PATIENT COUNSELING, PREOPERATIVE PLANNING

The diagnosis of breast cancer is devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance.¹⁰ There is a psychological advantage to having reconstruction performed during the same operation as resection because the breast’s preoperative form is immediately restored and little to no asymmetry is seen postoperatively.¹² One study showed that breast cancer patients who underwent reconstructive surgery had better body images and felt they had more control over their treatment compared with patients who simply had breast conservation therapy or mastectomy without reconstruction; these perceptions also conferred a psychological benefit among the patients who had reconstructive procedures.¹⁸

At the same time, all patients need to be counseled about the potential drawbacks of reconstruction, including the possibility of reoperation for positive margins, wound complications, or a disappointing or unacceptable aesthetic outcome.

Oncoplastic surgery is a multispecialty collaboration. Good communication and preoperative planning is imperative and must include the general surgeon, plastic surgeon, oncologist, and, most importantly, the patient. Considerations in how to approach diagnostic biopsies, lymph node sampling, timing of contralateral breast symmetrizing procedures, and the possibility of positive margins all need to be discussed preoperatively.^8,10

ADDITIONAL CONSIDERATIONS

Timing of reconstruction

Immediate reconstruction is preferred for many reasons, including a reduced incidence of wound healing problems, facility in administering postoperative radiation therapy, and better aesthetic results.^3,4,11 A one-stage procedure also facilitates breast remodeling, as there is no scar tissue to deal with. Patients’ psychological trauma of coping with a deformity is also reduced because better symmetry is achieved with immediate reconstruction.¹⁰

Additionally, some authors have reported lower rates of local recurrence in breast conservation therapy patients who received immediate reconstruction, likely owing to the larger amount of tissue resected and subsequent lower incidence of positive margins.^4,11,14 Local recurrence in patients undergoing breast conservation therapy and oncoplasty is between 2% and 9%, depending on the study.^11,12

Postoperative surveillance

Postoperative surveillance can still be performed effectively despite the tissue transposition involved in any of the oncoplastic reconstruction techniques. A new baseline mammogram is obtained, to which future imaging studies are compared. Fat necrosis may appear to be new calcifications. Titanium clips may also be placed within the defect cavity so that it can be tracked to its new location. These clips also aid in localizing postoperative radiation therapy.¹¹

Patient satisfaction

Several studies have assessed patient satisfaction with breast conservation therapy without and with reconstruction. Following breast conservation therapy without reconstruction, cosmetic results are rated as poor by 15% to 20% of patients.¹⁰ Patients notice breast asymmetry and are generally dissatisfied to some degree after breast conservation with radiation therapy and no further reconstruction.³ In contrast, a survey in a series of patients who had oncoplasty found that 95% reported good aesthetic results at short-term follow-up.¹⁰ Another series found that 88% of patients undergoing oncoplastic techniques reported fair to excellent outcomes at 2 years, and 82% did so at 5 years.¹² When these patients were further analyzed, assessments of cosmetic outcomes were worse in those who received preoperative rather than postoperative radiation therapy.¹²

SUMMARY

Oncoplastic surgical approaches can be applied to the full spectrum of patients undergoing breast conservation therapy. They are particularly useful when a large defect is anticipated, when a symmetrizing procedure is desired for the contralateral breast, and when the tumor-to-breast volume ratio is unfavorable for simple closure.¹⁴ Immediate reconstruction is clearly preferred over delayed reconstruction, as it is associated with fewer complications, easier administration of postoperative radiation therapy, better aesthetic results, and possibly lower rates of local recurrence. Patients are more satisfied with the cosmetic outcome of oncoplastic procedures compared with breast conservation therapy alone. Successful oncoplasty requires thorough patient counseling and comprehensive preoperative planning among patient, oncologist, and general and plastic surgeons.

Oncoplastic surgery refers to immediate or delayed breast reconstruction following partial mastectomy, also known as breast conservation therapy. The term was coined by Audretsch et al in 1998¹ and is now often referred to as oncoplasty. It involves four integral components:²

• Oncologically sound techniques of tumor removal
• Partial reconstruction of the breast to correct small defects
• Immediate reconstruction for larger defects using various principles of plastic surgery
• Creation of symmetry with the contralateral breast.

This article provides a brief overview of various procedures used for reconstruction following breast conservation therapy and the factors that guide selection among these procedures for individual patients. It concludes with a discussion of complications of oncoplastic procedures, patient counseling, and other general considerations in patient management.

THE RATIONALE FOR RECONSTRUCTION

Effects of radiation argue for immediate reconstruction

Although radiation therapy is integral to the comprehensive treatment of breast cancer after breast conservation therapy, radiation-induced changes to the breast are one of the greatest obstacles faced when delayed reconstruction is performed. Radiation results in deformation of the parenchyma, leading to retraction, fibrosis, vasculitis, and skin breakdown. The effects of radiation on breast tissue may possibly be a larger problem when reconstruction is delayed, as wound healing is inhibited and vascular supply is impaired. Therefore, immediate reconstruction should be undertaken whenever possible.⁷ (The timing of reconstruction is discussed in greater detail in the final article in this supplement, although mainly in the context of mastectomy.)

OPTIONS FOR RECONSTRUCTION

Various techniques of partial breast reconstruction can be used to achieve an aesthetically acceptable result. They can be thought of as volume-displacement procedures, such as local tissue rearrangement and reduction mammaplasty, or as volume-replacement procedures using flap reconstruction.⁸ Additionally, simple wound closure (primary closure) may be performed if small amounts of tissue can be removed without creating a noticeable defect, but simple closure is an option only for large breasts. The decision among techniques depends on a variety of factors, as delineated below.

Local tissue rearrangement

Local tissue rearrangement is defined as the use of local tissue (skin and subcutaneous and/or breast tissue) from either the breast or the axilla. This technique involves the transfer of adjacent breast parenchyma and skin to the area of the defect. It is dependent on a random blood supply and does not involve creating a parenchymal tissue pedicle.^4,5 It does rely, however, on a balance between the amount of tissue resected and the available residual breast size and volume. This procedure is not suitable for patients who require large-volume resection with a small breast or limited breast tissue.

When local tissue rearrangement is to be performed, the surgical incision needs to be planned by both the oncologic surgeon and the plastic surgeon to ensure an appropriate cosmetic outcome and prevent displacement or distortion of the nipple-areola complex. If such planning is not done, the cosmetic outcome may be compromised, thereby undermining one of the reasons for breast conservation in the first place. When full-thickness excisions of tissue are removed from a certain area of the breast—termed “no man’s land” by Grisotti and Calabrese⁷—the nipple-areola complex shifts to an unnatural position. Therefore, resections in this area, located superiomedial to the nipple, should include little or no skin.

Other techniques of tissue transposition include circumareolar incisions for tumors located adjacent to the nipple-areola complex, radially designed resections for lateral tumors, and donut-shaped resections for superior or lateral tumors.⁸

Reduction mammaplasty

Standard breast reduction techniques are used on the contralateral (uninvolved) breast. This matching procedure can be performed at the same time as the initial cancer operation or as a delayed procedure. The matching procedure is usually performed at a later date for those who need to undergo radiation therapy, allowing time for healing and for final breast volume and shape to be achieved. Reduction of the contralateral breast does not increase its risk for cancer; in fact, reduction may improve body image and make breast self-examinations and follow-up mammography easier.

Therapeutic reduction mammaplasty is highly versatile and gives a better aesthetic result in the immediate setting when compared with flap reconstruction. However, it is usually limited to patients with a brassiere cup size of D or larger.⁴

An advantage of reduction mammaplasty is that reducing the size of the affected breast facilitates postoperative radiation therapy. Some radiation oncologists are reluctant to administer radiation to a large breast because of increased toxicity to the skin and the likelihood of a poor aesthetic outcome. With reduction mammaplasty, lower radiation doses are required and the delivery of radiation is more uniform.⁴

Reduction mammaplasty is ideal for women with moderate-sized or large breasts with ptosis (sagging), for whom a reduction in size would be considered a positive outcome.¹⁰ Patients with symptomatic macromastia likewise benefit from reduction in breast volume. An additional advantage is that the reduction procedure on the contralateral breast affords the opportunity for tissue sampling from this presumedly uninvolved breast; occult carcinomas in the contralateral breast have been identified in a small percentage of patients.¹¹

At the same time, the exposure of the contralateral breast to surgery also constitutes the main disadvantage of this procedure, as both breasts are placed at risk for wound or nipple complications and the discomfort of surgery.⁹ Moreover, surgery time is also increased. Lastly, reduction mammaplasty can be offered only to patients who possess enough breast tissue to undergo reduction.¹²

Flap reconstruction is indicated in patients who have significant breast volume deficit after resection and have insufficient adjacent tissue for local tissue recruitment and rearrangement. This method of reconstruction is based on an axial blood supply, which means that a specific vascular pedicle is responsible for a given distribution of tissue. For this purpose, flaps can be either myocutaneous (muscle-skin flaps), fasciocutaneous (fascia, subcutaneous tissue, and skin) or adipocutaneous (containing fat and skin). Examples include the latissimus dorsi myocutaneous flap, the transverse thoracoepigastric skin flap, and the lateral thoracic adipocutaneous flap.^4–6

The latissimus dorsi myocutaneous flap is used most often, especially when more than 25% of the breast volume has been resected. Since a large volume of tissue is removed, either the tumor and a margin can be resected or a nipple-sparing subcutaneous mastectomy may be performed¹⁰ (nipple-sparing mastectomy would not be breast-conserving and has been discussed earlier in this supplement). This myocutaneous flap is based on the thoracodorsal vessels and was first described for volume replacement after breast-conserving surgery by Noguchi et al.¹³ A benefit of this flap is that most patients do not need reduction of the contralateral breast for symmetry, as the flap usually provides adequate tissue volume.⁴ This is beneficial for the patient, as she is not exposed to the potential complications of an operation on the contralateral breast.

The lateral thoracic adipocutaneous flap is another option. This flap has the benefit of sparing the muscle while using skin and fat from the axillary region. It can be based on one of three vascular pedicles that have been shown to be reliable as a sole blood supply. The most common pedicle for this technique is the thoracodorsal artery, as the main blood supply for the thoracodorsal artery perforator flap. This flap provides a potentially large amount of tissue for use and affords patients the chance to have a redundant roll of axillary tissue removed. This tissue can be used alone for reconstruction or in conjunction with a breast implant.⁶

One drawback of the latissimus dorsi flap is the potential for mismatch of skin color and texture when there is a need to address a significant skin deficit on the breast. Replacing a whole aesthetic unit, as opposed to only a small skin paddle, can minimize this potential; thus, using a larger amount of skin may provide a better aesthetic result. Rarely, if there is no skin defect, the muscle alone can be used, with no skin component.⁵ The lateral thoracic flap, on the other hand, may be more similar in skin color and texture to the native breast and may allow the scar to be better hidden in the axilla than is the case with the latissimus dorsi flap.⁶ Any type of flap presents potential donor site problems as well as breast complications (discussed below).

