Phẫu Thuật Tạo Hình (Tập 5): Tuyến Vú – Neligan (2018)

I
J
(I,J) The skin is tacked in place using temporary surgical clips with subsequent 3/0 vicryl and 3/0 monocryl closure.
Fig. 11.10, cont’d
A
D
B
E
Fig. 11.11  A 45-year-old patient with right-sided gynecomastia of large size, firm consistency, skin excess, and pseudoptosis, treated with conventional liposuction,
glandular resection, and Wise pattern skin excision. (A–C) Preoperative appearance and (D–F) postoperative result 5 months later. He had a suboptimal result with poor
scars but good symmetry at 5 months.
C
F

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SECTION I
CHAPTER 11 • Gynecomastia surgery
A
B
C
Fig. 11.12  A 37-year-old patient with bilateral gynecomastia of large size, firm consistency, and grade 2 ptosis, treated with conventional liposuction, glandular resection,
and Lalonde-type skin excision with no vertical scar. (A–C) Preoperative appearance and (D–F) markings. The neoareola is 20 mm wide, and its lower border must be
located at least 4 cm above the upper incision. (G–I) Postoperative result 4 months later. The horizontal scar is rather long, but the lack of a vertical scar avoids the telltale
appearances of a female breast reduction.
G
H
I

191
Treatment/surgical technique
D
E
F
Fig. 11.12, cont’d
contraction. However, tight adherence to underlying
tissues from internal scarring can sometimes be a
problem. We reserve skin reduction and excisional
techniques for severe gynecomastia with significant
excess after attempted liposuction.
Algorithmic approach to
gynecomastia surgery
From our experience we have proposed a unifying
approach to gynecomastia surgery (Fig. 11.14) which
seeks to maximize the strengths of the above different
modalities while minimizing the drawbacks of each
technique.6 In our practice, the starting point for all
cases is liposuction, even in those with firm subareolar
discs. While the latter group may still need open exci-
sion, the initial liposuction facilitates the surgery6,62 by
pretunneling, reducing bleeding, and contouring the
peripheries to prevent saucerization.
We always consent patients for the potential need for
open excision. Webster’s technique via an inferior peri-
areolar incision is indicated for firm subareolar lumps
and for residual glandular tissue following liposuction.
It is also technically easier to undertake liposuction at
the beginning of the operation rather than after excision.
Liposuction should therefore be performed to the
maximum extent to start with. Liposuction also stimu-
lates skin contraction, particularly with the ultrasound-
assisted modality. In our practice, conventional
liposuction is only used when UAL is not available
because the latter is more efficacious.54 Although the
superiority of UAL is not universally accepted, we have
shown it to be a more effective modality in treating
gynecomastia based on the objective parameters of
intraoperative conversion to open excision and need for
subsequent revisional surgery.54
Liposuction followed by open excision is very effec-
tive for most patients and has also been advocated for

192
SECTION I
CHAPTER 11 • Gynecomastia surgery
Fig. 11.13  Intraoperative images of conventional liposuction, glandular resection, and Lalonde-type skin excision with no vertical scar. (A) Conventional liposuction,
(B) de-epithelialization of an ellipse extending from the inframammary folds to a horizontal line about 4 cm below the neoareola “button hole”, (C) raising of skin flaps prior
to glandular resection, (D,E) redraping of skin flaps and neoareola, (F) closure.
A
B
C
D
E
F

193
Outcomes, prognosis, and complications
Fig. 11.14  Diagrammatic algorithm for a practical approach to the surgical
treatment of gynecomastia. SAL, suction-assisted lipectomy; UAL, ultrasound-
assisted liposuction. (From: Fruhstorfer BH, Malata CM. A systematic approach to
the surgical treatment of gynaecomastia. Br J Plast Surg. 2003;56:237–246.)
Gynaecomastia patient
Small to moderate
breast size
Moderate to large
breast size
Liposuction
(SAL/UAL)*
Liposuction
(SAL/UAL)*
Skin reduction
(LeJour/concentric)
Residual
lump
Open excision
Open excision
Flat male chest contour
Consider markings
for skin excision
Residual
lump
Redundant
skin
Only firm
subareolar nodule
*If available UAL is preferred to SAL, as it is more efficacious and
stimulates better skin contraction
**Excellent skin quality combined with the use of UAL may totally
obviate the need for open excision and skin reduction
**
marked gynecomastia with skin excess95,99–102 as long as
patients are made aware that they may need a second-
stage procedure 6 months later to address any residual
excess skin. Conventional liposuction is effective for soft
to moderately firm breasts, especially those with a
diffuse distribution. It is particularly unsuccessful in
patients with firm discrete subareolar lumps.
When there is skin excess or ptosis, we prefer to
address this at the original operation.103 This is especially
so in cases with poor or borderline skin elasticity. Such
patients needing skin reduction also benefit from initial
liposuction as it reduces the bulk; these patients are
often obese and therefore need tapering at the breast–fat
junction. The periareolar concentric mastopexy-type
reduction results in pleats or skin folds that settle down
satisfactorily after 2–3 months. However, the periareolar
Benelli suture is sometimes palpable, and the knot needs
to be buried deep to the dermis. The scars may also
stretch, and caution should be exercised in patients
prone to hypertrophic or keloid scarring. The vertical
component of the LeJour mammaplasty scar, like the
lateral wedge excision, is noticeable but leads to dra-
matic improvement in contour. Surprisingly, it is quite
well accepted by patients6. A lateral gathering and resec-
tion of the excess skin has been suggested by some, but
it may lead to nipples being positioned too laterally.
Skin reduction is an integral part of gynecomastia
surgery.
Postoperative care
Drains are not routinely used, except for large resections
or when skin reduction is performed, such as in post
massive weight loss patients.104 Following the proce-
dure, a pressure dressing consisting of fluffed-up gauze
or Reston foam (3M Health Care, Borken, Germany) is
applied and held in place with Microfoam or Mefix tape.
Patients are instructed to wear a gynecomastia pressure
garment day and night for 4–6 weeks. Oral antibiotics
are continued for a total of 5 days.
Outcomes, prognosis, and
complications
Although many plastic surgeons can obtain excellent
results using many treatment modalities, there is a
plethora of techniques. Therefore, a logical and inte-
grated approach along the above lines can lead to
predictable results in the surgical management of gyne-
comastia. Our starting point for all cases of gynecomastia
is liposuction, even in those cases with firm subareolar
discs, because it facilitates subsequent open excision. It
is also technically easier to undertake liposuction at the
beginning of the operation rather than after excision. We
only use conventional liposuction when ultrasonic
liposuction is not available.
In patients in whom open excision is not mandated
by the appearance and consistency we always consent
them for open excision in case the liposuction leaves
significant residual stromal tissue. Whenever there is
skin excess and/or ptosis, we prefer to address the skin
excess at the original operation especially in cases of
poor or borderline skin elasticity. This is in order to
avoid skin redundancy postoperatively. The choice of
skin reduction technique depends to a large extent on
the surgeon’s preference. We favor the periareolar con-
centric mastopexy-type reduction.
The possible complications of gynecomastia surgery
are shown in Box 11.5. Prior to the advent of liposuction,

