Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

References
Guss, CE, Divasta, AM. Adolescent gynecomastia. Pediatr Endocrinol Rev. 2017;14(4):371-377.This article discusses the pathophysiology of
gynecomastia. The medical workup is fully explained to help with management of these patients. Medical management and nonsurgical options are also
discussed.
Raveenthiran, V. Nenotal mastauxe (breast enlargement of the newborn). J Neonatal Surg. 2013;2(3):31.
Rohrich, R, Ha, RY, Kenkel, RY, Adams, WP Jr. Classification and management of gynecomastia: defining the role of ultrasound-assisted
liposuction. Plast Reconstr Surg. 2003;111(2):909-923.This landmark article discusses the use of ultrasound-assisted liposuction for the treatment of
gynecomastia. The authors explain the role of skin tightening this therapy has on the gynecomastia patients, and note safe and reproducible results
using ultrasound-assisted liposuction to treat gynecomastia. Their experience and surgical technique are highlighted.
Cuhaci, N, Polat, SB, Evranos, B, et al. Gynecomastia: clinical evaluation and management. Indian J Endocrinol Metab. 2014;18(2):150-158.
Cordova, A, Moschella, F. Algorithm for clinical evaluation and surgical treatment of gynaecomastia. J Plast Reconstr Aesthet Surg. 2008;61:41-
49.
Braunstein, GD. Gynecomastia. N Engl J Med. 2007;357:1229-1237.This is a comprehensive review article on the topic of Gynecomastia. The author
discusses the pathophysiology of the disease and early patient management and workup. Evaluation and treatment are also discussed with equal
attention to nonsurgical and surgical options. Useful algorithms for patient management are also presented.
Simon, BE, Hoffman, S, Kahn, S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51:48-52.
Nuzzi, L, Cerrato, FE, Erickson, CR, et al. Psychosocial impact of adolescent gynecomastia: a prospective case-control study. Plast Reconstr
Surg. 2013;131:890-896.
Kinsella, C Jr, Landfair, A, Rottgers, SA, et al. The psychological burden of idiopathic adolescent gynecomastia. Plast Reconstr Surg.
2012;129:1-7.Gynecomastia is a significant psychological burden for teenage boys, and patients often site social concerns during their consultation.
This study used psychological interviews to measure anxiety, depression, and social phobias in this population. They determined that gynecomastia in
adolescents placed them at high risk for issues with self-esteem and sexual identity.
Khan, HN, Rampaul, R, Blamey, RW. Management of physiological gynaecomastia with tamoxifen. Breast. 2004;13(1):61-65.
Plourde, PV, Kulin, HE, Santner, SJ. Clomiphene in the treatment of adolescent gynecomastia. Am J Dis Child. 1983;137(11):1080-1082.
Fagerlund, A, Cormio, L. Gynecomastia in patients with prostate cancer: a systemic review. PLoS One. 2015:1-11.
Rohrich, RJ, Beran, SJ, Kenkel, JM, et al. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast
Reconstr Surg. 1998;101(4):1090-1102.
Beckenstein, MS, Windle, BH, Stroup, RT. Anatomical parameters for nipple position and areolar diameter in males. Ann Plast Surg.
1996;36(1):33-36.
Shulman, A, Badani, E, Wolf, Y, Hauben, DJ. Appropriate location of the nipple-areola complex in males. Plast Reconstr Surg. 2001;108(2):348-
351.
Waltho, D, Hatchell, A, Thoma, A. Gynecomastia classification for surgical management: a systematic review and novel classification system.
Plast Reconstr Surg. 2016;139(3):638-648.
Hurwitz, D. Boomerang pattern correction of gynecomastia. Plast Reconstr Surg. 2015;135:433.This technique article discusses an optimal technique
for body contouring patients after massive weight loss, who are dissatisfied with their gynecomastia. Dr. Hurwitz presents a safe and effective
combination of a torsoplasty with gynecomastia correction to address both the vertical and horizontal tissue excess in this patient population.
Blau, M, Hazani, R. Correction of gynecomastia in body builders and patients with good physique. Plast Reconstr Surg. 2015;135:42.The
authors discuss their technique for addressing subareolar glandular excess in bodybuilders and those with minimal body fat. Using a direct glandular
excision, they are able to safely achieve a desired cosmetic outcome for these patients.
Kasielska-Trojan, A, Antoszewski, B. Gynecomastia surgery: impact on life quality. Ann Plast Surg. 2017;78(3):263-268.
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C H A P T E R 5 8
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Breast Cancer: Current Trends in Screening,
Patient Evaluation, and Treatment
Alvin C. Kwok and Christopher J. Pannucci
Key Points
In the United States, a woman born today has about a 1 in 8 chance of being diagnosed with breast
cancer during her life.
The American Cancer Society guidelines from 2015 recommend that women at the age of 55 years or
older with average risk should have biennial screening mammography.
Indications for postmastectomy radiation therapy include patients with large tumors (>5 cm), four or
more involved lymph nodes, positive or close margins, and those with locally advanced breast
cancer.
The 2014 American Society of Clinical Oncology guidelines recommend axillary lymph node
dissection for patients who have three or more metastatic sentinel lymph nodes on sentinel lymph
node biopsy (SLNB) or who have one or two metastatic lymph nodes on SLNB but who do not desire
whole-breast irradiation.
Oncologic factors suggestive of suitable cases for nipple-
 sparing mastectomies include tumors
>2 cm from the nipple and no clinical involvement of the skin or nipple.
In breast cancer patients who have undergone mastectomy, there is no difference in survival in
patients receiving chemotherapy within 4 to 8 weeks of surgery.
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Introduction
Breast cancer is the most common malignancy diagnosed worldwide; currently, it is the leading cause of
cancer-related death in women. 1 It is estimated that in 2017 there were 252,710 Americans diagnosed
with invasive breast cancer and 40,610 died of the disease. The lifetime risk of women developing breast
cancer is approximately 12.4%, or 1 in 8 women. Over the last 10 years, the incidence of new female breast
cancer cases has been relatively stable. Most women are diagnosed between 55 and 64 years old. The
average 5-year survival rate is 89.7% and patients with higher disease stage have decreased 5-year
survival. Death rates have been falling at an average rate of 1.8% per year. 2
The Women’s Health and Cancer Rights Act of 1998 increased access to reconstructive services for
women with breast cancer. Since that time, an increased proportion of women have undergone
reconstructive procedures by plastic surgeons. In the United States, there has been a nearly 20% increase
in rates of reconstruction from 1998 to 2007. During the same time period, there was an increasing
proportion of implant-based breast reconstruction compared with autologous-based breast reconstruction
and higher rates of bilateral mastectomy. 3,4
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Risk Factors
Although the etiology of most breast cancer is unknown, risk factors have been clearly defined. These
include female gender, increasing patient age, family history of breast cancer at a young age, early
menarche, late menopause, older age at first live childbirth, prolonged hormone replacement therapy,
previous exposure to therapeutic chest wall irradiation, benign proliferative breast disease, increased
mammographic density, and genetic mutations. Aside from gender, increasing age and genetic mutations
are the only substantial risk factors.
The National Cancer Institute (NCI) and National Surgical Adjuvant Breast and Bowel Project (NSABP)
have developed the Breast Cancer Risk Assessment Tool that can help women to estimate their risk of
developing invasive breast cancer (). This tool is also known as the
Gail Model. The model uses a women’s history of prior breast malignancy, gene mutations, age, age to
menarche, age at the time of her first live birth of child, family history, history of breast biopsy, and
race/ethnicity to calculate 5 year and lifetime risk of developing breast cancer. The Gail Model has only
been validated for women in the United States who are screened regularly for breast cancer.
Hereditary breast cancer accounts for up to 20% of breast cancer cases. More common syndromic breast
cancer susceptibility genes include BRCA 1 and 2, TP53 (Li-Fraumeni syndrome), PTEN (Cowden
syndrome), CDH1 (hereditary diffuse gastric cancer syndrome) STK11 (Peutz-Jeghers syndrome),
mismatch repair genes (Lynch syndrome), and NF1 (Neurofibromatosis 1). More common nonsyndromic
breast cancer susceptibility genes include PALB2, CHEK2, and ATM. Genetic testing should be
performed if a patient has a known mutation in a breast cancer susceptibility gene, if there are two or
more primary breast cancers on the same side of the family (in the same person or two separate
individuals), if there is one or more ovarian cancers on the same side of the family, if there is a first- or
second-degree relative who was diagnosed with breast cancer before the age of 45 years, or male breast
cancer. 5 Patients with strong family history of breast cancer or known genetic predisposition should
always be seen in coordination with a certified genetic counselor.