Flap reconstruction broadens the application of breast conservation therapy to women who would not otherwise be candidates because of the large volume of tissue they need to have removed.² Oncoplasty reconstruction also allows the oncologic surgeon to be more aggressive with tissue removal without concerns about compromising the aesthetic outcome. Patients with small to moderate breasts are therefore candidates for flap reconstruction, as even modest resections in such patients result in a large volume of tissue loss and the need for additional tissue to reconstruct the breast.¹⁴ Any of the aforementioned flaps are advantageous, as they are in close proximity to the breast and can readily be used for reconstruction.⁶

CHOICE OF TECHNIQUE

Many factors contribute to the choice among reconstructive methods for a particular patient after breast conservation therapy.

Tumor location plays a significant role. Kronowitz et al described using breast reduction as their primary reconstructive modality, particularly for tumors of the upper inner, upper outer, and lower inner quadrants of the breast.⁴ They used flap reconstruction only for outer-quadrant tumors, and they found that tumors of the lower outer quadrant were the largest and lent themselves to local tissue rearrangement, often with axillary tissue.⁴ Centrally located tumors usually require removal of the nipple-areola complex and can be challenging to reconstruct. The techniques include either (1) direct closure with some degree of local tissue remodeling, or (2) reduction mammaplasty. The majority of patients with centrally located tumors will need contralateral breast reduction for symmetry¹⁴ and nipple-areola reconstruction at a later date.

The size of the defect created by the tumor resection also significantly affects the choice of technique, as does the patient’s preoperative brassiere size. In the analysis by Kronowitz et al, defects smaller than 20% of the overall breast size were found to be amenable to breast reduction, whereas larger defects were reconstructed with flaps or local tissue rearrangement.⁴ Also, women with a brassiere cup size of D or larger tended to undergo breast reduction, whereas those with a size smaller than D underwent local tissue rearrangement or flap reconstruction.⁴

COMPLICATIONS

Complications of breast surgery include seromas (of the breast as well as the donor site when a flap is used), nipple necrosis, wound dehiscence, infection, hematoma, fat necrosis, and mastectomy flap necrosis. Postoperative hematomas and superficial wound infections tend to occur in the immediate postoperative period (usually within the first few days), whereas the other complications mentioned may take 1 to 2 weeks to develop. These complications are common to all breast operations and are not specific to reconstruction after breast conservation therapy.

Postoperative complications vary in frequency but are more common when reconstruction is delayed.^4,7 They also vary depending on the reconstructive technique. Donor-site seromas and fat necrosis are most common with immediate reconstruction using a flap; wound dehiscence is most common with delayed local tissue rearrangement; and breast seroma is most common with delayed reduction mammaplasty.⁴

Other issues to consider include the possible delay in adjuvant therapy in patients who experience wound healing problems, especially in those who are obese, who smoke, or who undergo therapeutic mammaplasty.^15,16 Moreover, operative time is increased with oncoplasty as compared with simple wide local excision, which increases patients’ exposure to anesthesia and thereby raises the risk of complications, particularly in older patients with comorbidities.¹⁶

Certain patient characteristics carry an increased risk for postoperative complications. These include tobacco smoking, previous breast surgeries, comorbidities that impair wound healing, and obesity.^4,15–17

The vasoconstrictive, thrombotic, and hypoxic effects of tobacco place patients who smoke at an increased risk for necrosis of the nipple-areola complex, as well as for pulmonary complications, when breast reduction is performed. The standard recommendation is cessation of smoking for 6 to 8 weeks preoperatively to reduce pulmonary risks, although rigorous scientific validation is lacking.¹⁷

Breasts that have been previously operated on have scarring of the skin and subcutaneous tissues, which may affect the surgical incision and technique. Additionally, vascular compromise of the underlying breast tissue and nipple-areola complex is a possibility in patients who have had previous breast operations.⁴ For these reasons, it is of utmost importance to obtain a full history of any previous breast procedures a patient has had.

Obesity is a risk factor for impaired wound healing, as delayed wound healing has been correlated with increased body mass index in patients undergoing breast reduction.¹⁵

What about positive margins?

Addressing positive margins can be problematic after breast conservation therapy with immediate reconstruction, as it is difficult to locate the resection margin after the breast tissue has been rearranged.^4,5,12,14 Patients who have positive margins will usually need to undergo completion mastectomy and opt for immediate reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi flap with an implant. Therefore, use of a TRAM flap for initial reconstruction after breast conservation therapy is discouraged.^4,14 If a TRAM flap is needed to restore the shape and contour of the breast after breast conservation, it is usually better to perform a mastectomy, as it provides a superior aesthetic result and reduces the risk of a subsequent malignancy since the breast tissue is removed.⁵

PATIENT COUNSELING, PREOPERATIVE PLANNING

The diagnosis of breast cancer is devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance.¹⁰ There is a psychological advantage to having reconstruction performed during the same operation as resection because the breast’s preoperative form is immediately restored and little to no asymmetry is seen postoperatively.¹² One study showed that breast cancer patients who underwent reconstructive surgery had better body images and felt they had more control over their treatment compared with patients who simply had breast conservation therapy or mastectomy without reconstruction; these perceptions also conferred a psychological benefit among the patients who had reconstructive procedures.¹⁸

At the same time, all patients need to be counseled about the potential drawbacks of reconstruction, including the possibility of reoperation for positive margins, wound complications, or a disappointing or unacceptable aesthetic outcome.

Oncoplastic surgery is a multispecialty collaboration. Good communication and preoperative planning is imperative and must include the general surgeon, plastic surgeon, oncologist, and, most importantly, the patient. Considerations in how to approach diagnostic biopsies, lymph node sampling, timing of contralateral breast symmetrizing procedures, and the possibility of positive margins all need to be discussed preoperatively.^8,10

ADDITIONAL CONSIDERATIONS

Timing of reconstruction

Immediate reconstruction is preferred for many reasons, including a reduced incidence of wound healing problems, facility in administering postoperative radiation therapy, and better aesthetic results.^3,4,11 A one-stage procedure also facilitates breast remodeling, as there is no scar tissue to deal with. Patients’ psychological trauma of coping with a deformity is also reduced because better symmetry is achieved with immediate reconstruction.¹⁰

Additionally, some authors have reported lower rates of local recurrence in breast conservation therapy patients who received immediate reconstruction, likely owing to the larger amount of tissue resected and subsequent lower incidence of positive margins.^4,11,14 Local recurrence in patients undergoing breast conservation therapy and oncoplasty is between 2% and 9%, depending on the study.^11,12

Postoperative surveillance

Postoperative surveillance can still be performed effectively despite the tissue transposition involved in any of the oncoplastic reconstruction techniques. A new baseline mammogram is obtained, to which future imaging studies are compared. Fat necrosis may appear to be new calcifications. Titanium clips may also be placed within the defect cavity so that it can be tracked to its new location. These clips also aid in localizing postoperative radiation therapy.¹¹

Patient satisfaction

Several studies have assessed patient satisfaction with breast conservation therapy without and with reconstruction. Following breast conservation therapy without reconstruction, cosmetic results are rated as poor by 15% to 20% of patients.¹⁰ Patients notice breast asymmetry and are generally dissatisfied to some degree after breast conservation with radiation therapy and no further reconstruction.³ In contrast, a survey in a series of patients who had oncoplasty found that 95% reported good aesthetic results at short-term follow-up.¹⁰ Another series found that 88% of patients undergoing oncoplastic techniques reported fair to excellent outcomes at 2 years, and 82% did so at 5 years.¹² When these patients were further analyzed, assessments of cosmetic outcomes were worse in those who received preoperative rather than postoperative radiation therapy.¹²

SUMMARY

Oncoplastic surgical approaches can be applied to the full spectrum of patients undergoing breast conservation therapy. They are particularly useful when a large defect is anticipated, when a symmetrizing procedure is desired for the contralateral breast, and when the tumor-to-breast volume ratio is unfavorable for simple closure.¹⁴ Immediate reconstruction is clearly preferred over delayed reconstruction, as it is associated with fewer complications, easier administration of postoperative radiation therapy, better aesthetic results, and possibly lower rates of local recurrence. Patients are more satisfied with the cosmetic outcome of oncoplastic procedures compared with breast conservation therapy alone. Successful oncoplasty requires thorough patient counseling and comprehensive preoperative planning among patient, oncologist, and general and plastic surgeons.

Oncoplastic surgery refers to immediate or delayed breast reconstruction following partial mastectomy, also known as breast conservation therapy. The term was coined by Audretsch et al in 1998¹ and is now often referred to as oncoplasty. It involves four integral components:²

• Oncologically sound techniques of tumor removal
• Partial reconstruction of the breast to correct small defects
• Immediate reconstruction for larger defects using various principles of plastic surgery
• Creation of symmetry with the contralateral breast.

This article provides a brief overview of various procedures used for reconstruction following breast conservation therapy and the factors that guide selection among these procedures for individual patients. It concludes with a discussion of complications of oncoplastic procedures, patient counseling, and other general considerations in patient management.

THE RATIONALE FOR RECONSTRUCTION

Effects of radiation argue for immediate reconstruction

Although radiation therapy is integral to the comprehensive treatment of breast cancer after breast conservation therapy, radiation-induced changes to the breast are one of the greatest obstacles faced when delayed reconstruction is performed. Radiation results in deformation of the parenchyma, leading to retraction, fibrosis, vasculitis, and skin breakdown. The effects of radiation on breast tissue may possibly be a larger problem when reconstruction is delayed, as wound healing is inhibited and vascular supply is impaired. Therefore, immediate reconstruction should be undertaken whenever possible.⁷ (The timing of reconstruction is discussed in greater detail in the final article in this supplement, although mainly in the context of mastectomy.)

OPTIONS FOR RECONSTRUCTION

Various techniques of partial breast reconstruction can be used to achieve an aesthetically acceptable result. They can be thought of as volume-displacement procedures, such as local tissue rearrangement and reduction mammaplasty, or as volume-replacement procedures using flap reconstruction.⁸ Additionally, simple wound closure (primary closure) may be performed if small amounts of tissue can be removed without creating a noticeable defect, but simple closure is an option only for large breasts. The decision among techniques depends on a variety of factors, as delineated below.

Local tissue rearrangement

Local tissue rearrangement is defined as the use of local tissue (skin and subcutaneous and/or breast tissue) from either the breast or the axilla. This technique involves the transfer of adjacent breast parenchyma and skin to the area of the defect. It is dependent on a random blood supply and does not involve creating a parenchymal tissue pedicle.^4,5 It does rely, however, on a balance between the amount of tissue resected and the available residual breast size and volume. This procedure is not suitable for patients who require large-volume resection with a small breast or limited breast tissue.

When local tissue rearrangement is to be performed, the surgical incision needs to be planned by both the oncologic surgeon and the plastic surgeon to ensure an appropriate cosmetic outcome and prevent displacement or distortion of the nipple-areola complex. If such planning is not done, the cosmetic outcome may be compromised, thereby undermining one of the reasons for breast conservation in the first place. When full-thickness excisions of tissue are removed from a certain area of the breast—termed “no man’s land” by Grisotti and Calabrese⁷—the nipple-areola complex shifts to an unnatural position. Therefore, resections in this area, located superiomedial to the nipple, should include little or no skin.

Other techniques of tissue transposition include circumareolar incisions for tumors located adjacent to the nipple-areola complex, radially designed resections for lateral tumors, and donut-shaped resections for superior or lateral tumors.⁸

Reduction mammaplasty

Standard breast reduction techniques are used on the contralateral (uninvolved) breast. This matching procedure can be performed at the same time as the initial cancer operation or as a delayed procedure. The matching procedure is usually performed at a later date for those who need to undergo radiation therapy, allowing time for healing and for final breast volume and shape to be achieved. Reduction of the contralateral breast does not increase its risk for cancer; in fact, reduction may improve body image and make breast self-examinations and follow-up mammography easier.