194
SECTION I
CHAPTER 11 • Gynecomastia surgery
BOX 11.5  Possible complications of gynecomastia surgery
• Bleeding and hematoma formation
• Seroma formation
• Infection
• Skin/nipple necrosis
• Contour deformity such as nipple inversion or depression
• Altered sensation of the nipples
• Skin redundancy
• Residual asymmetry
• Adverse scars (wide, hypertrophy, keloid, pigmentation)
• Overcorrection, undercorrection
• Occasional need for revision surgery: asymmetry, residual
tissue, skin Xs, depressed nipples
• “Recurrence”
Table 11.3  Summary of gynecomastia surgery perioperative
information for patients
Procedure time
90–120 min
Anesthetic time
General
Hospital stay
Day surgery, but occasionally 1 night stay
Time off work
1–2 weeks
No driving
1–2 weeks
Pressure
garment
4–6 weeks
No sports
6–8 weeks
gynecomastia surgery was historically associated with
a high rate of complication: notably hematoma forma-
tion, seromas, disfiguring scars, retraction of the nipple,
and reduced nipple sensitivity.97,98,105 Table 11.3 sum-
marizes the perioperative advice we give to patients.
Secondary procedures
Gynecomastia patients are by and large a surgically
challenging group of patients, not least because of their
high expectations of surgery. In patients who have
undergone surgical treatment it is sometimes necessary
to perform revision surgery several months after the
initial operation for a variety of reasons. These include
inadequate correction, patient dissatisfaction10, presence
of painful residual lumps, asymmetries, and “recur-
rence” (often related to weight gain). Overcorrection is
rare. Similar to other surgical conditions, the need for
revision surgery is an objective indicator of the effective-
ness of a particular treatment.
Conclusion
Today the surgeon is faced with a wide range of exci-
sional and liposuction procedures for gynecomastia. We
have presented an integrated approach to surgical
management and highlighted the roles of the different
treatment modalities. It is often difficult even for expe-
rienced surgeons to choose the most appropriate treat-
ment. Sometimes combinations of these modalities are
needed depending on the degree of gynecomastia.
In conclusion, surgical treatment of gynecomastia
consists of three basic steps that may not all be neces-
sary in a given patient: liposuction, open excision, and
skin reduction. Liposuction should always be used in
diffuse or large breast enlargements. It can be optional
in the small breast with a firm, subareolar nodule, but
facilitates the subsequent open excision. Our results
with ultrasonic liposuction have led us to conclude
that, when available, it is preferable to conventional
liposuction because it is more efficacious and stimulates
better skin contraction. Furthermore, there may also be
less bruising. Following liposuction, the consistency
of the breast is again assessed and open excision is
performed if a residual lump is present. Skin excision
is indicated if there is still noticeable skin excess. The
choice between concentric, vertical scar (LeJour tech-
nique), and elliptical skin reduction depends largely
on the amount of skin excess to be resected and also
the surgeon’s experience.
Although many plastic surgeons can obtain excellent
results using many treatment modalities, today’s
surgeon who is faced with a plethora of techniques can
achieve predictable results with high patient satisfaction
by following a pragmatic approach along the lines that
we have proposed.
6. Fruhstorfer BH, Malata CM. A systematic approach to the surgical
treatment of gynaecomastia. Br J Plast Surg. 2003;56:237–246. First
comprehensive algorithmic approach to the surgical management of
gynecomastia. It takes into account breast size, consistency, skin excess,
and skin quality.
8. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia:
evolving paradigm of management and comparison of techniques.
Plast Reconstr Surg. 2010;125:1301–1308. An algorithmic approach to
gynecomastia surgery, which establishes the role of minimally invasive
arthroscopic excision of firm to moderately firm and large gynecomastia
using remote incisions.
11. Webster JP. Mastectomy for gynecomastia through a semicircular
intra-areolar incision. Ann Surg. 1946;124:557–575. Original
description of the time-honored Webster’s technique of periareolar
approach to open excision for gynecomastia.
13. Teimourian B, Perlman R. Surgery for gynecomastia. Aesthetic Plast
Surg. 1983;7:155–157. First description of liposuction combined with open
excision for gynecomastia treatment. This has become a widely accepted
Access the complete reference list online at

195
Conclusion
method because of the frequent difficulty of removing breast parenchyma
by suction alone.
14. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg.
1992;16:287–298. Ultrasound-assisted liposuction was pioneered by
Michele Zocchi in the 1980s as described in this paper.
24. Braunstein GD. Gynecomastia. N Engl J Med. 1993;328:490–495.
Excellent overview of gynecomastia including prevalence, pathogenesis,
and treatment.
36. Simon BE, Hoffman S, Kahn S. Classification and surgical correction
of gynecomastia. Plast Reconstr Surg. 1973;51:48–52. Widely quoted
practical clinical classification of gynecomastia taking into account the size
of the breast and amount of redundant skin.
54. Wong KY, Malata CM. Conventional versus ultrasound-assisted
liposuction in gynaecomastia surgery: a 13-year review. J Plast
Reconstr Aesthet Surg. 2014;67:921–926. First paper to objectively
compare suction-assisted and ultrasound-assisted liposuction in
gynecomastia surgery.
55. Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary
solution. Plast Reconstr Surg. 1987;80:379–386. Gary Rosenberg
popularized the use of suction-assisted liposuction beyond the confines of
the breast in order to facilitate contouring and postoperative redraping of
the skin in gynecomastia surgery.
57. Hodgson ELB, Fruhstorfer BH, Malata CM. Ultrasonic liposuction
in the treatment of gynecomastia. Plast Reconstr Surg. 2005;116:646–
653, discussion 654–655. Evaluation of ultrasound-assisted liposuction
for gynecomastia surgery.

195.e1
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Ann Plast Surg. 1998;40:62–64.
76. Prado AC, Castillo PF. Minimal surgical access to treat
gynecomastia with the use of a power-assisted arthroscopic–
endoscopic cartilage shaver. Plast Reconstr Surg. 2005;115:
939–942.
77. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use
of ultrasonic liposuction with the pull-through technique for the
treatment of gynecomastia. Plast Reconstr Surg. 2003;112:891–895,
discussion 896–897.
78. Bracaglia R, Fortunato R, Gentileschi S, et al. Our experience
with the so-called pull-through technique combined with
liposuction for management of gynecomastia. Ann Plast Surg.
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79. Lista F, Ahmad J. Power-assisted liposuction and the pull-through
technique for the treatment of gynecomastia. Plast Reconstr Surg.
2008;121:740–747.
80. Benito-Ruiz J, Raigosa M, Manzano M, Salvador L. Assessment of
a suction-assisted cartilage shaver plus liposuction for the
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81. Iwuagwu OC, Calvey TAJ, Ilsley D, Drew PJ. Ultrasound guided
minimally invasive breast surgery (UMIBS): a superior technique
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82. Qutob O, Elahi B, Garimella V, et al. Minimally invasive excision
of gynaecomastia–a novel and effective surgical technique. Ann R
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83. Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr
Surg. 1966;38:414–419.
84. Letterman G, Schurter M. Surgical correction of massive
gynecomastia. Plast Reconstr Surg. 1972;49:259–262.
85. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach in
surgical management of gynecomastia. Plast Reconstr Surg.
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86. Saad MN, Kay S. The circumareolar incision: a useful incision for
gynaecomastia. Ann R Coll Surg Engl. 1984;66:121–122.
87. Freiberg A, Hong C. Apple-coring technique for severe
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88. Lai YL, Weng CJ, Noordhoff MS. Areolar reduction with inner
doughnut incision. Plast Reconstr Surg. 1998;101:1695–1699.
89. Becker H. The intra-areolar incision for breast augmentation. Ann
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90. Chiu DT, Siegel HW. The pinwheel technique: an adjunct to the
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195.e3
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1999;178:60–63.