The BRCA1 and BRCA2 genes are autosomal dominant tumor suppressor genes that help to repair
damaged DNA. BRCA 1 and 2 gene mutations account for 20% to 40% of the hereditary breast cancers.
Women with the BRCA1 mutation have a 55% to 65% risk of developing breast cancer and a 39% chance
of developing ovarian cancer by age 70 years. In contrast, women with the BRCA2 mutation have a
slightly lower risk of 45% for developing breast cancer and 11% to 17% chance of developing ovarian
cancer by age 70 years. In addition to breast and ovarian cancers, patients with the BRCA gene mutation
are also at higher risk for fallopian tube, peritoneal, prostate, and pancreatic cancer. Although tests are
helpful for identifying known genetic risk factors, those who have significant family history may have
genetic mutations that have not yet been formally identified. 6,7
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Types of Breast Cancer
The most common types of breast cancer include ductal carcinoma in situ (DCIS), invasive ductal
carcinoma, and invasive lobular carcinoma. In situ, or noninvasive, cancers increase a patient’s risk for
developing invasive cancer. DCIS can transform into invasive cancer. Lobular carcinoma in situ (LCIS)
does not transform into invasive disease but instead increases one’s risk by 7 to 12 times for developing
invasive cancer in either breast. 8,9 Other less common types of breast cancer include inflammatory breast
cancer, Paget disease, Phyllodes tumor, and angiosarcoma.
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Screening
The updated American Cancer Society guidelines of 2015 recommend that women with an average risk of
breast cancer should undergo regular screening mammography starting at age 45 years. Women between
the ages of 45 and 54 years are recommended to have annual screening mammography whereas women
at the age of 55 years and older are recommended to have biennial screening mammography. Screening
mammography is recommended to continue for as long as the patient has a life expectancy of 10 years or
longer. In contrary to previous guidelines, no regular clinical breast examinations for breast cancer are
recommended for average-risk women at any age. 10 Mammography is the standard imaging technique
for breast cancer screening. Other screening modalities such as MRI are only indicated for patients with
higher-than-average risk of developing breast cancer.
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Staging
Tumor classification using the TNM staging system outlined by the American Joint Committee on Cancer
(AJCC) is used to assist in prognosis and treatment of breast cancer. This system is built upon the extent
of disease for the tumor (T), status of the regional lymph nodes (N), and presence of distant metastases
(M). More recently, the AJCC has also added tumor grade, HER2, estrogen receptor (ER), progesterone
receptor (PR), and genomic assays as part of the breast cancer staging system. 11 Early-stage breast cancer
(stages I–II) is disease that is confined to the breast without extension to the chest wall or locoregional
lymph nodes. Early-stage breast cancer is usually treated surgically and in selected patients with
radiotherapy. Breast cancers that are stage III and above require locoregional control usually consisting of
surgery and adjuvant systemic therapy. 12 Surveillance, Epidemiology, and End Results Program data
from 2007 to 2013 showed that women with stage 0 or stage 1 breast cancer have a 5-year relative survival
rate of nearly 100%. Women with stage II breast cancer have a 5-year relative survival rate of
approximately 93%. Women with stage III and stage IV breast cancers have poorer prognoses with 5-year
relative survival rates of 72% and 22%, respectively. 13
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Work-Up
An abnormal palpable breast mass or new mammographic finding is usually followed by an ultrasonic
examination that can differentiate between solid and cystic breast masses. Ultrasound can also be used to
detect lymph nodes that are suspicious for axillary metastases. The primary tumor is then evaluated by
an image guided biopsy that, if found to be positive for malignancy, is treated with surgery. Although
breast MRIs are generally more sensitive than mammography or ultrasonography, they have not been
found to improve overall survival outcomes or improve locoregional recurrence rates. 14-17
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Surgical Treatment
Improved local control is causally associated with improved breast cancer survival. 18 The surgical
treatment of breast cancer has evolved. The first surgical treatment of breast cancer was the radical
mastectomy that was popularized by William Halstead at the end of the nineteenth century. Since then,
there has been a trend toward increasingly less invasive surgical management of breast cancer. Since the
introduction of the radical mastectomy, other techniques, such as the modified radical mastectomy,
partial mastectomy, skin-sparing mastectomy (SSM), and nipple-sparing mastectomy (NSM), have been
developed. Although traditional surgical management has been used to treat the breast affected by
cancer, there has also been an increasing trend toward risk reducing procedures such as contralateral
prophylactic mastectomies.
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Breast Conservation Therapy
Breast conservation therapy (BCT) couples surgical excision of the tumor with local radiotherapy. BCT is
appropriate for early stage breast cancer and has been shown to provide equivalent overall survival rates
compared to total mastectomy while still preserving the breast. 18 Despite similar survival rates, BCT has
a reported positive margin incidence rate of 20% to 70%. Several techniques have been developed to
decrease the positive margin rates including ultrasound needle localization, stereotactic needle
localization, bracketing, or taking additional margins. 19
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Neoadjuvant Systemic Therapy
Neoadjuvant systemic therapy is indicated for patients with inoperable tumors or if BCT is desired and
the tumor size would have otherwise required a mastectomy. Cytotoxic, hormonal, and/or trastuzumab
therapy can be used to reduce the amount of tumor burden in the breast and axilla without
compromising survival. Although the entire initial tumor bed does not need to be removed, any residual
palpable or radiographic lesions should be excised. For those who have complete clinical response,
surgical excision is still indicated. 18 Decisions regarding radiation therapy should be based upon
maximal stage from prechemotherapy tumor characteristics and/or pathologic stage regardless of the
tumor’s response to adjuvant systemic therapy. 20
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Mastectomy
The goal of a mastectomy is to remove all breast tissue thus decreasing the risk for cancer recurrence. The
anatomic borders of the breast are defined by the midline medially, the latissimus dorsi muscle laterally,
the clavicle superiorly, and the insertion of the rectus abdominus muscle inferiorly. Contemporary
techniques such as the SSM and the NSM can improve aesthetic outcome. 21
The SSM was first described in June 1991 by Toth and Lappert. This technique is defined by removal of
breast tissue with modified minimal incisions leaving as much skin as possible. Contraindications for
SSM are inflammatory carcinomas, locally advanced carcinomas, and smoking (relative contraindication).
Local recurrence rates after SSM are similar to other forms of mastectomy. 22
The NSM was a natural evolution from the SSM. It is performed by removal of all breast tissue without
excision of skin and the nipple-
 areolar complex. Oncologic contraindications for NSM include a 
 tumor
to nipple distance of <2 cm or clinical involvement of the 
 skin and/or nipple. The NSM is generally
performed with a frozen section from the posterior nipple margin to confirm no cancer invasion. If this
frozen section is positive, the NSM is converted into a SSM. Partial or full nipple necrosis has been
reported in 2% to 20% of NSMs. Overall survival, disease-free survival, or local recurrence has been
shown to be similar between NSM, SSM, and modified radical mastectomy. 21
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Contralateral Mastectomy
Rates of contralateral prophylactic mastectomy are increasing without evidence of substantial
improvement of overall survival. The National Comprehensive Cancer Network currently recommends
that women with breast cancer who are 35 years or younger, premenopausal, and carriers of a known
BRCA gene mutation should only consider additional risk-reduction strategies with appropriate
counseling. Except for the populations outlined earlier, risk-reduction prophylactic mastectomies of the
breast contralateral to the known unilateral breast cancer are discouraged. It is important to discuss with
those considering contralateral risk-reduction prophylactic mastectomy that these procedures are not
without their own risk of minor and major complications, and that symmetry procedures match the
native breast to the reconstructed side. 20
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Timing of Cancer Therapies Before and After Surgery
Patients who do not receive neoadjuvant chemotherapy and who undergo surgery within 60 days of their
diagnosis have improved overall survival. 23 For patients requiring neoadjuvant chemotherapy, overall
survival, 5-year recurrence-free survival, and locoregional recurrence-free survival are equivalent when
undergoing surgery within 8 weeks of completion of their neoadjuvant chemotherapy. 24 After a
mastectomy for patients with estrogen receptor, progesterone receptor, or HER-2/neu-positive breast
cancer, adjuvant systemic therapy has been shown to have similar outcomes on overall survival if
initiated within 4 to 8 weeks of surgery. Patients with triple negative breast cancer (estrogen receptor,
progesterone receptor, and HER-2/neu-negative breast cancers) have been shown to have an overall
survival benefit if adjuvant chemotherapy is initiated within 30 days of their surgery. 25 Postmastectomy
radiation therapy is associated with improved outcomes when performed within 6 to 8 weeks of surgery.