Therapeutic reduction mammaplasty is highly versatile and gives a better aesthetic result in the immediate setting when compared with flap reconstruction. However, it is usually limited to patients with a brassiere cup size of D or larger.⁴

An advantage of reduction mammaplasty is that reducing the size of the affected breast facilitates postoperative radiation therapy. Some radiation oncologists are reluctant to administer radiation to a large breast because of increased toxicity to the skin and the likelihood of a poor aesthetic outcome. With reduction mammaplasty, lower radiation doses are required and the delivery of radiation is more uniform.⁴

Reduction mammaplasty is ideal for women with moderate-sized or large breasts with ptosis (sagging), for whom a reduction in size would be considered a positive outcome.¹⁰ Patients with symptomatic macromastia likewise benefit from reduction in breast volume. An additional advantage is that the reduction procedure on the contralateral breast affords the opportunity for tissue sampling from this presumedly uninvolved breast; occult carcinomas in the contralateral breast have been identified in a small percentage of patients.¹¹

At the same time, the exposure of the contralateral breast to surgery also constitutes the main disadvantage of this procedure, as both breasts are placed at risk for wound or nipple complications and the discomfort of surgery.⁹ Moreover, surgery time is also increased. Lastly, reduction mammaplasty can be offered only to patients who possess enough breast tissue to undergo reduction.¹²

Flap reconstruction is indicated in patients who have significant breast volume deficit after resection and have insufficient adjacent tissue for local tissue recruitment and rearrangement. This method of reconstruction is based on an axial blood supply, which means that a specific vascular pedicle is responsible for a given distribution of tissue. For this purpose, flaps can be either myocutaneous (muscle-skin flaps), fasciocutaneous (fascia, subcutaneous tissue, and skin) or adipocutaneous (containing fat and skin). Examples include the latissimus dorsi myocutaneous flap, the transverse thoracoepigastric skin flap, and the lateral thoracic adipocutaneous flap.^4–6

The latissimus dorsi myocutaneous flap is used most often, especially when more than 25% of the breast volume has been resected. Since a large volume of tissue is removed, either the tumor and a margin can be resected or a nipple-sparing subcutaneous mastectomy may be performed¹⁰ (nipple-sparing mastectomy would not be breast-conserving and has been discussed earlier in this supplement). This myocutaneous flap is based on the thoracodorsal vessels and was first described for volume replacement after breast-conserving surgery by Noguchi et al.¹³ A benefit of this flap is that most patients do not need reduction of the contralateral breast for symmetry, as the flap usually provides adequate tissue volume.⁴ This is beneficial for the patient, as she is not exposed to the potential complications of an operation on the contralateral breast.

The lateral thoracic adipocutaneous flap is another option. This flap has the benefit of sparing the muscle while using skin and fat from the axillary region. It can be based on one of three vascular pedicles that have been shown to be reliable as a sole blood supply. The most common pedicle for this technique is the thoracodorsal artery, as the main blood supply for the thoracodorsal artery perforator flap. This flap provides a potentially large amount of tissue for use and affords patients the chance to have a redundant roll of axillary tissue removed. This tissue can be used alone for reconstruction or in conjunction with a breast implant.⁶

One drawback of the latissimus dorsi flap is the potential for mismatch of skin color and texture when there is a need to address a significant skin deficit on the breast. Replacing a whole aesthetic unit, as opposed to only a small skin paddle, can minimize this potential; thus, using a larger amount of skin may provide a better aesthetic result. Rarely, if there is no skin defect, the muscle alone can be used, with no skin component.⁵ The lateral thoracic flap, on the other hand, may be more similar in skin color and texture to the native breast and may allow the scar to be better hidden in the axilla than is the case with the latissimus dorsi flap.⁶ Any type of flap presents potential donor site problems as well as breast complications (discussed below).

Flap reconstruction broadens the application of breast conservation therapy to women who would not otherwise be candidates because of the large volume of tissue they need to have removed.² Oncoplasty reconstruction also allows the oncologic surgeon to be more aggressive with tissue removal without concerns about compromising the aesthetic outcome. Patients with small to moderate breasts are therefore candidates for flap reconstruction, as even modest resections in such patients result in a large volume of tissue loss and the need for additional tissue to reconstruct the breast.¹⁴ Any of the aforementioned flaps are advantageous, as they are in close proximity to the breast and can readily be used for reconstruction.⁶

CHOICE OF TECHNIQUE

Many factors contribute to the choice among reconstructive methods for a particular patient after breast conservation therapy.

Tumor location plays a significant role. Kronowitz et al described using breast reduction as their primary reconstructive modality, particularly for tumors of the upper inner, upper outer, and lower inner quadrants of the breast.⁴ They used flap reconstruction only for outer-quadrant tumors, and they found that tumors of the lower outer quadrant were the largest and lent themselves to local tissue rearrangement, often with axillary tissue.⁴ Centrally located tumors usually require removal of the nipple-areola complex and can be challenging to reconstruct. The techniques include either (1) direct closure with some degree of local tissue remodeling, or (2) reduction mammaplasty. The majority of patients with centrally located tumors will need contralateral breast reduction for symmetry¹⁴ and nipple-areola reconstruction at a later date.

The size of the defect created by the tumor resection also significantly affects the choice of technique, as does the patient’s preoperative brassiere size. In the analysis by Kronowitz et al, defects smaller than 20% of the overall breast size were found to be amenable to breast reduction, whereas larger defects were reconstructed with flaps or local tissue rearrangement.⁴ Also, women with a brassiere cup size of D or larger tended to undergo breast reduction, whereas those with a size smaller than D underwent local tissue rearrangement or flap reconstruction.⁴

COMPLICATIONS

Complications of breast surgery include seromas (of the breast as well as the donor site when a flap is used), nipple necrosis, wound dehiscence, infection, hematoma, fat necrosis, and mastectomy flap necrosis. Postoperative hematomas and superficial wound infections tend to occur in the immediate postoperative period (usually within the first few days), whereas the other complications mentioned may take 1 to 2 weeks to develop. These complications are common to all breast operations and are not specific to reconstruction after breast conservation therapy.

Postoperative complications vary in frequency but are more common when reconstruction is delayed.^4,7 They also vary depending on the reconstructive technique. Donor-site seromas and fat necrosis are most common with immediate reconstruction using a flap; wound dehiscence is most common with delayed local tissue rearrangement; and breast seroma is most common with delayed reduction mammaplasty.⁴

Other issues to consider include the possible delay in adjuvant therapy in patients who experience wound healing problems, especially in those who are obese, who smoke, or who undergo therapeutic mammaplasty.^15,16 Moreover, operative time is increased with oncoplasty as compared with simple wide local excision, which increases patients’ exposure to anesthesia and thereby raises the risk of complications, particularly in older patients with comorbidities.¹⁶

Certain patient characteristics carry an increased risk for postoperative complications. These include tobacco smoking, previous breast surgeries, comorbidities that impair wound healing, and obesity.^4,15–17

The vasoconstrictive, thrombotic, and hypoxic effects of tobacco place patients who smoke at an increased risk for necrosis of the nipple-areola complex, as well as for pulmonary complications, when breast reduction is performed. The standard recommendation is cessation of smoking for 6 to 8 weeks preoperatively to reduce pulmonary risks, although rigorous scientific validation is lacking.¹⁷

Breasts that have been previously operated on have scarring of the skin and subcutaneous tissues, which may affect the surgical incision and technique. Additionally, vascular compromise of the underlying breast tissue and nipple-areola complex is a possibility in patients who have had previous breast operations.⁴ For these reasons, it is of utmost importance to obtain a full history of any previous breast procedures a patient has had.

Obesity is a risk factor for impaired wound healing, as delayed wound healing has been correlated with increased body mass index in patients undergoing breast reduction.¹⁵

What about positive margins?

Addressing positive margins can be problematic after breast conservation therapy with immediate reconstruction, as it is difficult to locate the resection margin after the breast tissue has been rearranged.^4,5,12,14 Patients who have positive margins will usually need to undergo completion mastectomy and opt for immediate reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi flap with an implant. Therefore, use of a TRAM flap for initial reconstruction after breast conservation therapy is discouraged.^4,14 If a TRAM flap is needed to restore the shape and contour of the breast after breast conservation, it is usually better to perform a mastectomy, as it provides a superior aesthetic result and reduces the risk of a subsequent malignancy since the breast tissue is removed.⁵

PATIENT COUNSELING, PREOPERATIVE PLANNING

The diagnosis of breast cancer is devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance.¹⁰ There is a psychological advantage to having reconstruction performed during the same operation as resection because the breast’s preoperative form is immediately restored and little to no asymmetry is seen postoperatively.¹² One study showed that breast cancer patients who underwent reconstructive surgery had better body images and felt they had more control over their treatment compared with patients who simply had breast conservation therapy or mastectomy without reconstruction; these perceptions also conferred a psychological benefit among the patients who had reconstructive procedures.¹⁸

At the same time, all patients need to be counseled about the potential drawbacks of reconstruction, including the possibility of reoperation for positive margins, wound complications, or a disappointing or unacceptable aesthetic outcome.

Oncoplastic surgery is a multispecialty collaboration. Good communication and preoperative planning is imperative and must include the general surgeon, plastic surgeon, oncologist, and, most importantly, the patient. Considerations in how to approach diagnostic biopsies, lymph node sampling, timing of contralateral breast symmetrizing procedures, and the possibility of positive margins all need to be discussed preoperatively.^8,10

ADDITIONAL CONSIDERATIONS

Timing of reconstruction

Immediate reconstruction is preferred for many reasons, including a reduced incidence of wound healing problems, facility in administering postoperative radiation therapy, and better aesthetic results.^3,4,11 A one-stage procedure also facilitates breast remodeling, as there is no scar tissue to deal with. Patients’ psychological trauma of coping with a deformity is also reduced because better symmetry is achieved with immediate reconstruction.¹⁰

Additionally, some authors have reported lower rates of local recurrence in breast conservation therapy patients who received immediate reconstruction, likely owing to the larger amount of tissue resected and subsequent lower incidence of positive margins.^4,11,14 Local recurrence in patients undergoing breast conservation therapy and oncoplasty is between 2% and 9%, depending on the study.^11,12

Postoperative surveillance

Postoperative surveillance can still be performed effectively despite the tissue transposition involved in any of the oncoplastic reconstruction techniques. A new baseline mammogram is obtained, to which future imaging studies are compared. Fat necrosis may appear to be new calcifications. Titanium clips may also be placed within the defect cavity so that it can be tracked to its new location. These clips also aid in localizing postoperative radiation therapy.¹¹

Patient satisfaction

Several studies have assessed patient satisfaction with breast conservation therapy without and with reconstruction. Following breast conservation therapy without reconstruction, cosmetic results are rated as poor by 15% to 20% of patients.¹⁰ Patients notice breast asymmetry and are generally dissatisfied to some degree after breast conservation with radiation therapy and no further reconstruction.³ In contrast, a survey in a series of patients who had oncoplasty found that 95% reported good aesthetic results at short-term follow-up.¹⁰ Another series found that 88% of patients undergoing oncoplastic techniques reported fair to excellent outcomes at 2 years, and 82% did so at 5 years.¹² When these patients were further analyzed, assessments of cosmetic outcomes were worse in those who received preoperative rather than postoperative radiation therapy.¹²

SUMMARY

Oncoplastic surgical approaches can be applied to the full spectrum of patients undergoing breast conservation therapy. They are particularly useful when a large defect is anticipated, when a symmetrizing procedure is desired for the contralateral breast, and when the tumor-to-breast volume ratio is unfavorable for simple closure.¹⁴ Immediate reconstruction is clearly preferred over delayed reconstruction, as it is associated with fewer complications, easier administration of postoperative radiation therapy, better aesthetic results, and possibly lower rates of local recurrence. Patients are more satisfied with the cosmetic outcome of oncoplastic procedures compared with breast conservation therapy alone. Successful oncoplasty requires thorough patient counseling and comprehensive preoperative planning among patient, oncologist, and general and plastic surgeons.