SECTION I • Aesthetic Breast Surgery
12 
Breast implant-associated anaplastic large
cell lymphoma (ALCL)
Mark W. Clemens II and Roberto N. Miranda
SYNOPSIS
■ Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
is a distinct type of T-cell lymphoma involving the capsule or effusion
surrounding a breast implant that can present in patients receiving
either reconstructive or cosmetic breast implants.
■ BIA-ALCL presents in two-thirds of cases as a delayed (>1 year)
periprosthetic fluid collection, and as a capsular mass in one-third of
cases. One in eight patients will present with lymphadenopathy.
■ Optimal screening tools include ultrasound or positron emission
tomography (PET)/computed tomography (CT) with directed fine-needle
aspiration. Diagnosis should be made prior to surgical intervention.
■ Tissue, implants, and fluid specimens from suspected cases should be
sent to pathology for CD30 immunohistochemistry with a clinical
history and to “rule out ALCL”.
■ Operative treatment of confirmed cases should include removal of
bilateral implants, resection of the entire capsule, and complete
excision of the disease including involved lymph nodes.
■ The role of adjunctive treatments such as chemotherapy, chest wall
radiation, anti-CD30 immunotherapy, and stem cell transplant for
advanced disease is under investigation.
Introduction
BIA-ALCL is a rare T-cell lymphoma arising around
breast implants placed either for reconstructive or cos-
metic indications. Safety communications by the United
States Food and Drug Administration (FDA) in 2011,
2016, and 2017 cautioning about BIA-ALCL and textured
breast implants including clinical presentation, progno-
sis, and treatment options, and subsequently increased
public and physician awareness.1 This warning was
based upon case reports dating back to a sentinel case
described by Keech and Creech in 1997.2 Since the FDA
safety communication in 2011, a number of major gov-
ernment agencies around the world have developed
BIA-ALCL patient and physician recommendations.
The National Comprehensive Cancer Network (NCCN)
released standardized diagnosis and treatment guide-
lines for BIA-ALCL in 2016 which was subsequently
adopted by the American Society of Plastic Surgeons
(ASPS) and the American Society of Aesthetic Plastic
Surgeons (ASAPS).2a,3 The World Health Organization
(WHO) has officially recognized BIA-ALCL as a subset
of ALCL, and in 2014 its intergovernmental agency, the
International Agency for Research on Cancer (IARC),
designated BIA-ALCL a priority for further research to
determine malignancy etiology and mechanism of
pathogenesis.4 In 2015, the US National Cancer Institute
(NCI) posted specific surgical recommendations for the
treatment of BIA-ALCL.5 In 2015, the French National
Cancer Institute (Agence Nationale de Sécurité du
Médicament) released diagnosis and treatment recom-
mendations for BIA-ALCL and mandated that all breast
implants carry a warning that a clearly established link
exists between breast implants and ALCL.6 The past two
decades have been marked by a transition from limited
case reports of a novel periprosthetic T-cell lymphoma
to our current understanding and recognition of
BIA-ALCL.7 Several evolving concepts have helped to
define diagnostic tools, therapeutic strategies, and out-
comes of BIA-ALCL and are the focus of this chapter.
Lymphoma background
Lymphoma is a cancer of the immune system developing
from lymphocytes and is the most common malignancy
of the blood.8 Lymphoma broadly includes Hodgkin’s
lymphoma, non-Hodgkin’s lymphoma (NHL), and a
variety of lymphoproliferative disorders. In the USA,
approximately 65 000 cases of NHL were diagnosed in

197
BIA-ALCL: a new entity
BIA-ALCL: a new entity
BIA-ALCL is distinct from primary breast lymphoma
(PBL), which is a disease of the breast parenchyma,
representing 0.04–0.5% of breast cancers and 1–2% of all
lymphomas.23 PBL is predominantly a B-cell lymphoma
(65–90%),24,25 while BIA-ALCL is purely a T-cell lym-
phoma arising either in an effusion surrounding the
implant or or in scar capsule surrounding a breast
implant.26,27 All confirmed reported cases of BIA-ALCL
are ALK− and express the CD30 cell surface protein (Box
12.1, Figs. 12.1A,B & 12.2). Most cases are diagnosed
during implant revision surgery performed for a late-
onset (>1 year), persistent seroma and may be associated
with symptoms of pain, breast lumps, swelling, or breast
asymmetry. The number of BIA-ALCL cases reported in
primary augmentation and reconstruction for breast
cancer or prophylaxis are nearly equivalent; however,
the number of women receiving augmentation implants
outnumbers by double those women receiving recon-
structive implants. BIA-ALCL most commonly follows
an indolent course provided there is adequate surgical
ablation of the implant and surrounding capsule without
systemic therapy, but aggressive exceptions, disease
progression, and death have been reported.28 No risk
factors have been clearly identified for ALCL though
many have been theorized including the presence of a
subclinical biofilm, response to particulate from textured
implants, a consequence of capsular contracture or
repeated capsular trauma (such as with closed capsu-
lotomies), genetic predisposition, or an autoimmune
etiology, but these observations have not been confirmed
in formal epidemiological studies.29 Recent studies have
demonstrated a possible pathogenic mechanism of
chronic T-cell stimulation with local antigenic drive,
ultimately leading to the development of lymphoma.30
Further research is required to identify modifiable risk
factors, susceptible populations, and optimal screening
and surveillance modalities.
BOX 12.1  Criteria for diagnosis of breast implant-associated
anaplastic large cell lymphoma
1. A tumor with adequate pathologic specimen for analysis,
involving an effusion either surrounding a breast implant or
lining a breast implant capsule.
2. Neoplasm with large lymphoid cells with abundant cytoplasm
and pleomorphic nuclei.
3. Tumor demonstrates uniform expression of CD30 by
immunohistochemistry and a single clonally expanded T-cell
population by flow cytometry.
4. Negative for anaplastic lymphoma kinase (ALK) protein or
translocations involving the ALK gene at chromosome 2q23.
2010.9 Stein and colleagues first described ALCL in 1985
as a novel type of NHL characterized by large anaplastic
lymphoid cells that express the cell surface protein
CD30.10 Estimated incidence of T-cell NHL diagnoses in
the USA in 2014 was 17 302.11 This included 1982 cases of
ALCL, 758 of which occurred in females.12
ALCL was added as a distinct entity to the Kiel clas-
sification in 1988 and to the Revised European-American
Lymphoma (REAL) classification in 1994.13 The WHO
classification of lymphomas recognized the disease in
2001 and further delineated variants in their updated
2008 classification.14,15 NHL prognosis is determined
using the International Prognostic Index (IPI) based
upon presence of recognized risk factors such as the
Ann Arbor staging system, advanced age, elevated
serum lactate dehydrogenase (LDH), poor performance
status, and increased number of extranodal sites of
disease.16 Clinicopathologic subtypes of ALCL include
a spectrum of diseases from the more aggressive sys-
temic ALCL down to the indolent CD30 positive lym-
phoproliferative disorders of the skin that include a
benign lymphomatoid papulosis and sometimes the
indolent primary cutaneous ALCL (5-year OS (overall
survival) > 90–95%, lymph node metastases 5%).17 Mul-
tiple sites of disease, frequent lymphadenopathy, and
wide dissemination characterize systemic ALCL. Sys-
temic ALCL is further classified by either the expression
or absence of the anaplastic lymphoma kinase (ALK)
tyrosine kinase receptor gene translocation. ALK is most
commonly expressed as a result of the t(2;5) transloca-
tion involving the 2p23 and the 5q35 chromosomes that
create an oncogenic fusion protein of the ALK gene and
the nucleophosmin gene.18 ALK+ ALCL accounts for
approximately 50–80% of all ALCLs, occurs most com-
monly in males (male/female ratio: 6.5 : 1) under the age
of 30 years, and has a 5-year OS by IPI point value of
0/1: 90%, 2: 68%, 3: 33%, 4/5: 23%.5 In contrast, ALK−
ALCL is an immunophenotypically and cytogenetically
heterogeneous group and has a 5-year OS by IPI points
value of 0/1: 74%, 2: 62%, 3: 31%, 4/5: 13%. Standard
first-line chemotherapy is cyclophosphamide, hydroxy-
daunorubicin, vincristine, and prednisone (CHOP), and
refractory disease is treated with ifosfamide, carbopla-
tin, etoposide (ICE), or etoposide, methylprednisone,
cytarabine, cisplatin (ESHAP).19 When treated with
chemotherapy, ALK+ ALCL has a higher overall 5-year
survival rate than systemic ALK− ALCL (58% vs. 34%,
respectively).20,21 As a percentage of all T-cell lympho-
mas, ALK+ ALCL is more common in North America
than Europe or Asia (16.0% vs. 6.4% vs. 3.2%, respec-
tively). Systemic ALK− ALCL is more common in
Europe than North America or Asia (9.4% vs. 7.8% vs.
2.6%, respectively).22