26-29
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Management of the Axilla
Removal of axillary lymph nodes both provides pathologic staging data and helps with local control.
Unfortunately, removal of lymph nodes also results in significant morbidity. An axillary lymph node
dissection (ALND) has a 16% risk of the development of lymphedema at 5 years. Although a sentinel
lymph node biopsy (SLNB) is minimally invasive, it is still associated with a 5% rate of the development
of lymphedema at 5 years. In addition to lymphedema, there can be arm stiffness, pain, and paresthesia.
In the 1980s, two large studies (NSABP-B04 and the King’s-Cambridge trials) compared ALND and
radiation therapy with no treatment to the axilla in clinically node-negative patients. Each study
demonstrated that treating the axilla significantly decreased the recurrence rate but did not improve
survival rates in early stage breast cancer patients. With the development of lymphatic mapping
techniques, SLNB became established as the new standard for staging the axilla. The SLNB was first
described in 1994. The orderly manner with which lymph nodes drained allowed surgeons to use blue
dye and/or radioactive technetium to biopsy the first 1 to 4 nodes that took up the technetium or blue dye
to evaluate for metastases to the nodes. 30 SLNBs have been shown to have significantly less morbidity
than an ALND. Patients who undergo SLNB have improved arm volume, sensibility, and ROM
compared to those who undergo ALND. 31 In 2011, the American College of Surgeons Z0011 study was a
prospective multicenter randomized trial that showed that for clinical T1-T2 invasive breast cancer
patients with clinically negative lymph nodes that a SLNB with one to two positive SLNs was not inferior
to a complete ALND for regional control of the axilla. Patients with clinically positive nodes at the time of
diagnosis confirmed by fine needle aspiration (FNA) or core biopsy or patients who had no sentinel
nodes identified (e.g., a failure of the sentinel lymph node mapping procedure) are recommended to have
an ALND. 21,32,20,33
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Systemic Therapy
Systemic therapy has become increasingly precise. Chemotherapeutic regimens are becoming largely
based on the pathologic analysis of one’s tumor. In addition to a tumor’s molecular profile, indications for
chemotherapy include large tumor size (>2 cm), positive lymph nodes, ER-negative and PR-negative
tumors, HER-2/neu-positive tumors, and inflammatory breast cancer. Anthracycline-based systemic
therapies have been shown to improve survival compared to methotrexate-based regimens but they also
have more substantial side effects. Anthracyclines can have associated cardiotoxicity and thus should be
used carefully or avoided when treating elderly patients and those with previous cardiac disease.
Taxanes in combination with chemotherapy have also been shown to be more effective and thus have
become used as standard treatment. 5
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Radiation Therapy
Radiotherapy is an important component of local regional disease control. Whole-breast radiation
therapy with or without boost to tumor bed is required as a part of BCT and occurs after lumpectomy.
Current guidelines also recommend chest wall radiation after mastectomy if tumors are >5 cm, if
pathology margins are positive, or if there are positive ALNs. Accelerated partial breast irradiation
(APBI) is a technique that provides a more focused field of radiation after complete surgical excision of
in-breast disease but is still considered investigational and should be used within the confines of clinical
trials. The benefit of APBI is that it can be administered over a 1 to 2 week period as compared to the
typical 6 to 7 week period for whole-breast radiation. APBI commonly combines brachytherapy with
external-beam photon therapy to the tumor bed. 20
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Hormonal Blockade and Biologic Therapies
The relationship between breast cancer and hormone receptors has been well established since the 1950s.
Since them, endocrine therapies such as tamoxifen have been used to treat breast cancer. Selective
estrogen receptor modulators (SERMs), such as tamoxifen, block estrogen receptors in the breast, and
effectively block estrogen activity in breast tissue. Tumors that are progesterone receptor positive often
respond similarly to SERMs as ER-positive tumors. Hormonal blockade therapies are not without adverse
events. Tamoxifen, while reasonably well tolerated, has been shown to be associated with hot flashes,
headaches, menstrual abnormalities, a higher risk for endometrial cancer (cumulative risk 3.1% versus
1.6%), and a twofold increase in the incidence of pulmonary embolism. Current recommendations call for
at least 5 years of treatment with a longer course of 10 years having been shown to further reduce
recurrence and increase survival.
Aromatase inhibitors, such as anastrozole, have been demonstrated to increase disease-free survival,
increase time to recurrence, and decrease rates of distant metastases and contralateral breast cancer with
fewer adverse side effects compared to tamoxifen in ER-positive postmenopausal women. 5,34-36
Targeted biologic therapies are used to treat patients with HER-2/neu receptor positivity. HER-2/neu
receptor positive tumors are known to have a poorer prognosis with high rates of recurrence, relative
resistance to hormonal therapy, and resistance to some chemotherapeutics. The monoclonal antibody
against HER-2/neu, trastuzumab, has been shown to significantly improve outcomes in HER-2-positive
cancers. Current guidelines recommend the use of trastuzumab in patients with HER-2/neu-positive
tumors for 1 year. 5
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Questions
1. A 62-year-old female presents with stage II invasive ductal carcinoma. The tumor measures 2.8 cm
and is positioned 1.3 cm from her nipple. Clinically, she has no involvement of her axillary lymph
nodes. She desires to undergo a NSM. What are her oncologic contraindications to undergoing a
NSM?
a. Tumor is within 2 cm of her nipple
b. Tumor is >2.5 cm in size
c. Tumor is consistent with invasive ductal carcinoma
d. Patient is older than 60 years of age
e. Patient has stage II breast cancer
2. A 53-year-old female presents with stage III, ER/PR-positive, and Her-2/neu-positive right breast
cancer. She undergoes a right SSM with placement of a prepectoral tissue expander. Her oncologist
has recommended chemotherapy and would like to initiate it as soon as possible. How long after her
mastectomy can you delay chemotherapy without impacting her overall survival?
a. 8 weeks
b. 9 weeks
c. 10 weeks
d. 12 weeks
e. 14 weeks
3. A 56-year-old female comes to your clinic to be evaluated for bilateral mastopexy. She appears to
be a good candidate for a mastopexy. She has no personal or family history of breast cancer and
denies any new masses in her breasts. Her last mammogram was performed 14 months ago, and
there was no evidence of malignancy. How frequently should she have screening mammography?
a. Annually
b. Every 5 years
c. Biennially
d. No need for screening mammogram giving her low risk profile
e. Every 6 months
4. A 43-year-old female with an extensive family history of breast cancer was recently diagnosed
with stage IIA left breast cancer. Her mother was diagnosed with breast cancer at age 46 and her
sister was diagnosed at age 42. Genetic testing was performed, and she has no known genetic
predisposing for breast cancer. She presents for a NSM with SLNB with a submuscular tissue
expander placement. She had no clinically positive nodes preoperatively. Her SLNB demonstrated
three positive lymph nodes, and she undergoes an ALND. What are her indications for the ALND?
a. Stage IIA breast cancer
b. Preoperative history of clinically negative nodes
c. Family history of breast cancer
d. Greater than 2 positive sentinel lymph nodes
e. NSM
5. Patients with the BRCA gene mutations are at increased risk of developing breast and ovarian
cancer as well as which of the other cancers listed below?
a. Lung cancer
b. Pancreatic cancer
c. Basal cell carcinoma
d. Lymphoma
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e. Glioblastoma
1. Answer: a. NSM is becoming more popular technique. The overall rate of occult nipple
malignancy is 11.5%. Characteristics of the primary tumor that increase the risk for occult nipple
malignancy include tumor-nipple distance <2 cm, tumor stage >2, lymph node metastasis,
lymphovascular
invasion,
human
epidermal
growth
receptor-2-positive,
estrogen
receptor/progesterone receptor-negative, tumor size >5 cm, retroareolar/central location, and
multicentric tumors.