Timing of breast reconstruction after mastectomy involves many factors that are important in choosing between three options—immediate, delayed, or “delayed-immediate” reconstruction.

Immediate reconstruction is performed at the time of initial breast cancer surgery and allows for joint planning of incisions between the oncologic and plastic surgery teams. This produces the optimal aesthetic result since it allows for preservation of the breast skin envelope and sometimes for nipple preservation, and is oncologically safe for patients treated for cure of their cancers.

Delayed reconstruction involves initially performing a mastectomy and then determining the need for postmastectomy radiation, which cannot be assessed until review of permanent sections on pathology. Reconstruction is then performed after chemotherapy, radiation therapy, or both (if needed) are completed.

Delayed-immediate reconstruction involves placing a tissue expander at the time of skin-sparing mastectomy to preserve the breast skin envelope. After the final pathology is reviewed following mastectomy, immediate reconstruction is performed if the patient does not require postmastectomy radiation therapy. If radiation therapy is required, then the patient undergoes standard delayed reconstruction after the radiation therapy is completed. This allows for skin conservation, thereby improving aesthetic outcome, while still allowing final reconstructive decisions to be made after it is determined whether radiation will be required.

IMMEDIATE RECONSTRUCTION: WHEN INDICATED, THE OPTION WITH THE BEST AESTHETIC RESULTS

Currently, the majority of breast reconstructions are performed as immediate reconstructions at the time of mastectomy. Immediate reconstruction is a routine consideration for patients suspected to have stage 0, I, or IIA breast cancers (see table in the article on staging and surgical treatment by Hammer et al). These patients with early-stage cancer represent more than 70% of women who undergo mastectomy. Less-extensive resection of the breast skin by oncologic surgeons and the development of reconstructive options by plastic surgeons have improved quality of life for breast cancer patients.¹ Nipple-sparing mastectomy in selected patients is associated with high levels of patient satisfaction, improved aesthetic outcomes, and oncologic safety in the setting of early-stage tumors with no skin involvement.²

Oncologic safety is established

Numerous factors affect patient decision-making regarding reconstruction. The primary reason patients elect not to undergo immediate reconstruction is fear that reconstruction will hamper the ability to detect a cancer recurrence. In addition, patients as well as many physicians may have the unfounded fear that cancer cells can remain viable in the mastectomy bed and therefore that immediate reconstruction is ill-advised.

Multiple studies have shown that immediate reconstruction is oncologically safe after mastectomy, even in patients with locally advanced breast cancer.

In a study of 540 patients who underwent immediate reconstruction following mastectomy, Newman et al identified 50 patients with locally advanced breast cancer; all of these patients received postoperative chemotherapy, and 40% received postoperative radiation therapy as determined by tumor characteristics.³ At median follow-up of 58.5 months, there were no differences in either local or distant recurrence between these 50 patients and 72 matched patients with locally advanced breast cancer who did not undergo immediate reconstruction but received standard chemotherapy and radiation therapy for locally advanced disease.³

Similarly, a study by Langstein et al demonstrated that immediate reconstruction does not delay detection of cancer recurrence in the chest wall, in that the time to diagnosis of recurrence was similar whether patients underwent immediate reconstruction or not.⁴ No differences in local recurrence rates were noted based on the type of reconstruction performed (autologous flaps or implants). In addition, most cases of chest wall recurrence were associated with distant metastatic disease.⁴

Importance of physician input, other factors

Physician input is of vital importance to the patient considering mastectomy with immediate reconstruction. Traditionally, many patients have been advised by their health care providers to wait until mastectomy and chemotherapy or radiation therapy are complete before considering reconstruction. After undergoing such physically and emotionally exhausting treatments, however, patients are often spent and have no interest in undergoing another surgical procedure. Proper counseling by physicians—including the explanation that immediate reconstruction is associated with no difference in recurrence or survival outcomes compared with delayed reconstruction or no reconstruction at all—is essential to allay the fear of recurrence or death that often guides patients’ decision-making.

Indeed, a recent questionnaire-based study of factors influencing mastectomy patients’ choices regarding reconstruction found that patients regarded their surgeon’s advice as the most important factor.¹ Moreover, women in the study who chose to undergo reconstruction were more likely than women who chose mastectomy alone to identify their surgeon’s advice as the most important influencing factor. These women who chose reconstruction also were more likely than those not choosing reconstruction to have discussed their decision with their partner and to express interest in meeting other women who had undergone mastectomy. The study’s quality-of-life assessment demonstrated that women who chose reconstruction were in better physical health, placed more importance on body image and sexuality, and were less afraid of surgery compared with those not choosing reconstruction.¹

The type of cancerous lesion also contributes to patient decision-making regarding immediate reconstruction. Patients with ductal carcinoma in situ are twice as likely to choose immediate reconstruction as those with invasive cancer.⁵ Age plays an important role as well. Younger patients are more likely to elect to undergo reconstruction, with patients younger than age 50 having a 4.3-fold greater likelihood of choosing reconstruction than their older counterparts.⁵

Preoperative evaluation and postoperative histologic lymph node status determine the potential need for adjuvant therapy and facilitate optimal surgical decision-making. Chemotherapy usually begins within 30 to 40 days after surgery but can be delayed up to 12 weeks. Thus, a reconstruction that will be healed within this time frame is ideal. Reconstruction choices that involve well-vascularized tissue will optimize healing prior to chemotherapy. Chemotherapy cannot be started in the presence of seroma, infection, or necrotic tissue. In cases of breast conservation surgery and radiation therapy only, radiation can be delayed up to 8 weeks for complete healing prior to its commencement.

In a patient who will require radiation, autologous reconstruction (using the patient’s own tissue) is preferable to tissue expander and implant reconstruction. Indications for radiation after mastectomy include tumor invasion of the chest wall, invasive cancers larger than 5 centimeters, and, in some cases, positive lymph nodes. Patients who undergo radiation of an autologous flap often have some shrinkage of the flap volume. Dense scar formation, capsular contraction, and implant extrusion may occur with radiation of implants, leading to a poor cosmetic outcome. Implant reconstructions that fail for these reasons are best corrected by autologous means.

Another consideration that should be addressed between the oncologic surgeon and the plastic surgeon is the possibility of an axillary lymph node dissection after reconstruction in the event of a positive sentinel node biopsy. If the oncologic surgeon must return to the axilla for removal of nodes after reconstruction, cooperation is needed between the two teams for incision planning and dissection. This is especially true in cases of microvascular free-tissue transfer reconstruction, in which vessels in the axilla are used for anastomosis. Recent data suggest that most microsurgery practitioners prefer to use the internal mammary vessels to avoid the need to return for another operation involving the axilla, which can jeopardize flap viability.⁶

DELAYED RECONSTRUCTION: A VIABLE OPTION REQUIRING REALISTIC EXPECTATIONS

Although reconstruction at the time of mastectomy is the preferred approach at present, delayed reconstruction in a patient who previously had a mastectomy is also a viable option. Since surgical therapy for breast cancer has been practiced long before reconstructive procedures were in widespread use, many patients were not offered any reconstructive options at the time of mastectomy. Other patients chose to delay reconstruction until after radiation therapy and/or chemotherapy were completed.

Why patients may choose to delay

Delayed reconstruction may be preferable for patients who are not ready to make a decision at the time of initial surgery as a result of the overwhelming news of their cancer diagnosis and the many treatment options they have to consider. These patients may benefit from first focusing on treatment of their cancer and reserving consideration of reconstruction for later. In other cases, patients with multiple medical comorbidities may benefit from a staged procedure to minimize the length of surgery. It should be recognized, however, that if reconstruction is not performed at the time of initial mastectomy, the likelihood that it ultimately will be performed may be significantly reduced.

What prompts the decision to eventually seek reconstruction?

The goals of patients seeking delayed reconstruction are numerous. Some express a desire to put the “cancer phase” of their life behind them, while others hope to escape the stigma of being different. Generally these women wish to think, feel, and carry on their lives as they did before their mastectomy. In addition, patients may desire a tangible, lasting result to symbolize that their treatment is finished. In the late phase of the recovery process, breast reconstruction may be viewed as a healthy route of return to the patient’s “normal” life before cancer.

It is important for mastectomy patients to know that they are still candidates for breast reconstruction as a delayed procedure, even if their mastectomy was performed in the distant past.

Expectations must be tempered

The goal of delayed-immediate reconstruction is to optimize reconstruction in patients who are at risk of needing postmastectomy radiation therapy, since it is not known until after review of permanent sections, several days following mastectomy, whether these patients will require radiation.

The rationale

If immediate reconstruction is performed and the patient is found to have pathologic lymph node involvement, postoperative radiation therapy may compromise aesthetic results. Additionally, the reconstructed breast may pose technical difficulties in terms of delivery of radiation to the internal mammary nodes. At the same time, if breast reconstruction is delayed and final pathology review shows that radiation is not indicated, the mastectomy skin and shape of the breast skin envelope will be lost (and the aesthetic outcome compromised) unless measures are taken to preserve them.⁷

The protocol at a glance

Those measures to preserve the breast skin envelope consist of placement of a tissue expander at the time of mastectomy, pending final pathology results. If no radiation therapy is needed, the optimal reconstructive procedure can be chosen and performed within the next 1 to 2 weeks. If radiation is necessary, the expander can be deflated in the clinic before initiation of radiation therapy, to optimize radiation delivery to the internal mammary nodes. The expander can then be serially expanded after radiation, and delayed reconstruction with an autologous flap can be performed at a later date. Delayed-immediate reconstruction also offers the opportunity to revise the inframammary crease and debride any nonviable mastectomy skin.

Insurance coverage is federally mandated

Patients should be aware that the Women’s Health and Cancer Rights Act of 1998 (see article by Djohan et al earlier in this supplement) applies to delayed and delayed-immediate reconstruction as well as to immediate reconstruction, requiring that medical insurers that cover mastectomy cover these procedures as well.

CONCLUSIONS

The timing of breast reconstruction is determined primarily by patient factors and the necessity for postmastectomy radiation therapy. If the risk of needing postmastectomy radiation is low, then immediate reconstruction produces the optimal aesthetic outcome. The main advantage of immediate reconstruction is the availability of relatively supple nonscarred tissue that can be recruited for reconstruction. If the risk of needing postmastectomy radiation is high, then delayed reconstruction is preferable to optimize both radiation delivery and aesthetic outcome. Delayed reconstruction is somewhat more challenging, as it involves well-healed scar tissue that is already retracted and adherent to the chest. Nevertheless, reconstruction remains possible at this point and options depend on tissue quality and the plastic surgeon’s expertise. For patients with an increased risk of needing postmastectomy radiation, delayed-immediate reconstruction represents a viable approach that optimizes oncologic as well as aesthetic outcomes regardless of whether the patient ultimately does or does not need radiation therapy.