198
SECTION I
CHAPTER 12 • Breast implant-associated anaplastic large cell lymphoma (ALCL)
included nine patient deaths associated with the disease.
de Jong and colleagues reported an individually matched
case control study from the Netherlands nationwide
pathology database.60 The pathology database served a
total population of approximately nine million women.
The authors found a positive association for the develop-
ment of ALCL in women with breast implants compared
to those without an implant, with an odds ratio of 18.2
(95% confidence interval, 2.1–156.8). Based upon this
data, the authors estimated an incidence of 0.1–0.3 per
100 000 BIA-ALCL cases for women with prostheses per
year. A number of prior studies failed to show an associa-
tion between breast augmentation and risk of lymphoma;
however, these studies were limited by the number of
patients enrolled or by the insufficient time period
of follow-up.61–63 These studies underscore the difficulty
of determining the incidence and prevalence of a very
rare and recently recognized clinical entity. The United
States FDA Manufacturer and User Facility Device Expe-
rience (MAUDE) database has received 359 adverse
event reports of ALCL in women with breast implants as
of February 1, 2017.59 However, the FDA deems this data
as potentially duplicative, unverified, and unreliable.
The ASPS/FDA collaboration PROFILE prospective
registry reports 149 unique pathologically confirmed
BIA-ALCL cases in the United States as of June 1, 2017. In
a review of the top 40 global breast implant markets
worldwide, 464 adverse event reports of BIA-ALCL were
reported to government authorities.
An MD Anderson epidemiology study estimated a
lifetime prevalence of BIA-ALCL of 1:30,000 by compar-
ing pathologically confirmed cases in the United States
(US) with US textured implant sales. This study pre-
sumed that BIA-ALCL occurs only in textured breast
implants).59b This incidence was 67.6 times higher than
that of primary ALCL of the breast in the general popu-
lation. Mcguire and colleagues reported the results of
A
Fig. 12.1  (A) Wright Giemsa staining from a malignant effusion of breast
implant-associated anaplastic large cell lymphoma (BIA-ALCL) demonstrating
pleomorphic cells with horseshoe shaped nuclei, nuclear folding, and abundant
vacuolated cytoplasm (1000× magnification). (B) Immunohistochemistry in tissue
section demonstrates sheets of large cells positive for CD30 in a case of BIA-ALCL.
(From: Clemens MW, Miranda RN. Coming of age, breast implant-associated
anaplastic large cell lymphoma after 18 years of investigation. Clin Plast Surg.
2015;42(4).)
B
Fig. 12.2  Scanning electron micrograph (300× magnification) demonstrating
aggregates of lymphoma cells clustered on the surface of a textured silicone implant.
Epidemiology
Since 1997, approximately 99 patients have been reported
either in case reports of BIA-ALCL or literature reviews
(Fig. 12.3).31–57 Reporting has benefitted from formal rec-
ognition and wider physician education, which has led
to an exponential increase in published cases over the last
few years. Reliable epidemiological data for the incidence
and prevalence of BIA-ALCL has been difficult to deter-
mine for the estimated eleven million-plus women
worldwide with breast implants.58 The FDA database has
received approximately 359 adverse event reports of
ALCL in women with breast implants, which were
reported to the Manufacturer and User Facility Device
Experience (MAUDE) database as of February 2017. This

199
Diagnosis and treatment
Fig. 12.3  (A) Timeline of published cases of breast implant-
associated anaplastic large cell lymphoma (BIA-ALCL) as well
as (B) year of implant placement and diagnosis of BIA-ALCL.
200
150
100
50
0
1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
A
Year of implant placement
Year of ALCL diagnosis
10
0
2
4
6
8
1980
1987
1994
2001
2008
B
the US FDA mandated CA/CARE Trial of Biocell
implants, which was the largest series ever reported for
any type of textured implant, and included 17,656
women receiving 31,985 Biocell textured implants.
Within that series, six cases of breast implant–associated
ALCL cases occurred resulting in a risk of 1:2943
(95%CI:1350,8000).59c In 2016, the Australian Therapeutic
Goods Administration released an update on BIA-ALCL
estimating a disease risk of 1 in 1000 to 1 in 10,000
women with textured implants based on data from 60
national cases and reported manufacturer specific risks
of Allergan Biocell (1:3705), Silimed polyurethane
(1:3894), and Mentor Siltex (1:60631).59d This discrepancy
in risk between Australia and US data may be due to
geographic predisposition or physician reporting and
requires further study.
Diagnosis and treatment
The diagnosis and treatment of BIA-ALCL follows
standardized guidelines established by the National
Comprehensive Cancer Network (NCCN). Diagnosis of
BIA-ALCL can be difficult as it remains relatively rare
at most medical centers. Two-thirds of BIA-ALCL
patients will present as a malignant effusion associated
with the fibrous capsule surrounding an implant occur-
ring on average 9 years after implantation. Any seroma
occurring greater than 1 year after implantation not
readily explainable by infection or trauma should be
considered suspicious for disease (Fig. 12.4).48 One-third
of patients present with a mass, which may indicate a
more aggressive clinical course.68 Adrada and colleagues
reviewed 44 BIA-ALCL patients with imaging studies
and reported on the sensitivity/specificity for detecting
an effusion using ultrasound (84%/75%), computerized
tomography (55%/83%), magnetic resonance imaging
(82%/33%), and PET (38%/83%).64 Additionally, the
sensitivity/specificity to detect a BIA-ALCL mass was
reported for ultrasound (46%/100%), computerized
tomography (50%/100%), magnetic resonance imaging
(82%/33%), and PET (64%/88%). The sensitivity of
mammography was found to be inferior for BIA-ALCL
effusion and mass. Ultrasound is utilized at our institu-
tion as a screening tool for suspected cases and in
combination with PET for confirmed cases to determine
extension and for surveillance of disease.
For suspected patients, any aspiration of peripros-
thetic fluid should be sent to pathology for cytologic
evaluation and include a clinical history with the stated
intent to “rule out BIA-ALCL”. Pathologic evaluation
may demonstrate BIA-ALCL as individual cells, cell
clusters in aggregates, or as coherent sheets. Diagnosis
by hematoxylin and eosin staining alone can be difficult;
however, BIA-ALCL will demonstrate strong and
uniform membranous expression of CD30 immunohis-
tochemistry. Other T cell antigens are expressed variably