Reference:
Mallon, P, Feron, JG, Couturaud, B, et al. The role of nipple-sparing mastectomy in breast cancer: a
comprehensive review of the literature. Plast Reconstr Surg. 2013;131(5):969-984.
2. Answer: a. There is no difference in overall survival when comparing initiation of adjuvant
chemotherapy within 4 weeks or within 8 weeks after surgery for patients who have estrogen
receptor, progesterone receptor, or HER-2/neu-positive breast cancers. In patients with triple
negative breast cancers, initiation of adjuvant chemotherapy within 4 weeks of surgery has been
shown to improve overall survival.
Reference:
Gagliato, Dde M, Gonzalez-Angulo, AM, Lei, Xet al. Clinical impact of delaying initiation of adjuvant
chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32(8):735-744.
3. Answer: c. The updated American Cancer Society guidelines of 2015 recommend that women with
an average risk of breast cancer should undergo regular screening mammography starting at the age
of 45 years. Women between the ages of 45 and 54 years are recommended to have annual screening
mammography while women at the age of 55 years and older are recommended to have biennial
screening mammography. Screening mammography is recommended to continue for as long as the
patient has a life expectancy of 10 years or longer.
Reference:
Oeffinger, KC, Fontham, ET, Etzioni, R, et al. Breast cancer screening for women at average risk: 2015
guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614.
4. Answer: d. In 2011, the American College of Surgeons Z0011 study was a prospective multicenter
randomized trial that showed that for clinical T1–T2 invasive breast cancer patients with clinically
negative lymph nodes that a SLNB with one to two positive SLNs was not inferior to a complete
ALND for regional control of the axilla. Patients with clinically positive nodes at the time of
diagnosis confirmed by FNA or core biopsy or patients who had no sentinel nodes identified (e.g., a
failure of the sentinel lymph node mapping procedure) are recommended to have an ALND.
Reference:
Giuliano, AE, Hunt, KK, Ballman, KV, et al. Axillary dissection vs no axillary dissection in women
with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA.
2011;305(6):569-575.
5. Answer: b. The BRCA1 and BRCA2 genes are autosomal dominant tumor suppressor genes that
help to repair damaged DNA. BRCA 1 and 2 gene mutations account for 20% to 40% of the
hereditary breast cancers. Women with the BRCA1 mutation have a 55% to 65% risk of developing
breast cancer and a 39% chance of developing ovarian cancer by the age of 70 years. In contrast,
women with the BRCA2 mutation have a slightly lower risk of 45% for developing breast cancer and
11% to 17% chance of developing ovarian cancer by the age of 70 years. In addition to breast and
ovarian cancers, patients with the BRCA gene mutation are also at higher risk for fallopian tube,
peritoneal, prostate, and pancreatic cancer.
Reference:

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References
Network NCC. NCCN Guidelines Version 3.2017 Breast Cancer. Accessed
November 11, 2017.
Surveillance E, and End Results Program. Cancer Stat Facts: Female Breast Cancer.
Accessed November 11, 2017.
Jagsi, R, Jiang, J, Momoh, AO, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing
mastectomy in the United States. J Clin Oncol. 2014;32(9):919-926.
Kwok, AC, Goodwin, IA, Ying, J, Agarwal, JP. National trends and complication rates after bilateral mastectomy and immediate breast
reconstruction from 2005 to 2012. Am J Surg. 2015;210(3):512-516.
Matsen, CB, Neumayer, LA. Breast cancer: a review for the general surgeon. JAMA Surgery. 2013;148(10):971-980.
NIH NCI. BRCA1 and BRCA2: Cancer Risk and Genetic Testing; 2017.
Frey, JD, Salibian, AA, Schnabel, FR, Choi, M, Karp, NS. Non-BRCA1/2 breast cancer susceptibility genes: a new frontier with clinical
consequences for plastic surgeons. Plast Reconstr Surg Glob Open. 2017;5(11):e1564.
Society AC. Lobular Carcinoma In Situ (LCIS); 2017.
Society AC. Types of Breast Cancer; 2017.
Oeffinger, KC, Fontham, ET, Etzioni, R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American
Cancer Society. JAMA. 2015;314(15):1599-1614.
Cancer AJCo. Breast cancer. AJCC Cancer Staging Manual. 8th ed.; 2017.
Teven, CM, Schmid, DB, Sisco, M, Ward, J, Howard, MA. Systemic therapy for early-stage breast cancer: what the plastic surgeon should
know. Eplasty. 2017;17:e7.
Society AC. Breast Cancer Survival Rates; 2017.
Turnbull, L, Brown, S, Harvey, I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial.
Lancet. 2010;375(9714):563-571.
Morris, EA. Should we dispense with preoperative breast MRI? Lancet. 2010;375(9714):528-530.
Shin, H-C, Han, W, Moon, H-G, et al. Limited value and utility of breast MRI in patients undergoing breast-conserving cancer surgery. Ann
Surg Oncol. 2012;19(8):2572-2579.
Weber, JJ, Bellin, LS, Milbourn, DE, Verbanac, KM, Wong, JH. Selective preoperative magnetic resonance imaging in women with breast
cancer: no reduction in the reoperation rate. Arch Surg. 2012;147(9):834-839.
Kaufmann, M, Morrow, M, von Minckwitz, G, Harris, JR. Locoregional treatment of primary breast cancer. Cancer. 2010;116(5):1184-1191.
Edwards, SB, Leitman, IM, Wengrofsky, AJ, et al. Identifying factors and techniques to decrease the positive margin rate in partial
mastectomies: have we missed the mark? Breast J. 2016;22(3):303-309.
Gradishar, WJ, Anderson, BO, Balassanian, R, et al. Invasive breast cancer version 1.2016, NCCN clinical practice guidelines in oncology. J
Natl Compr Cancer Netw. 2016;14(3):324-354.
Cil, TD, McCready, D. Modern approaches to the surgical management of malignant breast disease: the role of breast conservation, complete
mastectomy, skin-and nipple-sparing mastectomy. Clin Plastic Surgery. 2018;45(1):1-11.
González, EG, Rancati, AO. Skin-sparing mastectomy. Gland Surg. 2015;4(6):541.
Bleicher, RJ, Ruth, K, Sigurdson, ER, et al. Time to surgery and breast cancer survival in the United States. JAMA Oncol. 2016;2(3):330-339.
Sanford, RA, Lei, X, Barcenas, CH, et al. Impact of time from completion of neoadjuvant chemotherapy to surgery on survival outcomes in
breast cancer patients. Ann Surg Oncol. 2016;23(5):1515-1521.
Gagliato, Dde M, Gonzalez-Angulo, AM, Lei, X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast
cancer. J Clin Oncol. 2014;32(8):735-744.
Whelan, TJ. Use of conventional radiation therapy as part of breast-conserving treatment. J Clin Oncol. 2005;23(8):1718-1725.
Buchholz, TA. Radiation therapy for early-stage breast cancer after breast-conserving surgery. New Engl J Med. 2009;360(1):63-70.
Punglia, RS, Saito, AM, Neville, BA, Earle, CC, Weeks, JC. Impact of interval from breast conserving surgery to radiotherapy on local
recurrence in older women with breast cancer: retrospective cohort analysis. BMJ. 2010;340:c845.
Silva, SB, Pereira, AAL, Marta, GN, et al. Clinical impact of adjuvant radiation therapy delay after neoadjuvant chemotherapy in locally
advanced breast cancer. Breast. 2018;38:39-44.
Rao, R, Euhus, D, Mayo, HG, Balch, C. Axillary node interventions in breast cancer: a systematic review. JAMA. 2013;310(13):1385-1394.
Madsen, AH, Haugaard, K, Soerensen, J, et al. Arm morbidity following sentinel lymph node biopsy or axillary lymph node dissection: a
study from the Danish Breast Cancer Cooperative Group. Breast. 2008;17(2):138-147.
Ozmen, T, Vinyard, AH, Avisar, E. Management of the positive axilla in 2017. Cureus. 2017;9(5).
Giuliano, AE, Hunt, KK, Ballman, KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel
node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575.