Timing of breast reconstruction after mastectomy involves many factors that are important in choosing between three options—immediate, delayed, or “delayed-immediate” reconstruction.

Immediate reconstruction is performed at the time of initial breast cancer surgery and allows for joint planning of incisions between the oncologic and plastic surgery teams. This produces the optimal aesthetic result since it allows for preservation of the breast skin envelope and sometimes for nipple preservation, and is oncologically safe for patients treated for cure of their cancers.

Delayed reconstruction involves initially performing a mastectomy and then determining the need for postmastectomy radiation, which cannot be assessed until review of permanent sections on pathology. Reconstruction is then performed after chemotherapy, radiation therapy, or both (if needed) are completed.

Delayed-immediate reconstruction involves placing a tissue expander at the time of skin-sparing mastectomy to preserve the breast skin envelope. After the final pathology is reviewed following mastectomy, immediate reconstruction is performed if the patient does not require postmastectomy radiation therapy. If radiation therapy is required, then the patient undergoes standard delayed reconstruction after the radiation therapy is completed. This allows for skin conservation, thereby improving aesthetic outcome, while still allowing final reconstructive decisions to be made after it is determined whether radiation will be required.

IMMEDIATE RECONSTRUCTION: WHEN INDICATED, THE OPTION WITH THE BEST AESTHETIC RESULTS

Currently, the majority of breast reconstructions are performed as immediate reconstructions at the time of mastectomy. Immediate reconstruction is a routine consideration for patients suspected to have stage 0, I, or IIA breast cancers (see table in the article on staging and surgical treatment by Hammer et al). These patients with early-stage cancer represent more than 70% of women who undergo mastectomy. Less-extensive resection of the breast skin by oncologic surgeons and the development of reconstructive options by plastic surgeons have improved quality of life for breast cancer patients.¹ Nipple-sparing mastectomy in selected patients is associated with high levels of patient satisfaction, improved aesthetic outcomes, and oncologic safety in the setting of early-stage tumors with no skin involvement.²

Oncologic safety is established

Numerous factors affect patient decision-making regarding reconstruction. The primary reason patients elect not to undergo immediate reconstruction is fear that reconstruction will hamper the ability to detect a cancer recurrence. In addition, patients as well as many physicians may have the unfounded fear that cancer cells can remain viable in the mastectomy bed and therefore that immediate reconstruction is ill-advised.

Multiple studies have shown that immediate reconstruction is oncologically safe after mastectomy, even in patients with locally advanced breast cancer.

In a study of 540 patients who underwent immediate reconstruction following mastectomy, Newman et al identified 50 patients with locally advanced breast cancer; all of these patients received postoperative chemotherapy, and 40% received postoperative radiation therapy as determined by tumor characteristics.³ At median follow-up of 58.5 months, there were no differences in either local or distant recurrence between these 50 patients and 72 matched patients with locally advanced breast cancer who did not undergo immediate reconstruction but received standard chemotherapy and radiation therapy for locally advanced disease.³

Similarly, a study by Langstein et al demonstrated that immediate reconstruction does not delay detection of cancer recurrence in the chest wall, in that the time to diagnosis of recurrence was similar whether patients underwent immediate reconstruction or not.⁴ No differences in local recurrence rates were noted based on the type of reconstruction performed (autologous flaps or implants). In addition, most cases of chest wall recurrence were associated with distant metastatic disease.⁴

Importance of physician input, other factors

Physician input is of vital importance to the patient considering mastectomy with immediate reconstruction. Traditionally, many patients have been advised by their health care providers to wait until mastectomy and chemotherapy or radiation therapy are complete before considering reconstruction. After undergoing such physically and emotionally exhausting treatments, however, patients are often spent and have no interest in undergoing another surgical procedure. Proper counseling by physicians—including the explanation that immediate reconstruction is associated with no difference in recurrence or survival outcomes compared with delayed reconstruction or no reconstruction at all—is essential to allay the fear of recurrence or death that often guides patients’ decision-making.

Indeed, a recent questionnaire-based study of factors influencing mastectomy patients’ choices regarding reconstruction found that patients regarded their surgeon’s advice as the most important factor.¹ Moreover, women in the study who chose to undergo reconstruction were more likely than women who chose mastectomy alone to identify their surgeon’s advice as the most important influencing factor. These women who chose reconstruction also were more likely than those not choosing reconstruction to have discussed their decision with their partner and to express interest in meeting other women who had undergone mastectomy. The study’s quality-of-life assessment demonstrated that women who chose reconstruction were in better physical health, placed more importance on body image and sexuality, and were less afraid of surgery compared with those not choosing reconstruction.¹

The type of cancerous lesion also contributes to patient decision-making regarding immediate reconstruction. Patients with ductal carcinoma in situ are twice as likely to choose immediate reconstruction as those with invasive cancer.⁵ Age plays an important role as well. Younger patients are more likely to elect to undergo reconstruction, with patients younger than age 50 having a 4.3-fold greater likelihood of choosing reconstruction than their older counterparts.⁵

Preoperative evaluation and postoperative histologic lymph node status determine the potential need for adjuvant therapy and facilitate optimal surgical decision-making. Chemotherapy usually begins within 30 to 40 days after surgery but can be delayed up to 12 weeks. Thus, a reconstruction that will be healed within this time frame is ideal. Reconstruction choices that involve well-vascularized tissue will optimize healing prior to chemotherapy. Chemotherapy cannot be started in the presence of seroma, infection, or necrotic tissue. In cases of breast conservation surgery and radiation therapy only, radiation can be delayed up to 8 weeks for complete healing prior to its commencement.

In a patient who will require radiation, autologous reconstruction (using the patient’s own tissue) is preferable to tissue expander and implant reconstruction. Indications for radiation after mastectomy include tumor invasion of the chest wall, invasive cancers larger than 5 centimeters, and, in some cases, positive lymph nodes. Patients who undergo radiation of an autologous flap often have some shrinkage of the flap volume. Dense scar formation, capsular contraction, and implant extrusion may occur with radiation of implants, leading to a poor cosmetic outcome. Implant reconstructions that fail for these reasons are best corrected by autologous means.

Another consideration that should be addressed between the oncologic surgeon and the plastic surgeon is the possibility of an axillary lymph node dissection after reconstruction in the event of a positive sentinel node biopsy. If the oncologic surgeon must return to the axilla for removal of nodes after reconstruction, cooperation is needed between the two teams for incision planning and dissection. This is especially true in cases of microvascular free-tissue transfer reconstruction, in which vessels in the axilla are used for anastomosis. Recent data suggest that most microsurgery practitioners prefer to use the internal mammary vessels to avoid the need to return for another operation involving the axilla, which can jeopardize flap viability.⁶

DELAYED RECONSTRUCTION: A VIABLE OPTION REQUIRING REALISTIC EXPECTATIONS

Although reconstruction at the time of mastectomy is the preferred approach at present, delayed reconstruction in a patient who previously had a mastectomy is also a viable option. Since surgical therapy for breast cancer has been practiced long before reconstructive procedures were in widespread use, many patients were not offered any reconstructive options at the time of mastectomy. Other patients chose to delay reconstruction until after radiation therapy and/or chemotherapy were completed.

Why patients may choose to delay

Delayed reconstruction may be preferable for patients who are not ready to make a decision at the time of initial surgery as a result of the overwhelming news of their cancer diagnosis and the many treatment options they have to consider. These patients may benefit from first focusing on treatment of their cancer and reserving consideration of reconstruction for later. In other cases, patients with multiple medical comorbidities may benefit from a staged procedure to minimize the length of surgery. It should be recognized, however, that if reconstruction is not performed at the time of initial mastectomy, the likelihood that it ultimately will be performed may be significantly reduced.

What prompts the decision to eventually seek reconstruction?

The goals of patients seeking delayed reconstruction are numerous. Some express a desire to put the “cancer phase” of their life behind them, while others hope to escape the stigma of being different. Generally these women wish to think, feel, and carry on their lives as they did before their mastectomy. In addition, patients may desire a tangible, lasting result to symbolize that their treatment is finished. In the late phase of the recovery process, breast reconstruction may be viewed as a healthy route of return to the patient’s “normal” life before cancer.

It is important for mastectomy patients to know that they are still candidates for breast reconstruction as a delayed procedure, even if their mastectomy was performed in the distant past.

Expectations must be tempered

The goal of delayed-immediate reconstruction is to optimize reconstruction in patients who are at risk of needing postmastectomy radiation therapy, since it is not known until after review of permanent sections, several days following mastectomy, whether these patients will require radiation.

The rationale

If immediate reconstruction is performed and the patient is found to have pathologic lymph node involvement, postoperative radiation therapy may compromise aesthetic results. Additionally, the reconstructed breast may pose technical difficulties in terms of delivery of radiation to the internal mammary nodes. At the same time, if breast reconstruction is delayed and final pathology review shows that radiation is not indicated, the mastectomy skin and shape of the breast skin envelope will be lost (and the aesthetic outcome compromised) unless measures are taken to preserve them.⁷

The protocol at a glance

Those measures to preserve the breast skin envelope consist of placement of a tissue expander at the time of mastectomy, pending final pathology results. If no radiation therapy is needed, the optimal reconstructive procedure can be chosen and performed within the next 1 to 2 weeks. If radiation is necessary, the expander can be deflated in the clinic before initiation of radiation therapy, to optimize radiation delivery to the internal mammary nodes. The expander can then be serially expanded after radiation, and delayed reconstruction with an autologous flap can be performed at a later date. Delayed-immediate reconstruction also offers the opportunity to revise the inframammary crease and debride any nonviable mastectomy skin.

Insurance coverage is federally mandated

Patients should be aware that the Women’s Health and Cancer Rights Act of 1998 (see article by Djohan et al earlier in this supplement) applies to delayed and delayed-immediate reconstruction as well as to immediate reconstruction, requiring that medical insurers that cover mastectomy cover these procedures as well.

CONCLUSIONS

The timing of breast reconstruction is determined primarily by patient factors and the necessity for postmastectomy radiation therapy. If the risk of needing postmastectomy radiation is low, then immediate reconstruction produces the optimal aesthetic outcome. The main advantage of immediate reconstruction is the availability of relatively supple nonscarred tissue that can be recruited for reconstruction. If the risk of needing postmastectomy radiation is high, then delayed reconstruction is preferable to optimize both radiation delivery and aesthetic outcome. Delayed reconstruction is somewhat more challenging, as it involves well-healed scar tissue that is already retracted and adherent to the chest. Nevertheless, reconstruction remains possible at this point and options depend on tissue quality and the plastic surgeon’s expertise. For patients with an increased risk of needing postmastectomy radiation, delayed-immediate reconstruction represents a viable approach that optimizes oncologic as well as aesthetic outcomes regardless of whether the patient ultimately does or does not need radiation therapy.

Timing of breast reconstruction after mastectomy involves many factors that are important in choosing between three options—immediate, delayed, or “delayed-immediate” reconstruction.