200
SECTION I
CHAPTER 12 • Breast implant-associated anaplastic large cell lymphoma (ALCL)
effect distortion on imaging, or the mass may protrude
outward into the soft tissue.
Patients with biopsy proven BIA-ALCL must be
referred to a lymphoma oncologist. Surgical treatment
of BIA-ALCL requires complete tumor ablation, which
includes removal of the implant, complete removal of
any disease mass with negative margins, and total
capsulectomy. Because an implant capsule may drain to
multiple regional lymph node basins, there does
not appear to be a role for sentinel lymph node biopsy
in the treatment of BIA-ALCL. Fine-needle aspiration of
enlarged lymph nodes can yield a false negative, and
with the most common being CD4 (80–84%), CD43
(80–88%), CD3 (30–46%), CD45 (36%), and CD2 (30%).65
Expression of CD5, CD7, CD8, or CD15 is rare. Ultra-
sound may help define the extent of a seroma and can
be helpful in identifying any associated capsule masses.
Clinical examination should include evaluation of
regional lymph nodes. Volumes of an effusion can range
from 20 to 1000 mL and is typically viscous. The sur-
rounding capsule may be thickened and fibrous or may
be deceptively normal in appearance, consistent with
the under appreciation of this lymphoma. If a mass is
present, it can protrude into the implant creating a mass
Fig. 12.4  Diagnosis and Management of BIA-ALCL follows standardized guidelines of the National Comprehensive Cancer Network (NCCN). Approach to a patient with a
delayed seroma and treatment of BIA-ALCL are summarized above per NCCN guidelines. Abbreviations: CHOP: cyclophosphamide, hydroxydaunorubicin, vincristine, and
prednisone; IHC: immunohistochemistry; PROFILE: Patient Registry and Outcomes For breast Implants and anaplastic large cell Lymphoma etiology and Epidemiology,
(From: Clemens MW, Butler CE. ASPS/PSF efforts on BIA-ALCL. Plastic Surgery News. 2015;26(7).)
Functional or physical signs (effusion, enlargement, pain,
inflammation, mass ulceration) with breast implant
Cytology of FNA, histology,
flow cytometry, CD30 IHC of effusion
Pathology second consultation by
tertiary cancer center
Recommend discussion by multidisciplinary team:
plastic surgeon, oncologist, surgical oncologist, pathologist
Total capsulectomy, explantation,
surgical oncologist recommended
Monitoring by oncologist for surveillance
with US or PET/CT every 6 months for 2 years3
Surgery (lymph nodes, organ mets)
Chemotherapy:
Consider CHOP brentuximab vedotin
Localized disease
Advanced disease (stage II–IV)
Adjuvant Tx
decided by
multidisciplinary
meeting
Total
capsulectomy
possible
Lymphoma workup and staging:
Bone marrow biopsy, PET/CT scan
Histologic confirmation of BA-ALCL
Report to PROFILE registry
Referral of patient to oncologist
Fine-needle
aspiration (FNA)
Biopsy and
oncology consult
Ultrasound of breast and lymph node areas
MRI
Mass ± lymph nodes ± effusion
Effusion
if inconclusive
if diagnosis
indeterminate
of lymphoma

201
Clinical characteristics and outcomes
resection may be the definitive treatment in the majority
of cases. Surgery should be performed with strict onco-
logic technique including use of specimen orientation
sutures, placement of surgical clips within the tumor
bed, and use of new instruments if performing a contra-
lateral explantation. At this time, the FDA does not
recommend screening or prophylactic implant removal
for asymptomatic patients or patients with familial
susceptibility cancer. Although reimplantation is not
recommended, several BIA-ALCL patients have received
implant replacement with a smooth implant following
definitive treatment, and these patients are being closely
monitored for any disease sequelae.
Staging
Patients with BIA-ALCL or any type of lymphoma are
traditionally staged by the 1971 Ann Arbor classifica-
tion, which stages disease based upon progression as a
“liquid tumor”.66 Under this classification, nearly all
BIA-ALCL patients fall under one of two stages, either
stage IE (84%) or stage IIE (16%) (Fig. 12.5A & B).
Although most patients with BIA-ALCL have a relatively
indolent clinical course, reports of deaths attributable to
disease emphasize the importance of a timely diagnosis
and adequate treatment with appropriate surveillance
or else disease progression can occur with detrimental
effect. Patients with BIA-ALCL who have died were
described as having local or regional extension of their
disease, and no patients with BIA-ALCL have developed
widely disseminated disease. This pattern of progres-
sion suggests that BIA-ALCL is a distinct entity, and
displays progression more similar to solid tumors than
to other non-Hodgkin lymphomas. This pattern of
disease spread is also better suited to a clinical and
pathologic staging system modeled after the American
Joint Committee on Cancer (AJCC) TNM (tumor, lymph
node, metastasis) system for staging solid tumors.67
A recent BIA-ALCL TNM staging system is more
applicable than the Ann Arbor system for predicting
prognosis and for evaluating treatment regimens in
patients with BIA-ALCL (Figs. 12.6A,B & 12.7A,B;
Table 12.1).68
Clinical characteristics and outcomes
The clinico-pathologic features of BIA-ALCL have
been reported in several literature reviews. In 2014,
Miranda et al. reviewed the long-term follow-up of 60
BIA-ALCL patients.56 The mean age was 52 years old
(range 28–87 years) with a median of 9 years (range 1–32
years) between implantation and lymphoma diagnosis.
Patients presented with either a malignant effusion or
therefore excisional biopsies should be performed of
any suspicious lymph nodes. The involvement of a
surgical oncologist in the management of this lymphoma
is strongly recommended with the aim of obtaining
optimal surgical control. An incomplete resection or
inadequate local surgical control may subject the patient
to the need for adjunctive treatments such as chemo-
therapy and radiation therapy, whereas complete
Time from diagnosis (years)
Ann-Arbor stage I
Ann-Arbor stage II
p=0.032
Probability of event-free survival
1.0
0.8
0.6
0.4
0.2
0.0
0
2
4
6
8
10
12
14
16
A
Fig. 12.5  Survival curves according to Ann Arbor stage. (A) Event-free survival,
(B) overall survival. (From: Clemens MW, Medeiros LJ, Butler CE, et al. Complete
surgical excision is essential for patients with breast implant-associated anaplastic
large cell lymphoma. J Surg Onc. 2016;34(2):160-168.)
Time from diagnosis (years)
Ann-Arbor stage I
Ann-Arbor stage II
p=0.005
Probability of event-free survival
1.0
0.8
0.6
0.4
0.2
0.0
0
2
4
6
8
10
12
14
16
B