Burstein, HJ, Temin, S, Anderson, H, et al. Adjuvant endocrine therapy for women with hormone receptor–positive breast cancer: American
Society of Clinical Oncology Clinical Practice Guideline focused update. J Clin Oncol. 2014;32(21):2255-2269.
Shagufta, Ahmad, I. Tamoxifen a pioneering drug: an update on the therapeutic potential of tamoxifen derivatives. Eur J Med Chem.
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2018;143:515-531.
Cuzick, J, Forbes, JF, Sestak, I, et al. Long-term results of tamoxifen prophylaxis for breast cancer—96-month follow-up of the randomized
IBIS-I trial. J Natl Cancer Inst. 2007;99(4):272-282.
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Key References
Network NCC. NCCN Guidelines Version 3.2017 Breast Cancer. Accessed
November 11, 2017.These are peer reviewed national guidelines for the work-up and treatment of breast cancer.
Matsen, CB, Neumayer, LA. Breast cancer: a review for the general surgeon. JAMA Surg. 2013;148(10):971-980.This is a concise review of
screening, work-up, and treatment of breast cancer with a focus on pertinent information for a surgeon.
Oeffinger, KC, Fontham, ET, Etzioni, R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American
Cancer Society. JAMA. 2015;314(15):1599-1614.These paper outlines the most recent American Cancer Society guidelines for breast cancer screen for
women at average risk.
Gagliato, Dde M, Gonzalez-Angulo, AM, Lei, X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast
cancer. J Clin Oncol. 2014;32(8):735-744.This paper examines the risks of delaying adjuvant chemotherapy.
Giuliano, AE, Hunt, KK, Ballman, KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel
node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575.This is also known as the American College of Surgeons Z0011 study.
The results of this paper set the standard for how surgeons decide on whether or not to perform an ALND.
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C H A P T E R 5 9
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Breast Reconstruction: Prosthetic Techniques
Peter W. Thompson and Grant W. Carlson
Key Points
Implant-based reconstruction is the most common method of breast reconstruction employed by
plastic surgeons.
Advantages of implant-based reconstruction include decreased operative time, no donor site
morbidity, and faster patient recovery.
Disadvantages include implant-related complications such as infection, capsular contracture, and
implant malposition.
Prosthetic reconstruction may be performed in an immediate or delayed fashion, in one or two
stages. Healthy patients with smaller breasts, early stage breast cancer, and healthy mastectomy skin
flaps are the best candidates for immediate and single-stage reconstruction.
Acellular dermal matrix in implant-based reconstruction is a useful adjunct to provide total implant
coverage while defining and maintaining implant position.
Adjuvant radiation therapy significantly increases the rate of complications and reconstructive
failure following implant-based reconstruction while decreasing patient-
 reported aesthetic
outcomes and quality-of-life measures.
Acute complications such as hematoma, infection, and mastectomy skin flap necrosis must be treated
quickly and aggressively to avoid implant loss and suboptimal aesthetic outcome.
The primary technical goal of breast reconstruction is to recreate a breast mound in the postmastectomy
patient. Prosthetic breast reconstruction techniques use tissue expanders and breast implants to
accomplish this goal.
In 2002, breast reconstruction using prosthetic techniques became the most popular method of immediate
breast reconstruction, outpacing autologous methods. According to a survey of the Nationwide Inpatient
Sample database, the rate of immediate prosthetic breast reconstructions increased by 11% per year over a
period of time from 1998 to 2008, whereas the rate of autologous reconstruction remained stable. 1 The
reasons for this trend are likely multifactorial, including the increased prevalence of contralateral
prophylactic mastectomy, a favorable operative morbidity profile for prosthetic reconstruction, and
changes in patterns of reimbursement for breast reconstruction procedures. 2 In 2016, 81% of breast
reconstructive procedures used prosthetic techniques. 3
Prosthetic breast reconstruction techniques, also called implant-based reconstructions, hold certain
widely accepted advantages over autologous methods (Table 59.1). First, prosthetic techniques minimize
operative and donor site morbidity. The time required to perform placement of an implant or tissue
expander is significantly shorter (around 1–1.5 hours) than that required for an autologous flap, which
can extend beyond 6 hours of operative time. No dissection of donor site tissue, tunneling into the
mastectomy defect or dissection of recipient vessels, is necessary with prosthetic techniques. Prosthetic
techniques preserve autologous methods of reconstruction as options for future procedures, should
patient preference or necessity determine the need for conversion. Hospital length of stay and patient
recovery are generally shorter with prosthetic techniques compared to autologous reconstruction.
TABLE 59.1
Advantages and Disadvantages of Implant-Based Reconstruction
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Advantages
Shorter operative time
Shorter hospital stay
Shorter recovery
No donor tissue or recipient vessel dissection necessary
Disadvantages
Implant-related complications (implant infection, capsular contracture, implant malposition, rippling, rupture)
Less natural feel compared to autologous tissue
Difficult to achieve symmetry in unilateral reconstruction
Prosthetic reconstruction techniques also have several disadvantages compared to autologous methods
(see Table 59.1). First, it can be more difficult to match the appearance of an implant reconstruction to a
contralateral native breast in the setting of unilateral reconstruction, making symmetry harder to achieve.
Second, breast implants and tissue expanders can experience device-related complications including
implant infection or exposure, capsular contracture, implant malposition, implant visibility or rippling,
and implant rupture. Third, an implant does not behave like normal breast tissue or autologous tissue in
look, feel, and development of ptosis over time.
For properly selected patients undergoing breast reconstruction, prosthetic techniques have the potential
to create an attractive breast mound that can help improve a patient’s psychosocial, physical, and sexual
well-being following mastectomy. 4 In this chapter, we highlight some of the different viewpoints
concerning timing, technique, and patient selection for implant-based reconstruction.
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Patient Selection for Prosthetic Techniques
Successful prosthetic breast reconstruction begins with proper patient selection. Careful attention to
patient and oncologic factors in the planning stages of breast reconstruction will ensure an optimal
aesthetic outcome with an acceptable complication profile. Risk factors for complications in implant
reconstruction include the following:
Smoking
Obesity (BMI >30)
Large breasts
Diabetes (Hgb A1C >6.5%)
The patient selection process begins with a thorough discussion of patient expectations. One important
consideration is the desired postoperative breast volume. Maintaining premastectomy breast volume
after reconstruction in a patient with macromastia may be difficult or impossible using prosthetic
reconstruction techniques if an appropriately sized implant is not available; in addition, large
mastectomy specimen weight was found to be an independent risk factor for implant loss in prosthetic
reconstruction. 5
Certain patient comorbidities make the rate of complications following prosthetic reconstruction
unacceptably high. It is accepted that smokers have an increased rate of overall complications, tissue
necrosis, and need for reoperation in general following plastic surgical procedures 6 ; there is also ample
evidence that smoking increases the rate of complications specifically following prosthetic breast
reconstruction. An analysis of ACS-NSQIP data demonstrated that active smokers have an odds ratio of
four for early tissue expander loss compared to nonsmokers. 7 Two studies from the Memorial Sloan-
Kettering Cancer Center demonstrated that smoking more doubles the rate of mastectomy skin flap
necrosis, infection, and reconstructive failure in patients undergoing implant-based reconstruction
(Figure 59.1). 8,9 The authors also demonstrated a dose-
 response effect for tobacco use, with the incidence
of complications increasing with the number of packs per day smoked. 8 Interestingly, although some
surgeons recommend smoking cessation for at least a month prior to surgery, there is some evidence that
the rate of complications in former smokers, those who stopped smoking 1 month or more before surgery,
is similar to the rate of complications in active smokers. 8,9 Patients should be thoroughly educated about
the detrimental effects of tobacco, and if active smoking continues, serious consideration should be given
to delaying reconstruction.
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FIGURE 59.1 Mastectomy skin flap necrosis. Partial-thickness (A) and full-thickness (B) mastectomy skin flap necrosis
following implant-based reconstruction in patients with history of smoking.