Immediate reconstruction is performed at the time of initial breast cancer surgery and allows for joint planning of incisions between the oncologic and plastic surgery teams. This produces the optimal aesthetic result since it allows for preservation of the breast skin envelope and sometimes for nipple preservation, and is oncologically safe for patients treated for cure of their cancers.

Delayed reconstruction involves initially performing a mastectomy and then determining the need for postmastectomy radiation, which cannot be assessed until review of permanent sections on pathology. Reconstruction is then performed after chemotherapy, radiation therapy, or both (if needed) are completed.

Delayed-immediate reconstruction involves placing a tissue expander at the time of skin-sparing mastectomy to preserve the breast skin envelope. After the final pathology is reviewed following mastectomy, immediate reconstruction is performed if the patient does not require postmastectomy radiation therapy. If radiation therapy is required, then the patient undergoes standard delayed reconstruction after the radiation therapy is completed. This allows for skin conservation, thereby improving aesthetic outcome, while still allowing final reconstructive decisions to be made after it is determined whether radiation will be required.

IMMEDIATE RECONSTRUCTION: WHEN INDICATED, THE OPTION WITH THE BEST AESTHETIC RESULTS

Currently, the majority of breast reconstructions are performed as immediate reconstructions at the time of mastectomy. Immediate reconstruction is a routine consideration for patients suspected to have stage 0, I, or IIA breast cancers (see table in the article on staging and surgical treatment by Hammer et al). These patients with early-stage cancer represent more than 70% of women who undergo mastectomy. Less-extensive resection of the breast skin by oncologic surgeons and the development of reconstructive options by plastic surgeons have improved quality of life for breast cancer patients.¹ Nipple-sparing mastectomy in selected patients is associated with high levels of patient satisfaction, improved aesthetic outcomes, and oncologic safety in the setting of early-stage tumors with no skin involvement.²

Oncologic safety is established

Numerous factors affect patient decision-making regarding reconstruction. The primary reason patients elect not to undergo immediate reconstruction is fear that reconstruction will hamper the ability to detect a cancer recurrence. In addition, patients as well as many physicians may have the unfounded fear that cancer cells can remain viable in the mastectomy bed and therefore that immediate reconstruction is ill-advised.

Multiple studies have shown that immediate reconstruction is oncologically safe after mastectomy, even in patients with locally advanced breast cancer.

In a study of 540 patients who underwent immediate reconstruction following mastectomy, Newman et al identified 50 patients with locally advanced breast cancer; all of these patients received postoperative chemotherapy, and 40% received postoperative radiation therapy as determined by tumor characteristics.³ At median follow-up of 58.5 months, there were no differences in either local or distant recurrence between these 50 patients and 72 matched patients with locally advanced breast cancer who did not undergo immediate reconstruction but received standard chemotherapy and radiation therapy for locally advanced disease.³

Similarly, a study by Langstein et al demonstrated that immediate reconstruction does not delay detection of cancer recurrence in the chest wall, in that the time to diagnosis of recurrence was similar whether patients underwent immediate reconstruction or not.⁴ No differences in local recurrence rates were noted based on the type of reconstruction performed (autologous flaps or implants). In addition, most cases of chest wall recurrence were associated with distant metastatic disease.⁴

Importance of physician input, other factors

Physician input is of vital importance to the patient considering mastectomy with immediate reconstruction. Traditionally, many patients have been advised by their health care providers to wait until mastectomy and chemotherapy or radiation therapy are complete before considering reconstruction. After undergoing such physically and emotionally exhausting treatments, however, patients are often spent and have no interest in undergoing another surgical procedure. Proper counseling by physicians—including the explanation that immediate reconstruction is associated with no difference in recurrence or survival outcomes compared with delayed reconstruction or no reconstruction at all—is essential to allay the fear of recurrence or death that often guides patients’ decision-making.

Indeed, a recent questionnaire-based study of factors influencing mastectomy patients’ choices regarding reconstruction found that patients regarded their surgeon’s advice as the most important factor.¹ Moreover, women in the study who chose to undergo reconstruction were more likely than women who chose mastectomy alone to identify their surgeon’s advice as the most important influencing factor. These women who chose reconstruction also were more likely than those not choosing reconstruction to have discussed their decision with their partner and to express interest in meeting other women who had undergone mastectomy. The study’s quality-of-life assessment demonstrated that women who chose reconstruction were in better physical health, placed more importance on body image and sexuality, and were less afraid of surgery compared with those not choosing reconstruction.¹

The type of cancerous lesion also contributes to patient decision-making regarding immediate reconstruction. Patients with ductal carcinoma in situ are twice as likely to choose immediate reconstruction as those with invasive cancer.⁵ Age plays an important role as well. Younger patients are more likely to elect to undergo reconstruction, with patients younger than age 50 having a 4.3-fold greater likelihood of choosing reconstruction than their older counterparts.⁵

Preoperative evaluation and postoperative histologic lymph node status determine the potential need for adjuvant therapy and facilitate optimal surgical decision-making. Chemotherapy usually begins within 30 to 40 days after surgery but can be delayed up to 12 weeks. Thus, a reconstruction that will be healed within this time frame is ideal. Reconstruction choices that involve well-vascularized tissue will optimize healing prior to chemotherapy. Chemotherapy cannot be started in the presence of seroma, infection, or necrotic tissue. In cases of breast conservation surgery and radiation therapy only, radiation can be delayed up to 8 weeks for complete healing prior to its commencement.

In a patient who will require radiation, autologous reconstruction (using the patient’s own tissue) is preferable to tissue expander and implant reconstruction. Indications for radiation after mastectomy include tumor invasion of the chest wall, invasive cancers larger than 5 centimeters, and, in some cases, positive lymph nodes. Patients who undergo radiation of an autologous flap often have some shrinkage of the flap volume. Dense scar formation, capsular contraction, and implant extrusion may occur with radiation of implants, leading to a poor cosmetic outcome. Implant reconstructions that fail for these reasons are best corrected by autologous means.

Another consideration that should be addressed between the oncologic surgeon and the plastic surgeon is the possibility of an axillary lymph node dissection after reconstruction in the event of a positive sentinel node biopsy. If the oncologic surgeon must return to the axilla for removal of nodes after reconstruction, cooperation is needed between the two teams for incision planning and dissection. This is especially true in cases of microvascular free-tissue transfer reconstruction, in which vessels in the axilla are used for anastomosis. Recent data suggest that most microsurgery practitioners prefer to use the internal mammary vessels to avoid the need to return for another operation involving the axilla, which can jeopardize flap viability.⁶

DELAYED RECONSTRUCTION: A VIABLE OPTION REQUIRING REALISTIC EXPECTATIONS

Although reconstruction at the time of mastectomy is the preferred approach at present, delayed reconstruction in a patient who previously had a mastectomy is also a viable option. Since surgical therapy for breast cancer has been practiced long before reconstructive procedures were in widespread use, many patients were not offered any reconstructive options at the time of mastectomy. Other patients chose to delay reconstruction until after radiation therapy and/or chemotherapy were completed.

Why patients may choose to delay

Delayed reconstruction may be preferable for patients who are not ready to make a decision at the time of initial surgery as a result of the overwhelming news of their cancer diagnosis and the many treatment options they have to consider. These patients may benefit from first focusing on treatment of their cancer and reserving consideration of reconstruction for later. In other cases, patients with multiple medical comorbidities may benefit from a staged procedure to minimize the length of surgery. It should be recognized, however, that if reconstruction is not performed at the time of initial mastectomy, the likelihood that it ultimately will be performed may be significantly reduced.

What prompts the decision to eventually seek reconstruction?

The goals of patients seeking delayed reconstruction are numerous. Some express a desire to put the “cancer phase” of their life behind them, while others hope to escape the stigma of being different. Generally these women wish to think, feel, and carry on their lives as they did before their mastectomy. In addition, patients may desire a tangible, lasting result to symbolize that their treatment is finished. In the late phase of the recovery process, breast reconstruction may be viewed as a healthy route of return to the patient’s “normal” life before cancer.

It is important for mastectomy patients to know that they are still candidates for breast reconstruction as a delayed procedure, even if their mastectomy was performed in the distant past.

Expectations must be tempered

The goal of delayed-immediate reconstruction is to optimize reconstruction in patients who are at risk of needing postmastectomy radiation therapy, since it is not known until after review of permanent sections, several days following mastectomy, whether these patients will require radiation.

The rationale

If immediate reconstruction is performed and the patient is found to have pathologic lymph node involvement, postoperative radiation therapy may compromise aesthetic results. Additionally, the reconstructed breast may pose technical difficulties in terms of delivery of radiation to the internal mammary nodes. At the same time, if breast reconstruction is delayed and final pathology review shows that radiation is not indicated, the mastectomy skin and shape of the breast skin envelope will be lost (and the aesthetic outcome compromised) unless measures are taken to preserve them.⁷

The protocol at a glance

Those measures to preserve the breast skin envelope consist of placement of a tissue expander at the time of mastectomy, pending final pathology results. If no radiation therapy is needed, the optimal reconstructive procedure can be chosen and performed within the next 1 to 2 weeks. If radiation is necessary, the expander can be deflated in the clinic before initiation of radiation therapy, to optimize radiation delivery to the internal mammary nodes. The expander can then be serially expanded after radiation, and delayed reconstruction with an autologous flap can be performed at a later date. Delayed-immediate reconstruction also offers the opportunity to revise the inframammary crease and debride any nonviable mastectomy skin.

Insurance coverage is federally mandated

Patients should be aware that the Women’s Health and Cancer Rights Act of 1998 (see article by Djohan et al earlier in this supplement) applies to delayed and delayed-immediate reconstruction as well as to immediate reconstruction, requiring that medical insurers that cover mastectomy cover these procedures as well.

CONCLUSIONS

The timing of breast reconstruction is determined primarily by patient factors and the necessity for postmastectomy radiation therapy. If the risk of needing postmastectomy radiation is low, then immediate reconstruction produces the optimal aesthetic outcome. The main advantage of immediate reconstruction is the availability of relatively supple nonscarred tissue that can be recruited for reconstruction. If the risk of needing postmastectomy radiation is high, then delayed reconstruction is preferable to optimize both radiation delivery and aesthetic outcome. Delayed reconstruction is somewhat more challenging, as it involves well-healed scar tissue that is already retracted and adherent to the chest. Nevertheless, reconstruction remains possible at this point and options depend on tissue quality and the plastic surgeon’s expertise. For patients with an increased risk of needing postmastectomy radiation, delayed-immediate reconstruction represents a viable approach that optimizes oncologic as well as aesthetic outcomes regardless of whether the patient ultimately does or does not need radiation therapy.

Variceal hemorrhage is a medical emergency in which up to 20% of patients die.¹ Even if the patient survives an initial episode of variceal bleeding, the probability of another episode is high: the rebleeding rate without treatment is 70% within 1 year. The mortality rate with rebleeding is 33%.

With such overwhelming consequences, the best strategy in any patient with cirrhosis and known varices is to try to prevent the first episode of bleeding.

WHO IS AT RISK?