202
SECTION I
CHAPTER 12 • Breast implant-associated anaplastic large cell lymphoma (ALCL)
Table 12.1  Proposed TNM staging for breast implant-associated anaplastic large cell lymphoma
Tumor extent
T1
T2
T3
T4
T
Confined to effusion or a layer
on luminal side of capsule
Early capsule infiltration
Cell aggregates or sheets
infiltrating the capsule
Lymphoma infiltrates
beyond the capsule
Lymph nodes
N0
N1
N2
N
No lymph node involvement
One regional lymph
node (+)
Multiple regional lymph
nodes (+)
Metastasis
M0
M1
M
No distant spread
Spread to other organs/
distant sites
Stages
IA
T1N0M0
IB
T2N0M0
IC
T3N0M0
IIA
T4N0M0
IIB
T1-3N1M0
III
T(4)N(1–2)M0
IV
T(any)N(any)M1
TNM, tumor, lymph node, metastasis.
a
b
c
d
e
f
g
h
A
capsule
capsule
Fig. 12.6  Breast implant-associated anaplastic
large cell lymphoma (BIA-ALCL) staging system:
this TNM (tumor, lymph node, metastasis) staging
system was modeled after the American Joint
Committee on Cancer (AJCC) TNM system for
solid tumors. T1: Lymphoma cells confined to the
effusion or a layer on the luminal side of the
capsule (Ia, Ib); T2: lymphoma cells superficially
infiltrate the luminal side of the capsule (Ic);
T3: clusters or sheets of lymphoma cells infiltrate
into the thickness of the capsule (IIa); and
T4: lymphoma cells infiltrate beyond the capsule
(IIb), into the adjacent soft tissue or breast
parenchyma (III, IV). (From: Clemens MW,
Medeiros LJ, Butler CE, et al. Complete surgical
excision is essential for patients with breast
implant-associated anaplastic large cell lymphoma.
J Surg Onc. 2016;34(2):160-168.)

203
Diagnosis and treatment
B
Ia
IIa
III
IV
IIb
Ib
Ic
Fig. 12.6, cont’d

204
SECTION I
CHAPTER 12 • Breast implant-associated anaplastic large cell lymphoma (ALCL)
an adequate surgical approach. Radiation therapy has
also been used for local control of disease, and further
research is required to determine specific indications for
adjunctive treatments. Patients with a breast mass had a
worse OS and PFS (p=0.052 and p=0.03, respectively). At
this time, it is unclear whether the association of mass
and worse prognosis indicates a more aggressive variant,
a more progressed disease, or perhaps a consequence of
inadequate surgical ablation of tumor infiltration. Event
free survival and overall survival by different treatment
modalities are summarized in Fig. 12.8A & B.
Hart et al. performed a meta-analysis and identified
53 BIA-ALCL patients.69 For patients with available
clinical data, the authors noted rates of 17.3% extracap-
sular disease and 23.1% with the presence of a mass.
Furthermore, 39.6% of patients were treated with surgery
alone, 9.4% with surgery and radiation, 18.9% with
surgery and chemotherapy, 30.2% with surgery, chemo-
therapy, and radiation, and 1.9% with chemotherapy
alone. At a median follow-up of 15 months (3.6–90
months), disease recurrence was 28.3%, of which 73.3%
were treated with salvage chemotherapy. BIA-ALCL
was attributed to four patient deaths. Extracapsular
disease extension was associated with increased risk for
recurrence (p<0.0001) and patient death (p=0.0008). This
study also found a statistically significant difference in
3- and 5-year survival rates between patients presenting
with and without a mass (p=0.0308 and p=0.0308, respec-
tively). While BIA-ALCL may follow a relatively indolent
course in most patients, reports of disseminated cancer
and deaths attributed to the disease emphasize the
importance of timely diagnosis and adequate treatment
with appropriate surveillance.
Brody and colleagues recently reported a summary
of 79 published patients and 94 previously unreported
cases.70 The authors report that for all implants where
surface characteristics were known, there was at least
one textured device used within the patient’s surgical
history. The authors reconfirm that there are no known
pure smooth implant cases and importantly note that
BIA-ALCL has been reported in association with all
major forms of implant texturing techniques from
current implant manufacturers. Microbiology cultures
were negative in all cases when taken, although formal
biofilm evaluation was not performed. The authors
noted that most patients had a slow disease progression
and a good prognosis when adequately treated, but
conceded occasional lymphadenopathy, metastases,
and nine attributable deaths.
Setting research priorities
Further research into the development of primary cell
lines and biologic models is important to fully elucidate
seroma (70%) or a distinct mass (30%). The median OS
was 12 years (median follow-up, 2 years; range 0–14
years). A total capsulectomy with implant removal was
performed in 93% of patients. Overall survival and
progression free survival (PFS) were similar between
patients who received and did not receive chemo-
therapy (p=0.44 and p=0.28, respectively), suggesting
that some patients may achieve optimal outcomes with
Fig. 12.7  Survival curves according to breast implant-associated anaplastic large
cell lymphoma (BIA-ALCL) TNM (tumor, lymph node, metastasis) staging. (A)
Event-free survival, (B) overall survival. MDACC, MD Anderson Cancer Center.
(From: Clemens MW, Medeiros LJ, Butler CE, et al. Complete surgical excision is
essential for patients with breast implant-associated anaplastic large cell lymphoma.
J Surg Onc. 2016;34(2):160-168.)
Time from diagnosis (years)
MDACC stage I
MDACC stage II
MDACC stage III
p=0.030
Probability of event-free survival
1.0
0.8
0.6
0.4
0.2
0.0
0
2
4
6
8
10
12
14
16
A
Time from diagnosis (years)
Probability of event-free survival
1.0
0.8
0.6
0.4
0.2
0.0
0
2
4
6
8
10
12
14
16
MDACC stage I
MDACC stage II
MDACC stage III
p=0.007
B