Diabetes has been associated with an increased risk of wound healing complications in a variety of
surgical procedures, and breast reconstruction is no exception. NSQIP database analysis suggests that
diabetes increases the overall 30-day complication rate and the rate of wound healing complications in
expander/implant-based reconstruction. 10 In addition, data from Hart et al. suggest that even well-
controlled diabetes (average preoperative blood glucose 137 mg/dL) increases the 1-year rate of wound
healing problems following prosthetic but not autologous reconstruction. 11 In patients with poorly
controlled diabetes, referral to diabetic educators and endocrine specialists may be appropriate before
consideration of reconstruction. A team-based approach to perioperative glucose management should be
undertaken with the goal of preoperative Hgb A1C <6.5%, and perioperative glucose levels under
200 mg/dL. 12
Obesity is also associated with worse outcomes following breast reconstruction. Using the MarketScan
database, Huo et al. demonstrated that the 1-year rate of infectious and wound complications in patients
undergoing expander/implant reconstruction was significantly higher in patients with BMI >30. 13
Similarly, McCarthy et al. demonstrated that patients with BMI >30 were almost seven times more likely
to experience reconstructive failure following prosthetic reconstruction than their nonobese counterparts.
9 In addition, device projection may be severely limited in patients with overly thick mastectomy flaps;
therefore, obese patients should be counseled that preoperative weight loss will not only decrease their
risk of postoperative complications, but also potentially improve the appearance of the final result.
Successful patient selection for prosthetic breast reconstruction must also consider oncologic factors.
Close communication with the ablative surgeon is extremely important during the planning phase of
breast reconstruction to avoid complications and optimize outcomes. The size of the tumor and lymph
node status are crucial pieces of information for the reconstructive surgeon; clinical staging helps
determine the likely need for adjuvant radiotherapy, which can greatly affect complication rates
following implant-based reconstruction. Other important factors to discuss with the ablative surgeon that
may influence the choice to pursue implant-based reconstruction include the plan for unilateral versus
bilateral mastectomy, and whether a nipple-sparing mastectomy approach is appropriate.
A thorough physical exam can help determine if a patient is an appropriate candidate for prosthetic
reconstruction. The preoperative breast size must be taken into account; macromastia is not a
contraindication to implant-based reconstruction, but does require attention to tailoring of the skin
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envelope, such as with skin-reducing mastectomy methods (Figure 59.2). 14 Examination of potential
donor sites is important, as a lack of adequate tissue or volume will immediately disqualify patients from
undergoing reconstruction with autologous techniques.
FIGURE 59.2 Skin-reducing mastectomy. Preoperative (A) and postoperative (B) views following skin-reducing mastectomy
with implant reconstruction and nipple-areola reconstruction.
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Timing of Prosthetic Reconstruction
The plastic surgeon undertaking an implant-based breast reconstruction must decide whether to perform
the reconstruction in an immediate fashion (at the time of mastectomy) or delayed fashion (as a staged
procedure following recovery from mastectomy and/or adjuvant therapy). Each approach has distinct
advantages and disadvantages (Table 59.2). Immediate breast reconstruction, by preserving the original
skin envelope and native breast borders, has been purported to optimize aesthetic outcomes and patient
satisfaction, 15 while minimizing the negative psychological impact of mastectomy on a patient’s self-
image. 16 In addition, immediate reconstruction potentially minimizes the number of trips to the
operating room and recovery downtime. Proponents of delayed prosthetic reconstruction have argued
that this approach results in a lower rate of complications including mastectomy skin flap necrosis,
capsular contracture, and need for device removal.
17,18 The decision to perform a prosthetic
reconstruction in an immediate or delayed fashion should be based on patient factors, oncologic factors,
and technical aspects of the mastectomy itself. In general, immediate reconstruction will achieve optimal
results in patients with a lower preoperative risk profile (nonsmoker, nonobese) and early stage cancers.
Delayed reconstruction is more appropriate in patients with advanced stage cancers in whom close tumor
surveillance is needed or adjuvant therapy is likely; in addition, if there is concern about the viability of
the mastectomy skin flaps and adequate tissue for device coverage at the time of mastectomy, an
intraoperative decision to delay reconstruction may be appropriate (Figure 59.3). 19
TABLE 59.2
Advantages of Immediate and Delayed Prosthetic Reconstruction
Immediate
Preserves native skin envelope and breast borders
Minimizes trips to the operating room
Improved psychological and emotional outcome
Delayed
Decreased risk of complications in setting of patient comorbidities or need for adjuvant radiation
Decreased risk of mastectomy skin flap necrosis
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FIGURE 59.3 Delayed placement of tissue expander in breast reconstruction. A. Preoperative view following bilateral
mastectomy. B. Following delayed placement of tissue expander and inflation. C. Following exchange for permanent implant
and nipple-areola reconstruction.
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Technical Considerations in Implant-Based Reconstruction
Single- Versus Two-Stage Reconstruction
As previously mentioned, prosthetic breast reconstruction may be completed with either a two-stage
(placement of tissue expander followed by exchange for permanent implant) or single-stage (direct
placement of permanent implant after mastectomy) approach. A direct-to-implant approach has the
obvious advantage of eliminating (1) multiple office visits for device expansion, (2) risk of infection
related to expander filling access and manipulation, and (3) second-stage surgery for expander-to-implant
exchange. Single-stage implant breast reconstruction can achieve excellent outcomes with acceptable
revision rates in properly selected patients, but is technically demanding, requiring precise implant
selection and positioning following an often unpredictable extirpative procedure. A quality mastectomy
is a major determinant of the success of direct-to-implant reconstruction; a skin-sparing or nipple-sparing
mastectomy with appropriate skin flap thickness and viability that preserves the inframammary fold will
help avoid the complications of implant malposition, skin flap necrosis and device exposure. Adjuncts
such as indocyanine green angiography can provide an objective assessment of skin flap perfusion, and
acellular dermal matrix (discussed later) is a useful tool for providing total implant coverage and
securing implant position. Patient comorbidities such as diabetes and smoking, need for adjuvant
radiation, and increasing premastectomy breast size have all been found to be risk factors for
postoperative complications following single-stage reconstruction. 20,21 Few individual studies have
demonstrated any significant difference in complication rates between single- and two-stage prosthetic
reconstruction; however, in a recent systematic review and head-to-head meta-analysis, Basta et al. found
a significantly increased risk of skin flap necrosis, need for reoperation, and reconstructive failure in
patients undergoing direct-to-implant reconstruction (OR 1.43, 1.25, and 1.87, respectively). The overall
absolute rate of implant loss was 14.4% for single- and 8.7% for two-stage reconstruction. 22
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Acellular Dermal Matrix
Acellular dermal matrix (ADM) exists in various forms as human or animal cadaveric, decellularized
dermis. It is useful as an adjunct to prosthetic breast reconstruction for its ability to better define the
mastectomy space and provide support to soft tissues, essentially acting as a hammock to stabilize the
implant or expander device. When used in single- or two-stage reconstruction, ADM can help maintain
the device in the optimal position on the chest wall, add definition to the inframammary fold and lateral
breast border, and improve lower pole projection (Figure 59.4). In several studies, these advantages have
translated into improved aesthetic outcomes as determined by independent observer subjective review, 23
compared to prosthetic reconstruction without ADM or even compared to total submuscular coverage. 24
In the setting of two-stage prosthetic reconstruction, the use of ADM was associated with a higher
intraoperative fill volume and shorter time to optimal expansion. 25 There are data suggesting that ADM
is useful in both the primary prevention and secondary treatment of capsular contracture. Compared to
an expected 5-year capsular contracture rate of between 10% and 30%, multiple series in the recent
literature have demonstrated a much lower rate (between 0% and 4%) when ADM is used as an adjunct
to prosthetic reconstruction. 23,26,27 Several of the patients in these studies had breast irradiation before or
after surgery, suggesting that the use of ADM may ameliorate some of the negative sequelae associated
with radiation treatment. These benefits may come at the expense of a higher complication rate; multiple
retrospective reviews have demonstrated a higher incidence of acute postoperative complications
including infection, seroma, skin flap necrosis, and reconstructive failure in prosthetic reconstructions
employing ADM. 28-30 The strength of this data is diminished by selection bias and confounders such as
morbid obesity, which is also known to contribute to higher seroma rates. Taken together, most surgeons
feel that, in properly selected patients (i.e., normal BMI, nonsmokers), the benefits of ADM use likely
outweigh the potential drawbacks.
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FIGURE 59.4 Submuscular placement of tissue expander with acellular dermal matrix for lower pole support and coverage.
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Implant Selection
Choice of device is an important component of planning both expander-based and direct-to-implant
reconstruction. There are many options for size, shape, and texture of both expanders and permanent
implants.