Esophageal varices are present in 30% of patients with compensated cirrhosis and in up to 60% of those with decompensated cirrhosis (ie, with evidence of ascites or encephalopathy).²

The risk of variceal hemorrhage is related to three factors:

• The size of the varices. Varices 5 mm in diameter or smaller have a 7% risk of bleeding in 2 years, while those larger than 5 mm have a 30% risk of bleeding within 2 years.³
• The appearance of the varices. Morphologic features of varices, including red wale signs (red streaks of the mucosa overlying the varix), have been correlated with an increased risk of hemorrhage.
• The severity of liver dysfunction, as assessed by the Child-Pugh classification—an index of liver dysfunction based on serum albumin concentration, bilirubin level, prothrombin time, and the presence of ascites and encephalopathy. A high Child-Pugh score (ie, class B or C), representing decompensated cirrhosis, is associated with an increased risk of bleeding.

HOW VARICES DEVELOP: PORTAL HYPERTENSION

Esophageal varices form as a result of increased portal pressure, the product of increased portal venous inflow and resistance to outflow from the portal venous system. Portal hypertension is a major complication of chronic liver disease. In cirrhosis, architectural distortion of the liver causes an increase in the intrahepatic vascular resistance.

Portal venous inflow depends on mesenteric arteriolar tone, increasing when tone decreases. In cirrhotic patients, the increase in portal pressure results from a combination of increased portal blood flow secondary to splanchnic arteriolar vasodilation and elevated resistance to outflow through distorted hepatic sinusoids.

The potent vasodilator nitric oxide (NO) plays an important role in portal hypertension. In patients with cirrhosis, NO bioavailability is decreased in the intrahepatic circulation due to defects in the posttranslational regulation of endothelial NO synthase.⁴ This deficiency of NO, along with mechanical factors in the sinusoids, contributes to the increase in intrahepatic resistance. In the systemic and splanchnic circulation, NO bioavailability is increased due to upregulation and posttranslational regulation of endothelial NO synthase, thereby increasing splanchnic vasodilatation and leading to increased portal venous inflow.⁵ This results in a marked increase in cardiac output and so-called hyperdynamic circulation.

Portal hypertension results in the development of collateral circulation, including venous channels in the esophagus and stomach, by the dilation of preexisting vessels and active angiogenesis. Esophagogastric varices increase in size with the severity of portal hypertension and can rupture when the tension in their walls exceeds a maximal point.

HEPATIC VEIN PRESSURE GRADIENT: A PROXY FOR PORTAL PRESSURE

Ideally, the portal venous pressure should be directly measured. However, since direct measurement is invasive and impractical, the hepatic vein pressure gradient (HVPG) can be measured instead and correlates well with the portal pressure.⁶

The normal HVPG is 5 mm Hg or less; anything above this value denotes portal hypertension. However, studies have shown that varices may develop but do not bleed if the HVPG is less than 12 mm Hg.⁸

TWO WAYS TO PREVENT BLEEDING

Bleeding can be prevented either by reducing the portal venous pressure or by obliterating the varices. Portal pressure can be reduced by placing a portosystemic shunt either surgically or percutaneously with radiographic guidance or by giving drugs such as nonselective beta-blockers, nitrates, or a combination of these drugs. Variceal obliteration is typically done by endoscopic methods with either injection of a sclerosant or band ligation.

NONSELECTIVE BETA-BLOCKERS: THE MAINSTAY OF TREATMENT

Nonselective beta-blockers, the most commonly used drugs for preventing first esophageal variceal bleeding, decrease portal pressure by blocking both beta-1 and beta-2 adrenergic receptors.⁹ Beta-1 blockade decreases portal flow by decreasing the heart rate and cardiac output, while blockade of beta-2 receptors results in unopposed alpha-adrenergic-mediated vasoconstriction.

Selective beta-blockers do not appear to be as useful for primary prophylaxis. More than 2 decades ago, metoprolol (Toprol, Lopressor), a beta-1 selective antagonist, was compared with propranolol (Inderal), a nons-elective agent, in patients with cirrhosis and portal hypertension.¹⁰ Although both drugs significantly reduced the heart rate and cardiac output, only those taking propranolol showed a marked fall in portal pressure (mean decrease of 6.8 mm Hg vs 3.8 mm Hg with metoprolol) and a significant reduction in hepatic blood flow. The differences were thought to be related to beta-2 blockade of vasodilator receptors in the splanchnic circulation, which occurs only with nonselective beta-blockers such as propranolol.

The two nonselective beta-blockers most often used to prevent variceal bleeding are nadolol (Corgard) and propranolol. Both have been extensively studied in preventing a first variceal hemorrhage.

Effectiveness of beta-blockers

D’Amico et al¹¹ performed a meta-analysis in 1995, examining nine trials (996 patients total) of the effectiveness of beta-blockers in preventing a first variceal hemorrhage. Seven trials found that bleeding risk was reduced with beta-blockers (significantly in four), one trial found that risk was unchanged, and one trial found that risk was increased—an outlier due to a small sample size. The meta-analysis showed a significant bleeding reduction with the use of a beta-blocker, either including the outlier trial (pooled odds ratio 0.54; 95% confidence interval 0.39–0.74) or excluding it (pooled odds ratio 0.48; 95% confidence interval 0.35–0.66).

Mortality rates were also reduced in seven trials, but the reduction was statistically significant in only one. However, in the pooled estimate, the mortality risk reduction approached statistical significance (pooled odds ratio 0.75; 95% confidence interval 0.57–1.06).

Ideo et al¹² gave either nadolol or placebo to 79 patients with cirrhosis and large esophageal varices that had never bled. Nadolol was found to protect against a first variceal hemorrhage: at 2-year follow-up, only 1 of the 30 patients allocated to nadolol had had bleeding, vs 11 of the 49 patients in the placebo group.

Merkel et al¹³ found that the risk of variceal bleeding was lower in patients who started treatment with beta-blockers when their varices were small (12% at 5 years) than in those who started treatment after a diagnosis of large esophageal varices (22% at 5 years). They concluded that nadolol helps prevent small varices from growing into larger ones.

Response to beta-blockers is not uniform

Although beta-blockers decrease the portal pressure in many cirrhotic patients, the response is not uniform. In a study of 60 cirrhotic patients,¹⁴ 40% showed no reduction or even a slight increase in HVPG with propranolol. Most patients showed a significant reduction in heart rate (17.5% ± 10%) after receiving 40 mg of propranolol. In the patients whose HVPG did not decrease by at least 10% with 40 mg of propranolol, increasing the dose caused a decrease in HVPG without a further decrease in heart rate. This suggests that 40 mg of propranolol successfully produced beta-1 blockade but that a higher dose was required for effective beta-2 blockade.

Failure to respond in certain patients may be due to a concurrent rise in collateral or hepatic sinusoidal resistance, or both. This was confirmed in a study in portal-hypertensive rats treated with propranolol.¹⁵ The reduction in portal blood flow expected was accompanied by a disproportionately small reduction in portal pressure, which was thought to be due to a rise in portal and collateral vascular resistance.

An HVPG ≤ 12 mm Hg? Studies have shown that the most important predictor of efficacy of prophylaxis for variceal bleeding is a decrease in the HVPG to 12 mm Hg or less or a decrease in the initial HVPG of more than 20%.⁹ Although measuring the HVPG is invasive, expensive, and not routinely done in clinical practice, several studies have investigated the role of measuring hemodynamic response to medication.

Merkel et al¹⁶ measured the HVPG in 49 cirrhotic patients with previously nonbleeding varices before starting therapy with beta-blockers with or without nitrates and after 1 to 3 months of treatment. They followed the patients for up to 5 years. The mean HVPG value at baseline was 18.8 mm Hg. At 3 years of follow-up, 7% of those who had responded well to therapy (defined as achieving an HVPG less than 13 mm Hg or a decrease of more than 20%) had experienced a bleeding episode, which was significantly less than the rate (41%) in those who did not meet those hemodynamic end points. No patient reaching an HVPG of 12 mm Hg or less during treatment had variceal bleeding during follow-up.

Groszmann et al¹⁷ also prospectively measured the HVPG in patients with cirrhosis and varices, but their patients received either propranolol or placebo. Variceal hemorrhage occurred in 13 patients (11 of 51 in the placebo group and 2 of 51 in the propranolol group), all of whom had an HVPG greater than 12 mm Hg. Again, none of the patients whose HVPG was decreased to 12 mm Hg or less bled from esophageal varices.

Unfortunately, routine HVPG measurement to guide primary prophylaxis is an expensive strategy. Data suggest that measuring the HVPG is cost-effective only when the cost of measuring the HVPG is very low, the risk of variceal bleeding is very high, or the patient is expected to survive at least 3 to 5 years.¹⁸

A heart rate of 55 to 60? An alternative to HVPG measurement to monitor the effectiveness of beta-blocker therapy is to follow the heart rate. A 25% reduction from baseline or a heart rate of 55 to 60 beats per minute is the standard goal^19,20; yet, at least 40% of patients treated with enough propranolol to decrease the heart rate by 25% do not respond with significant HVPG reductions.^14,21

So, although beta-blockade is effective peripherally, it may not reduce HVPG to less than 12 mm Hg or 20% from baseline, and direct HVPG measurement is still the gold standard.

Treatment should be lifelong

Once a patient is started on a beta-blocker to prevent variceal hemorrhage, the treatment should be lifelong.

In 2001, a group of patients (most of them in Child-Pugh class A or B) completing a prospective randomized controlled trial of propranolol for primary prevention of variceal hemorrhage were tapered off propranolol or placebo.²² Of the 49 patients, 9 experienced variceal hemorrhage (6 of 25 former propranolol recipients and 3 of 24 former placebo recipients), and 17 patients died (12 former propranolol and 5 former placebo recipients), suggesting that treatment should be maintained for life.

Therefore, when beta-blocker therapy is discontinued, the risk of variceal hemorrhage returns to what would be expected in an untreated population.

Beta-blockers may not prevent varices

Although many trials have shown that beta-blockers are effective as prophylaxis against a first variceal hemorrhage, there is no evidence that these drugs prevent varices from forming in cirrhotic patients.

Groszmann et al²³ treated more than 200 patients who had biopsy-proven cirrhosis and portal hypertension (HVPG > 6 mm Hg) but no varices with timolol (Blocadren), a nonselective beta-blocker, or placebo. At a median follow-up of about 55 months, the groups did not differ significantly in the incidence of primary events (development of varices or variceal hemorrhage) or treatment failures (transplantation or death). Varices developed less frequently among patients with a baseline HVPG of less than 10 mm Hg and among those whose HVPG had decreased by more than 10% at 1 year. In patients whose HVPG increased by more than 10%, varices developed more frequently.

Contraindications, side effects

The major drawbacks to therapy with beta-blockers are their contraindications and side effects.

Contraindications include chronic obstructive lung disease, psychosis, atrioventricular heart blocks, and aortic-valve disease.

Side effects are reported in 15% of patients but severe events are rare.²⁴ Still, an estimated 10% to 20% of patients discontinue treatment because they cannot tolerate it.²⁵ The more common complaints include fatigue, shortness of breath, sexual dysfunction, and sleep disorders.

Dosage

No specific starting dose of beta-blockers is agreed upon, but nadolol 20 to 40 mg once daily or long-acting propranolol 60 mg once daily can be used as initial therapy.²⁵ Once-daily dosing increases the likelihood of compliance.

Since portal pressure progressively declines from 12 noon to 7 PM and then increases throughout the night and back to baseline by 9 AM,²⁶ we recommend that the medication be taken in the evening to counteract increases in portal pressure that occur in the middle of the night.