205
Medico-legal considerations
Time from diagnosis (years)
Probability of event-free survival
1.0
0.8
0.6
0.4
0.2
0.0
0
2
4
6
8
10
12
14
16
Definitive surgery
Limited survey
Chemotherapy
XRT
p<0.001
A
Fig. 12.8  Survival curves according to treatment approaches. (A) Event-free
survival, (B) overall survival. XRT, x-radiation therapy. (From: Clemens MW,
Medeiros LJ, Butler CE, et al. Complete surgical excision is essential for patients
with breast implant-associated anaplastic large cell lymphoma. J Surg Onc.
2016;34(2):160-168.)
Time from diagnosis (years)
Probability of event-free survival
1.0
0.8
0.6
0.4
0.2
0.0
0
2
4
6
8
10
12
14
16
Definitive surgery
Limited survey
Chemotherapy
XRT
p<0.001
B
Future research is warranted to determine if certain
patients have a predisposition to developing the disease
and if any modifiable risk factors exist either with the
patient or type of implant utilized. Kim and colleagues
recently reported on an updated RAND corporation
sponsored multidisciplinary consensus to evaluate
current knowledge gaps in diagnosis, management, and
surveillance of BIA-ALCL.71 Panelists agreed that late
seromas occurring >1 year after breast implantation
should be evaluated via ultrasound, and, if a seroma is
present, the fluid should be aspirated and sent to an
experienced hematopathologist for culture, cytology,
flow cytometry, and cell block. Surgical removal of the
affected implant and capsule (as completely as possible)
should take place, which is sufficient to eradicate capsule-
confined BIA-ALCL; surveillance should consist of clini-
cal follow-up at least every 6 months for at least 5 years
and breast ultrasound yearly for at least 2 years; and
BIA-ALCL is generally a biologically indolent disease
with a good prognosis, unless it extends beyond the
capsule and/or presents as a mass. (For patient manage-
ment examples see Figs. 12.9A–F & 12.10A–C.) The panel
disagreed as to whether chemotherapy and radiation
therapy should be given to all patients with BIA-ALCL,
or which patients may benefit, and recommended further
investigation in larger studies with longer follow-up.
Advances in the treatment of T cell lymphomas gives
promise for BIA-ALCL refractory to surgical therapy
alone. Brentuximab vedotin is a novel anti-CD30 mono-
clonal antibody that has changed the management of
systemic ALCL with a reported objective response rate
of 86% and a complete remission rate of 59% in relapsed
or refractory systemic ALCL.72,73 Prospective trials of
BIA-ALCL patients at major referral centers may help
delineate chemotherapeutic sensitivity and efficacy of
novel agents.
Medico-legal considerations
Following recommendations made by the FDA in 2011,
implant manufacturers added a written warning, about
the existence of BIA-ALCL, to breast implant package
inserts within the USA and Canada. Breast implant
informed consent examples, which include the risk of
BIA-ALCL, were subsequently produced by the Ameri-
can Society of Plastic Surgeons (ASPS) and are avail-
able for download from
With respect to BIA-ALCL, risk disclosure should have
at least three basic objectives. The first objective is
to make patients aware of the existence of this
rare disease; the second is for patients to understand
common presenting symptoms such as a breast mass
or delayed-presentation seroma or effusion; and the
third is to compel patients to take action and follow-up
the exact etiology and pathogenesis of BIA-ALCL.
Lechner and colleagues reported the establishment and
characterization of a BIA-ALCL model cell line (TLBR-
1) as well as heterotransplantation of the disease into
immunocompromised mice. Establishment of cell lines
from effusion or excisional biopsies will be important to
completely characterize the disease and for the identifi-
cation of potential molecular targets.

206
SECTION I
CHAPTER 12 • Breast implant-associated anaplastic large cell lymphoma (ALCL)
A
B
C
D
Fig. 12.9  (A,B) Clinical image of a 52-year-old woman who received a cosmetic breast augmentation with textured silicone implants. Twenty years after implantation, she
developed swelling of the left breast of recent onset which was aspirated multiple times. The patient then received a partial capsulectomy, implant removal, and mastopexy.
(C) Adequate tumor resection was questionable, and despite being asymptomatic, the patient underwent a completion capsulectomy with excision of the posterior capsular
wall. (D) Postoperative pathology again demonstrated persistent breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) disease of her chest wall and now
with free margins. (E) Tissue section demonstrates a nodule with compact tumor cells. (F) Immunohistochemistry demonstrates most tumor cells that express CD30.
Patient received no further adjunctive treatments and is currently 2 years disease free.
E
F

207
Reporting of cases
implants undergo MRI evaluation for implant failure at
3 years postimplantation. Because insurance policies do
not cover this screening, the suggested study is not
widely performed.74 Fortunately, a similar trend has
not been seen with regards to screening for BIA-ALCL.
Whereas MRI screening is for a device failure, patients
with delayed seromas are being screened for the pres-
ence of a malignant lesion of the breast. Therefore,
physicians should not hesitate to perform pathologic
review of an effusion with CD30 immunohistochemistry
(which is not performed on routine specimen evalua-
tion) if they have a reasonable clinical suspicion of a
cancer. WHO is expected to address BIA-ALCL in their
updated 2016 classification of lymphomas, and formal
recognition will facilitate physician awareness, patient
education, reporting, and management.
Reporting of cases
Many resources exist for oncologists and surgeons treat-
ing a BIA-ALCL patient. The Plastic Surgery Foundation
paired the ASPS and the US FDA to form the PROFILE
registry (Patient Registry and Outcomes For breast
with a physician should these symptoms occur. At an
initial consultation, printed copies of a patient’s signed
consent as well as procedure specific informational
pamphlets will enable patients to further digest surgi-
cal details at their leisure in their own homes, and
engenders more effective recall. The legal threshold for
inclusion of a specific risk in informed consent is
unfortunately vague, and therefore the decision to
include BIA-ALCL in informed consent should ideally
be by self-obligation, not mandate. Despite the realities
of a litigious society, it is important to remember that
informed consent is a process, not an event, and there
should be an ongoing conversation rather than just a
form signing. Liability more frequently results from a
lack of communication, and surgeons are most com-
monly judged not by their mistakes, but how they
have managed them.
The future of insurance coverage of complications
related to breast implants continues to evolve and is not
guaranteed. An analogy has been raised with regards to
screening for breast implant ruptures. When the US
moratorium on silicone implants ended in 2006, the
FDA recommended all women with silicone breast
A
B
Fig. 12.10  (A) Clinical image of a 77-year-old woman who received a right
mastectomy for breast cancer in 2003. Eleven years after implantation, she
developed swelling of the right breast of recent onset. (B,C) Patient then received a
total capsulectomy and implant removal. Patient is 2 years disease free and received
PET-CT scans every 6 months for the first 2 years for surveillance. Patient declined
further reconstruction.
C