There is a more limited range of options in choice of tissue expanders. Most commercially available tissue
expanders designed for use in breast reconstruction use a textured surface, a relative anatomic shape for
differential filling of the lower pole, and a magnetic port for filling with saline. Expanders are available in
different height, projection, capacity, and base width. Among these, base width is the most important
parameter for intraoperative device selection; matching the device base width to the width of the breast
footprint on the chest wall eliminates dead space and skin redundancy while optimizing the final
expansion pocket. Expander capacity is less important, as many expander devices may be filled well
beyond their stated maximum volumes. 31
Permanent implants are available in an ever-increasing variety of sizes, shapes, textures, fills, and
cohesivity. In general, there are several decisions that must be made when selecting a permanent implant.
Most available data directly comparing different types of implant exist in the breast augmentation
literature, and must be extrapolated to breast reconstruction.
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Saline Versus Silicone
Both saline and silicone have distinct advantages and disadvantages from both the patient and surgeon
perspective. It is easier to detect a saline implant rupture. Saline implants require a less rigorous
surveillance protocol, but likely have higher rates of implant visibility and rippling. Silicone implants
more closely resemble the look and feel of the native breast tissue, but silicone leak or implant rupture
may be harder to detect and can lead to capsular contracture; in contrast, saline is physiologically inert
and is simply absorbed if there is a leak. Available data suggest that rates of rupture and capsular
contracture may be slightly higher in silicone implants than in saline at 10 years following implantation.
32-34 There is also some evidence that patients have improved overall satisfaction as well as self-assessed
psychological and sexual function after receiving silicone versus saline implants in breast reconstruction.
35 There is no evidence to support the idea that patients with silicone implants are more likely to develop
rare neurologic or connective tissue diseases. 36
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Smooth Versus Textured
Textured implants were developed in an attempt to reproduce lower rates of capsular contracture
obtained historically with placement of polyurethane-coated devices. In general, rates of capsular
contracture do appear to be lower with textured devices, though this difference appears less significant
when implants are placed in the submuscular position. 37,38 Again, these data are extrapolated from
literature specific to breast augmentation. Another benefit of textured implants includes a more stable
position within the pocket, which theoretically decreases lower pole stretch over time. There appears to
be a small increase in risk of breast-implant-associated anaplastic large-cell lymphoma (BIA-ALCL) with
use of textured devices. This effect may be greatest with macrotextured implants. The overall incidence of
this complication is still low (∼1/30,000), but discussion of BIA-ALCL is an important part of the
informed consent process. 39
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Round Versus Anatomic
Anatomic-shaped implants have been in use for several years and are preferred by some plastic surgeons
in breast reconstruction for their ability to better match the device to the original breast footprint
following mastectomy. Shaped implants may result in improved upper pole shape and volume,
especially in reconstruction of breasts that are taller than they are wide. Placing an anatomic implant is
more technically challenging, because without precise pocket control, implant rotation may result.
Patients may also report a somewhat firmer feel compared to a softer, round silicone implant. In practice,
there has been little detectable difference in patient satisfaction, aesthetic outcome, or complication rates
between shaped and round implants in breast reconstruction. Interestingly, blinded expert observers in
one study were not routinely able to differentiate which type of implant a patient had received. 40 All
currently available anatomic-shaped implants are also textured to limit unwanted implant
movement/rotation; therefore, all of the risks and benefits of textured devices also apply to shaped
devices.
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Standard Technique for Submuscular, Two-Stage Implant-Based Reconstruction With
Acellular Dermal Matrix
Procedure begins with assessment of mastectomy cavity, including evaluation of mastectomy skin flap
thickness/regularity, hemostasis, and preservation of native breast footprint (i.e., violation of
inframammary fold). The breast base width may be measured, and expander size selection is made. Note
is made of the mastectomy specimen weight. Indocyanine green angiography may be performed as an
adjunct to evaluate mastectomy skin flap viability. If viability or skin quality is a concern, placement of a
device is relatively contraindicated and may be deferred to a later time. If native breast borders have been
violated, recreation of these natural landmarks such as the lateral breast border and inframammary fold
may be accomplished with placement of absorbable sutures.
The lateral border of the pectoralis muscle is identified and raised; the submuscular plane is defined
superiorly and medially to the sternal origin of the muscle. A lighted retractor or headlamp, long cautery
tip, and muscle paralysis help with this step. After the submuscular plane is developed, the inferior
origins of the pectoralis muscle along the inframammary fold are divided and released to the level of the
sternum. Additional muscle origin along the most inferior portions of the sternum may be divided
further if increased lower pole projection is needed or desired. Care is taken to maintain perfect
hemostasis when large intercostal and internal mammary artery perforators are encountered.
A rectangular or contoured piece of ADM is brought onto the field. Usually, a piece 8 × 16 cm in size is
more than sufficient. The ADM is anchored medially at the junction of the muscle and chest wall, and
then anchored with interrupted absorbable sutures to the thick fascial attachments of the inframammary
fold. Laterally, the ADM is sutured to the chest wall to reapproximate the lateral breast border. Excess
ADM is trimmed away, leaving a curvilinear sling along the lower and lateral aspects of the mastectomy
cavity.
At this point, the cavity is irrigated with antibiotic solution and hemostasis confirmed once again in both
the subcutaneous and submuscular space. The previously selected tissue expander is brought onto the
field and all air removed from the device. The expander is then inserted into the submuscular space and
anchored medially and laterally to the chest wall using the suture tabs on the device (if available).
The inferior border of the pectoralis muscle is sutured to the superior border of the ADM sling to prevent
window-shading of the muscle. Excess ADM is removed to set the appropriate muscle tension. The device
should now be completely covered by the combination of muscle in the upper pole and ADM in the
lower pole. Drains are placed in the subcutaneous space and brought out below the lateral aspect of the
inframammary fold. One or two drains may be used depending on the amount of dead space. The tissue
expander port may now be accessed and the expander filled as desired. After filling the expander, the
mastectomy incision may be tailor tacked and a final indocyanine green perfusion assessment performed.
If there is a worsening in the appearance of the flaps with the expander in place, volume may be removed
from the device, as appropriate, to take pressure off of the skin flaps. The mastectomy incision is
meticulously closed in two layers with absorbable monofilament suture. A surgical dressing is applied
and the patient is placed in a surgical bra or chest binder. Overnight admission for pain control is
standard at our institution.
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Implant-Based Reconstruction in the Setting of Adjuvant Therapy
The need for adjuvant or neoadjuvant therapy can complicate the decision to employ prosthetic
techniques in breast reconstruction, negatively impacting the ability of the reconstructive surgeon to
create an aesthetic and natural appearing breast mound (Figure 59.5). Radiation of a prosthetic device can
lead to increased rates of early complications such as infection, seroma, and mastectomy flap necrosis, as
well as delayed complications such as capsular contracture, poor aesthetic outcome, and reconstructive
failure. The odds ratio of developing any complication following radiation of an implant-based
reconstruction is approximately 4.2 compared to no radiation, 41 and the rate of reconstructive failure is
generally accepted to be around 20% compared to 3% in those not receiving adjuvant radiotherapy. 42
Compared to radiation of an autologous reconstruction, patients undergoing postmastectomy radiation
therapy following implant reconstruction have been shown to have higher rates of overall complications
and significantly lower patient-reported quality-of-life scores as determined by the BREAST-Q. 43
However, patient desire for implant-based reconstruction, a shortage of autologous options, or
unplanned need for adjuvant therapy may still result in the need to radiate a prosthetic reconstruction.
Considerable effort has been devoted to determining the optimal timing and protocol for radiation
therapy to minimize complication rate while maximizing aesthetic outcome and patient quality of life.
FIGURE 59.5 Effect of radiation on appearance of reconstructed breast. Preradiation (A) and postradiation (B) views of
implant reconstruction, demonstrating skin color change, contraction of skin envelope, and nipple-areola malposition.