ENDOSCOPIC VARICEAL LIGATION

Endoscopic variceal ligation has been investigated extensively for use as prophylaxis against first variceal hemorrhage. The procedure involves placing a rubber band around a varix aspirated into a cylinder on the tip of an endoscope.

Effectiveness of ligation

Lay et al,²⁷ in a prospective, randomized trial in 126 cirrhotic patients endoscopically judged to be at high risk of hemorrhage, found that ligation significantly reduced the 2-year cumulative bleeding rate (19% with ligation vs 60% in an untreated control group) and the overall mortality rate (28% vs 58%). The lower risk of bleeding in the ligation group was attributed to a rapid reduction of variceal size; 60% of those in the ligation group had complete eradication of varices and 38% had varices reduced in size.

Imperiale and Chalasani²⁸ performed a meta-analysis in 2001 that included 601 patients in five trials comparing prophylactic ligation with untreated controls and 283 patients in four trials comparing ligation with beta-blocker therapy. Compared with no treatment, ligation reduced the risk of first variceal hemorrhage, bleeding-related death, and death from any cause. Compared with propranolol, ligation reduced the risk of first-time bleeding but had no effect on the death rate.

Schepke et al,²⁹ in a randomized controlled multicenter trial in 152 cirrhotic patients with two or more esophageal varices, found that neither bleeding incidence nor death rate differed significantly between ligation and propranolol.

Lui et al³⁰ followed 172 cirrhotic patients with grade II or III esophageal varices for 6 years and found that ligation was equivalent to propranolol. However, many patients reported side effects with propranolol, and 30% of patients withdrew from propranolol treatment, making ligation a more attractive option.

Khuroo et al³¹ performed a meta-analysis of eight randomized controlled trials including 596 patients and found that ligation significantly reduced the rates of first gastrointestinal hemorrhage by 31% and of first variceal hemorrhage by 43%. In subgroup analysis, ligation had a significant advantage compared with beta-blockers in trials with patients with a high bleeding risk, ie, trials in which more than 30% of patients were in Child-Pugh class C and more than 50% of the patients had large varices.

Jutabha et al³² performed a multicenter, prospective trial (published in 2005) in 62 patients with high-risk esophageal varices randomized to propranolol or banding. The trial was ended early after an interim analysis showed that the failure rate of propranolol was significantly higher than that of banding (6/31 vs 0/31, P = .0098). Esophageal variceal hemorrhage occurred in 4 (12.9%) of the patients in the propranolol group compared with 0 in the ligation group. Similarly, 4 patients in the propranolol group died, compared with 0 in the ligation group. All the patients in this trial were liver transplant candidates and therefore all had severe liver disease.

In another trial favoring variceal banding over beta-blockers, Psilopoulos et al³³ in 2005 followed 60 patients with cirrhosis and esophageal varices with no history of bleeding. Thirty percent of the patients in the propranolol group developed variceal bleeding compared with 6.7% in the ligation group (P = .043).

Lay et al³⁴ followed 100 cirrhotic patients for 2 years and found comparable cumulative bleeding rates with ligation vs propranolol (18% vs 16%, respectively) and also comparable rates of death (28% vs 24%, respectively).

Sarin et al³⁵ investigated the role of propranolol in addition to ligation in the prevention of first hemorrhage in 144 patients. Adding propranolol did not further decrease the incidence of initial bleeding (7% in the combination group vs 11% in the ligation-only group). Survival rates were similar at 20 months: 92% in the combination group vs 85% in the ligation-only group. However, the rate of variceal recurrence was lower with combination therapy: 6% in the combination group vs 15% with ligation alone.

Does esophageal variceal ligation increase gastric varices?

A less researched topic is whether variceal ligation results in gastric hemodynamic changes that increase the size of fundal varices and worsen portal hypertensive gastropathy.

Yuksel et al³⁶ found that 37 of 85 patients had fundal varices before they underwent ligation of esophageal varices, increasing to 46 after the procedure, a statistically significant increment. The severity of portal hypertensive gastropathy also increased.

Further research is required regarding the long-term consequences of these findings.

ANGIOTENSIN II RECEPTOR ANTAGONISTS: ROLE UNKNOWN

Angiotensin II increases portal pressure, and angiotensin II levels are elevated in patients with cirrhosis, suggesting that this hormone plays a role in the pathogenesis of portal hypertension.

Losartan (Cozaar), an angiotensin II receptor antagonist, was found to decrease the HVPG significantly in patients with severe and moderate portal hypertension in a pilot study³⁷ in 1999. However, in two subsequent studies,^38,39 losartan only moderately reduced the HVPG and caused hypotension and a reduction in the glomerular filtration rate. The role of angiotensin II receptor blockers in primary prevention of variceal bleeding is still unknown.

SURGICAL PORTAL DECOMPRESSION HAS BEEN ABANDONED

The first method investigated to prevent variceal bleeding was surgical portal decompression.

A meta-analysis of four randomized controlled trials in 302 patients with varices of all sizes compared portocaval shunt surgery and medical therapy.¹¹ Although shunt surgery was very effective in preventing variceal bleeding, the risk of chronic or recurrent encephalopathy was significantly increased (odds ratio 2.0), as was the risk of death (odds ratio 1.6).

These poor results, combined with advances in endoscopic procedures, led to the abandonment of surgical shunting for primary prophylaxis.

TIPS PROCEDURE: NO ROLE AT PRESENT

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is used to treat the main consequences of portal hypertension, including ascites and variceal hemorrhage. The procedure entails accessing the hepatic vein via the right jugular vein and placing a stent to the portal vein, forming a low-resistance channel and allowing blood to return to the systemic circulation.

TIPS placement increases the risk of encephalopathy; liver failure is a rare complication, and procedural complications (ie, shunt dysfunction) also occur. Trials comparing the TIPS procedure with other forms of therapy to prevent first variceal hemorrhages have not been performed.⁴⁰ Research to improve the outcome of the TIPS procedure is ongoing, but currently this procedure has no role in primary prevention of variceal bleeding.

ENDOSCOPIC SCLEROTHERAPY MAY INCREASE THE RISK OF DEATH

Numerous clinical trials evaluated sclerotherapy as prophylaxis against a first esophageal variceal hemorrhage. The procedure involves injecting a sclerosant in and around varices.

In a large Veterans Administration study,⁴¹ sclerotherapy was compared with sham treatment in 281 men with alcoholic liver disease who had documented varices but no history of bleeding. The trial was terminated after 22.5 months because the rate of all-cause mortality was significantly higher in the sclerotherapy group (32.5%) than in the sham therapy group (17.4%). The higher death rate did not persist after the treatment was discontinued, and it was speculated that, although sclerotherapy had reduced new episodes of variceal hemorrhage, the procedure might have caused bleeding from esophageal ulcers, leading to an increased mortality rate in that group.

The PROVA Study Group from Norway and Denmark found similar results when 286 cirrhotic patients were randomized to receive sclerotherapy, propranolol, combination sclerotherapy and propranolol, or no treatment to prevent a first variceal hemorrhage.⁴² The incidence of variceal bleeding was almost identical in the four groups, but the mortality rate with variceal bleeding was 2.75 times higher in the sclerotherapy groups than in the other groups (P = .002). It was speculated that repeated sclerotherapy sessions might be poorly tolerated by patients in Child-Pugh classes B and C and might have contributed to the precipitation of liver failure and other common complications of cirrhosis.

A meta-analysis by D’Amico et al¹¹ evaluated 19 trials (1,630 patients) comparing sclerotherapy with nonactive treatment. Sclerotherapy tended to be favorable in trials with a high bleeding rate in the control patients and unfavorable in trials with a low bleeding rate. The benefit seen in patients at high risk is consistent with the efficacy of sclerotherapy for preventing rebleeding, whereas the harmful effect in the low-risk patients points towards side effects and complications exceeding the potential benefits.

In general, currently available evidence suggests that the benefits of prophylactic sclerotherapy are marginal, and therefore sclerotherapy is not recommended as primary prophylaxis for variceal hemorrhage.

NITRATES: NO LONGER USED AS MONOTHERAPY

Unlike vasoconstrictors, which decrease portal pressure by decreasing blood flow, vasodilators reduce hepatic pressure by decreasing intrahepatic and portocollateral vascular resistance.⁴³ In addition, larger doses directly affect the arterial circulation, lowering systemic and therefore splanchnic perfusion pressure.⁴⁴ Unfortunately, the systemic vasodilatory effects of nitrates exacerbate the hyperdynamic state that is characteristic of cirrhosis, thereby limiting their use and tolerability in many patients.

A trial comparing propranolol vs isosorbide mononitrate initially found that the groups did not differ significantly with regard to bleeding rates and 2-year survival rates,⁴⁵ but a 6-year follow-up found the likelihood of death greater in patients older than 50 years in the nitrate group.⁴⁶ In an additional study comparing isosorbide mononitrate vs placebo in patients with contraindications to or intolerance of beta-blockers, no difference in the relative risk of first variceal hemorrhage was found between the two groups.⁴⁷ Therefore, nitrates are no longer used as monotherapy to prevent variceal bleeding.

Combination therapy with beta-blockers plus nitrates is controversial. In a trial in 1996, Merkel et al⁴⁸ found the cumulative risk of variceal bleeding was 18% at 40 months with nadolol alone vs 7.5% with nadolol plus isosorbide mononitrate. However, in a later trial, Garcia-Pagán et al⁴⁹ found no significant advantage to combination therapy. The incidence of variceal bleeding at 1 year was 8.3% in the group receiving propranolol plus placebo and 5% in the group receiving propranolol plus isosorbide mononitrate; at 2 years, the rates were 10.6% vs 12.5%.

RECOMMENDATIONS FOR SCREENING AND PROPHYLAXIS

Based on Garcia-Tsao G, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922–938.

• All patients with cirrhosis should be screened for varices at the time of diagnosis.
• The size of the varices, including small (≤ 5 mm) and large (> 5 mm), and the presence of red wale marks on the varices should be recorded.
• Patients who have no varices on screening endoscopy should be rescreened every 3 years if their liver function is stable or every year if their liver function deteriorates. (Varices grow at a rate proportional to the severity of the liver disease.)
• Patients with portal hypertension but without varices do not need treatment with nonselective beta-blockers. Endoscopy should be performed at the intervals suggested above.
• Those who are found to have small varices on screening endoscopy but who have well-compensated liver disease (Child-Pugh class A) and no red wale marks should be rescreened every other year because the development of large varices is greater in patients with small varices on initial endoscopy than in patients with no varices. Emerging data support the use of beta-blockers to prevent varices from increasing in size.
• Patients who have small varices with red wale signs or who are in Child-Pugh class B or C have an increased risk of bleeding and should be treated with beta-blockers. If beta-blockers are not used, endoscopy should be done every year to look for an increase in variceal size.
• Patients who have large varices without red wale signs or who are in Child-Pugh class B or C should be treated with nonselective beta-blockers. The dose should be adjusted to achieve maximal tolerable decrease in heart rate to a minimum of 55 beats per minute, and treatment should be continued indefinitely.
• Endoscopic variceal ligation is an acceptable alternative to beta-blocker treatment as first-line therapy in those who cannot tolerate beta-blockers or who have contraindications to their use, or in those who have red wale marking or who are in Child-Pugh class B or C.