December 2012 VOL 3, NO 6

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Uncategorized

Beginning the Breast Reconstructive Journey: Importance of Reconstructive Surgery Referrals and State-of-the-Art Oncoplastic Breast Reconstruction

Steven Kronowitz, MD, FACS

Dr Kronowitz, a plastic surgeon who performs breast reconstruction surgery only, presented state-of-the-art breast reconstruction techniques. He discussed the importance of breast reconstructive referrals and some of the barriers that might interfere with patients obtaining referrals for reconstruction. He emphasized that it is always best if the patient discusses reconstruction early and has reconstruction surgery before radiation therapy. He noted that for breast remodeling, it is best to use the patient’s own tissue, and it’s best done at the time the tumor is removed. This works for patients who are a C cup or larger and have a small tumor, and prevents a later lumpectomy defect. For reconstruction after radiation, the breast can be smaller and can be repaired with fat grafts, and the other breast can be reconstructed to match. Dr Kronowitz presented photos taken before, during, and after the various types of reconstructive surgeries, and discussed flaps for reconstruction for patients with small breasts, radiation, scarring, and other situations. He makes an effort to use techniques resulting in the least amount of scarring to reduce stigma. The type of radiation therapy will affect the type of reconstruction that must be performed.

Dr Kronowitz discussed data from studies about reconstruction. Patients are more likely to be referred if they are treated in high-volume practices at major cancer centers. There are low rates of referral for reconstruction by general surgeons who treat a lot of patients in major metropolitan areas. Patients are less likely to be referred if they are Latina, black, older, or had already had chemotherapy or radiation therapy. Regardless of ethnicity, patients who did receive breast reconstruction were more satisfied than those who did not. He noted that in a multivariate analysis neither the type of insurance (private, Medicare, or Medicaid) nor patient age had any effect on whether the patient was referred for or underwent breast reconstruction.

Patients are more willing to have a mastectomy if reconstruction is discussed and patients with invasive disease or ductal carcinoma in situ wait shorter times for surgery. Delayed reconstruction means skin is gone that could have aided in reconstruction, which is even harder if done after radiation. Immediate reconstruction is better and saves 3-dimensional structure and skin. Dr Kronowitz pointed out that skin-sparing mastectomy is safe because it is rare for skin to be involved in the cancer. He discussed implant-based reconstruction that used to be a 2-stage process with tissue expanders but is now often a 1-stage, nipple-sparing mastectomy going directly to implant, which is a more difficult surgery. Although it is better to do both breasts at once, this is not a reason for a double mastectomy. He also discussed the use of dermal and other matrices and several abdominal flap procedures. He prefers muscle-sparing procedures.

Strategies for breast reconstruction for patients who may or will require postmastectomy radiation were presented. In patients with early stage breast cancer, it may not be known until after reconstruction if the patient will need radiation. For patients with later stage breast cancer, of course it is known that radiation will be needed. Immediate reconstruction before radiation will ruin the reconstruction results and may interfere with the radiation treatment.

However, when reconstruction is performed after radiation there can be a lot of problems. Dr Kronowitz presented the approach of delayed-immediate breast reconstruction for patients who may or will require radiation therapy after mastectomy. At MD Anderson, patients often receive chemotherapy. He puts in an expander, which he deflates before radiation. He said it is also possible to use an implant, which has a higher rate of complication, or perform deep inferior epigastric perforator flap surgery. A prospective trial that was conducted (the results are published) showed that reconstruction had no effect on survival. Reconstruction can be performed in patients with up to stage III breast cancer.

Dr Kronowitz concluded by noting that radiation oncologists are now part of the treatment team and often refer patients for reconstructive surgery. He described surveillance as a nonissue. He performs a lot of postradiation reconstruction, usually 3 months after treatment. He doesn’t do postreconstruction mammograms routinely outside of clinical studies because there is no difference in overall survival even in patients experiencing a recurrence of their cancer. He said that reconstruction used to involve reconnection of nerves, which is not done as frequently now, and has a variable outcome.

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