When breast reconstruction is undertaken in the setting of adjuvant radiation therapy, the plastic
surgeon’s goal of creating an aesthetic, symmetric, and natural appearing breast mound must not
overshadow the oncologic goals of local and systemic eradication of breast cancer cells. Further
complicating reconstructive planning, the indications for radiotherapy in breast cancer appear to be
expanding. In general, postmastectomy radiation is considered in any clinical scenario with an elevated
risk of locoregional recurrence. The indications for radiation therapy as outlined by the National
Comprehensive Cancer Network (NCCN) are as follows 44 :
Radiation indicated
Following breast conservation therapy
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Inflammatory breast cancer (may also be considered as neoadjuvant therapy)
Any T4 tumor
Four or more positive axillary lymph nodes
Local or regional recurrence (if radiation not previously administered)
Radiation should be strongly considered
Tumor >5 cm
Between one and three positive axillary lymph nodes
Positive margins
Radiation may be considered
Close margins (<1 mm)
High-risk features (central or medially located tumor, tumor >2 cm in young patient or with
pathologic extensive lymphovascular invasion)
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Timing of Adjuvant Radiation Therapy
Following two-stage prosthetic reconstruction (placement of a tissue expander followed by second-stage
replacement with a permanent implant), the treatment team must decide whether to administer radiation
before or after exchange of the expander for a permanent implant. Multiple studies have addressed the
question of timing, comparing outcomes in patients who have received radiation to the expander versus
radiation to the permanent implant. Some studies have found an increased rate of reconstructive failure
(complication necessitating device removal) when the permanent implant undergoes radiation, 45,46 but
others have found no significant difference in the rate of any complication including reconstructive
failure. 47 In a 2015 study by Cordeiro et al., radiation of the permanent implant was associated with a
higher rate of capsular contracture and subsequently worse aesthetic outcomes. 46 In this same study,
however, patient-reported quality-of-life measures were no different between radiation of the expander
versus the permanent implant. In the setting of radiation of the tissue expander, increasing the interval of
time between completion of radiation and exchange to permanent implant appears to improve outcomes,
with intervals ranging from 3 to 8 months. 48,49
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Technical Aspects of Radiation Delivery
Other factors that may influence prosthetic reconstructive outcome include the dose and fractionation of
radiation delivery, as well as whether treatment is delivered to a fully expanded, partially expanded or
fully deflated tissue expander. A full discussion of the data supporting different radiation doses, targets,
and delivery methods is beyond the scope of this chapter, except to say that there is significant variability
in practice patterns in both the United States and abroad. 50 It is possible that these factors may affect
reconstruction success and complication rates in a given practice, and it is important to be familiar with
the protocol used in a given institution when evaluating published results. With regard to radiation of
tissue expanders, some controversy exists regarding the optimal inflation status at the time of radiation
delivery. Some authors argue that attempting to radiate a fully or even partially inflated expander may
result in alteration of the dose delivered to the chest wall and internal mammary nodes, and that
complete deflation of the expander followed by reexpansion at completion of radiation is preferable. 51
However, with modern techniques and modeling, more recent data seem to suggest that radiation of even
a fully inflated expander or permanent implant is safe, does not result in decreased radiation dose
administration, and may result in a lower rate of complications compared to radiation of a deflated
device. 52 Again, the importance of a team approach is emphasized; detailed discussion and close
coordination of care between the plastic surgeon, breast surgeon, and radiation oncologist will help to
optimize the patient experience and reconstructive outcome.
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Implant Reconstruction in the Setting of Previous Radiation Treatment
Another common clinical scenario is the patient who requires salvage mastectomy following previous
breast conservation therapy with local recurrence. In these patients, reported complication rates in
patients undergoing breast reconstruction with prosthetic techniques vary widely. One systematic review
reported the rate of major complications associated with prosthetic reconstructions of previously
irradiated breasts at 49%. 53 The rates of early complications such as infection, seroma, and mastectomy
skin flap necrosis are significantly higher in previously radiated patients undergoing prosthetic
reconstruction compared to nonirradiated patients. 53-56 In addition, late complications such as capsular
contracture and reconstructive failure appear to be two to three times more likely in previously irradiated
patients. 57 The well-known chronic tissue effects of radiation such as fibrosis and decreased vascularity
are likely to blame for the increased complication rate; the soft tissue envelope of the breast simply does
not respond as well to stress or expansion following radiation. Compared to postmastectomy radiation,
prosthetic reconstruction of the previously irradiated breast appears to have a similar or slightly worse
risk profile. 53,56 Sbitany et al. demonstrated that compared to patients who underwent preoperative
radiation, patients with postmastectomy radiation exposure had lower rates of wound breakdown and
infections requiring procedures for resolution. 56 Despite the complication rate, in their systematic review,
Momoh et al. conclude that the rate of successful completion of prosthetic reconstruction in previously
irradiated breasts was 83%. 53 This supports the conclusions of multiple authors that despite a higher rate
of complications, prosthetic reconstruction can be effectively accomplished in the previously irradiated
breast. 54-56 Attempts to maximize the safety of this approach include a careful clinical assessment of the
skin for discoloration, quality and elasticity, as well as the location of previous scars, which may
necessitate removal of prohibitive amounts of skin. Interestingly, the use of ADM in previously irradiated
patients is not protective against reconstructive failure and may increase the rate of skin flap and
infectious complications, perhaps due to its inability to incorporate into a poorly vascularized, irradiated
mastectomy flap. 56 Although increasing the time interval between previous irradiation and salvage
mastectomy beyond 1 year does not appear to improve the rate of complications, performing the
reconstruction in a delayed rather than immediate fashion may result in a lower rate of reconstructive
failure. 57 All things considered, undertaking a prosthetic reconstruction in a previously irradiated breast
can be done effectively and with acceptable aesthetic outcomes. Patient education should include a frank
discussion of the possible postoperative course and a realistic appraisal of expectations. Reconstructive
failure and need for conversion to an autologous reconstruction is a realistic potential outcome.
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Effect of Systemic Therapy on Prosthetic Reconstruction
Neoadjuvant or adjuvant systemic therapies used in the treatment of breast cancer include
chemotherapeutic regimens and hormonal therapies. Chemotherapeutics have varying degrees of
myelosuppressive potential, resulting in thrombocytopenia, anemia, and neutropenia. These adverse
effects raised concerns about the safety of breast reconstruction in patients receiving chemotherapy either
before or after expander or implant placement. Several experimental studies demonstrated an increased
rate of wound healing complications in animals receiving specific chemotherapeutic agents, 58,59 however
similar results in clinical trials have not been reliably reproduced. On the balance, there is no clear
evidence that either neoadjuvant or adjuvant chemotherapy increases complication rates in patients
undergoing prosthetic reconstruction, 60-62 but these studies varied in the timing, dose, and regimen of
chemotherapy administered. Similarly, there is no evidence that hormonal therapies such as tamoxifen or
aromatase inhibitors increase complication rates in prosthetic reconstructions. 63 Many patients who
require adjuvant systemic therapy for advanced stage breast cancer will also require radiation therapy; as
expected, patients who receive both chemotherapy and radiation also experience radiation-related
complication profiles.
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Complications in Implant-Based Reconstruction
Hematoma
Hematoma is estimated to occur in 2% to 3% of implant-based reconstructions. 23 Acute hematoma is
most likely to occur in the first 24 to 48 hours after surgery, and the telltale swelling and ecchymosis are
often clinically obvious (Figure 59.6). Surgical drains are not useful for evacuation of blood clots; most
hematomas require return to the operating room for evacuation, though finding a single bleeding source
at the time of reexploration is rare. Left untreated, even small hematomas can increase the risk of
mastectomy skin flap necrosis, capsular contracture, and poor aesthetic outcome.
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FIGURE 59.6 Acute hematoma following nipple-sparing mastectomy.
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Infection
The overall rate of infection following implant-based reconstruction was estimated at 7.6% in a recent
meta-analysis. 64 Surgical site infections present in a spectrum of severity, from cellulitis involving the
incision to frank abscess in the implant pocket with whole breast erythema, swelling and purulent output
from the incision and drain (Figure 59.7). Minimal cellulitis may often be managed with empiric
outpatient antibiotic therapy, whereas pocket infections often require admission for IV antibiotics,
surgical exploration, and implant removal. Implant salvage may be considered in properly selected cases;
a recent retrospective review by Reish et al. identified elevated white blood cell count at admission and
methicillin-resistant S. aureus (MRSA) infection as predictors of salvage failure. 65 Gram-positive bacteria
such as Staphylococcus, Streptococcus, and Propionibacteria are the most common pathogenic organisms in
implant-associated infection. 66
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