208
SECTION I
CHAPTER 12 • Breast implant-associated anaplastic large cell lymphoma (ALCL)
28. Kim B, Roth C, Young VL, et al. Anaplastic large cell lymphoma and
breast implants: results from a structured expert consultation
process. Plast Reconstr Surg. 2011;128:629–639. The authors conducted a
structured expert consultation process to evaluate evidence for the
association of breast implants with anaplastic large cell lymphoma (ALCL),
and to determine the clinical significance and a potential biological model
based on their interpretation of the published evidence. Panelists agreed that
(1) there is a positive association between breast implants and ALCL
development but possible under recognition of the true number of cases; (2)
a recurrent, clinically evident delayed seroma after breast implantation
should be aspirated and sent for CD30 immunohistochemistry analysis; (3)
anaplastic lymphoma kinase-negative ALCL that develops around breast
implants is a clinically indolent disease with a favorable prognosis that is
distinct from systemic anaplastic lymphoma kinase-negative ALCL; (4)
management should consist of removal of the involved implant and capsule,
which is likely to prevent recurrence, and evaluation for other sites of
disease; and (5) adjuvant radiation or chemotherapy should not be offered to
women with capsule-confined disease. The authors’ assessment yielded
consistent results on a number of key issues regarding ALCL in women with
breast implants, and was used as the basis for the Food and Drug
Administration (FDA) safety communication in 2011.
56. Miranda RN, Aladily TN, Prince HM, et al. Breast implant-
associated anaplastic large-cell lymphoma: long-term follow-up of
60 patients. J Clin Oncol. 2014;32:114–120. Miranda et al. reviewed the
long-term follow-up of 60 breast implant-associated anaplastic large cell
lymphoma (BIA-ALCL) patients. The mean age was 52-years-old (range
28–87 years) with a median of 9 years (range 1–32 years) between
implantation and lymphoma diagnosis. Patients presented with either a
malignant effusion or seroma (70%) or a distinct mass (30%). The median
overall survival (OS) was 12 years (median follow-up 2 years; range 0–14
years). A total capsulectomy with implant removal was performed in 93%
of patients. OS and progression-free survival (PFS) were similar between
patients who received and did not receive chemotherapy (p=0.44 and
p=0.28, respectively), suggesting that some patients may achieve optimal
outcomes with an adequate surgical approach. Patients with a breast mass
had a worse rate of OS and PFS (p=0.052 and p=0.03, respectively). The
association of a mass may indicate either a worse prognosis of a more
aggressive variant, more progressed disease, or perhaps a consequence of
inadequate surgical ablation of tumor infiltration.
60. de Jong D, Vasmel WL, de Boer JP, et al. Anaplastic large-cell
lymphoma in women with breast implants. JAMA. 2008;300:2030–
2035. de Jong and colleagues reported an individually matched case
control study from the Netherlands nationwide pathology database. The
pathology database served a total population of approximately nine million
women. The authors found a positive association for the development of
ALCL in women with breast implants compared to those without
implants, with an odds ratio of 18.2 (95% confidence interval, 2.1–156.8).
Based upon this data, the authors estimated an incidence of 0.1–0.3 per
100 000 BIA-ALCL cases for women with prostheses per year. This study
contradicted a number of prior studies that failed to show an association
between breast augmentation and risk of lymphoma. In addition, those
prior studies were woefully limited in power and length of follow-up.  
This study emphasized the difficulty in determining the incidence and
prevalence of a very rare and recently recognized clinical entity.
68. Clemens MW, Medeiros LJ, Butler CE, et al. Complete surgical
excision is essential for patients with breast implant-associated
anaplastic large cell lymphoma. J Clin Oncol. 2015:160–168 The
authors evaluated the efficacy of different treatment modalities utilized for
BIA-ALCL in order to determine an optimal treatment approach. A total
of 128 patients were reviewed for pathologic findings, and clinical
follow-up and malignant tissue specimens were centralized for 87 patients
with BIA-ALCL. At a median follow-up of 45 months (range 3–217
months), the median OS after diagnosis of BIA-ALCL was 13 years, and
the OS rate was 93% at 3 years and 89% at 5 years. Patients with
lymphoma confined by the fibrous capsule surrounding the implant had
better event-free survival (EFS) and OS than patients with lymphoma
spread beyond the capsule (p=0.03). Patients who underwent a complete
surgical excision that included total capsulectomy with breast implant
removal had better OS (p=0.022) and EFS (p=0.014) when compared with
patients who received partial capsulectomy, systemic chemotherapy, or
radiation therapy. Based upon observed disease progression characteristics,
a novel solid tumor TNM (tumor, lymph node, metastasis) staging system
was proposed. The authors concluded that surgical management with
complete surgical excision is essential to achieve optimal EFS in patients
with BIA-ALCL.
69. Hart A, Lechowicz MJ. Breast implant-associated anaplastic large
cell lymphoma: treatment experience in 53 patients. Aesthet Surg J.
2014;34(6):884–894. Hart et al. performed a meta-analysis and identified
53 BIA-ALCL patients. For patients with available clinical data, the
authors noted rates of 17.3% with extracapsular disease and 23.1% with
the presence of a mass. A total of 39.6% of patients were treated with
surgery alone, 9.4% with surgery and radiation, 18.9% with surgery and
chemotherapy, 30.2% with surgery, chemotherapy, and radiation, and
1.9% with chemotherapy alone. At a median follow-up of 15 months
(3.6–90 months), disease recurrence was 28.3%, of which 73.3% were
treated with salvage chemotherapy. BIA-ALCL was attributed to four
patient deaths. Extracapsular disease extension was associated with
increased risk for recurrence (p<0.0001) and patient death (p=0.0008).
This study also found a statistically significant difference in 3- and 5-year
survival rates between patients presenting with and without a mass
(p=0.0308 and p=0.0308, respectively).
70. Brody GS, Deapen D, Clive T, et al. Anaplastic large cell lymphoma
(ALCL): occurring in women with breast implants analysis of 173
cases. Plast Reconstr Surg. 2015;135(3):695–705. Brody and colleagues
recently reported a summary of 79 published patients and 94 previously
unreported cases. The authors report that for all implants where surface
characteristics were known, there was at least one textured device used
within the patient’s surgical history. The authors reconfirm that there are
no known pure smooth implant cases and importantly note that
BIA-ALCL has been reported in association with all major forms of
implant texturing techniques from current implant manufacturers. The
authors noted most patients having slow disease progression and a good
prognosis when adequately treated, but conceded occasional
lymphadenopathy, metastases, and nine attributable deaths.
Access the complete reference list online at

Implants and anaplastic large cell Lymphoma etiology
and Epidemiology). The purpose of PROFILE is to
increase the scientific data on BIA-ALCL in women with
breast implants as well as to support research to char-
acterize BIA-ALCL and to elucidate the exact role of
breast implants in the etiology of the disease. In addi-
tion to providing plastic surgeons, oncologists, and
patients with the information they need about breast
implants and treatment of BIA-ALCL, confirmed cases
in the registry will be available for analytical epidemio-
logical studies. Treating physicians are encouraged to
report confirmed cases to the PROFILE website, which
can be found at
Conclusions
Timely diagnosis of BIA-ALCL will depend on the mil-
lions of women with breast implants having access to
heightened surveillance, knowledgeable physicians,
and appropriate testing and medical care. BIA-ALCL
is a rare lymphoma associated with breast implants,
although the exact etiology and pathogenesis remain
unclear. Accurate diagnosis and complete surgical treat-
ment is important for definitive treatment of patients.
Further research is critical for prevention, diagnosis,
and optimal treatment of BIA-ALCL.

208.e1
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43. Bautista-Quach MA, Nademanee A, Weisenburger DD, Chen W,
Kim YS. Implant-associated primary anaplastic large-cell lymphoma
with simultaneous involvement of bilateral breast capsules. Clin
Breast Cancer. 2013;13:492–495.
44. Farace F, Bulla A, Marongiu F, et al. Anaplastic large cell lymphoma
of the breast arising around mammary implant capsule: an Italian
report. Aesthetic Plast Surg. 2013;37:567–571.
45. Ivaldi C, Perchenet AS, Jallut Y, Casanova D. About two cases of
lymphoma in implant capsule: a difficult diagnosis, an unknown
pathology]. Ann Chir Plast Esthet. 2013;58:688–693.
46. Parthasarathy M, Orrell J, Mortimer C, Ball L. Chemotherapy-
resistant breast implant-associated anaplastic large cell lymphoma.
BMJ Case Rep. 2013.
47. Thompson PA, Prince HM. Breast implant-associated anaplastic
large cell lymphoma: a systematic review of the literature and
mini-meta analysis. Curr Hematol Malig Rep. 2013;8:196–210.
48. Zakhary JM, Hamidian Jahromi A, Chaudhery S, Kim M.
Anaplastic large cell lymphoma in the setting of textured breast
implant: a call for patients and physicians education. J la State Med
Soc. 2013;165:26–29.
49. Wong AK, Lopategui J, Clancy S, et al. Anaplastic large cell
lymphoma associated with a breast implant capsule: a case report
and review of the literature. Am J Surg Pathol. 2008;32:1265–1268.
50. Taylor KO, Webster HR, Prince HM. Anaplastic large cell
lymphoma and breast implants: five Australian cases. Plast Reconstr
Surg. 2012;129:610e–617e.
51. George EV, Pharm J, Houston C, et al. Breast implant-associated
ALK-negative anaplastic large cell lymphoma: a case report and
discussion of possible pathogenesis. Int J Clin Exp Pathol.
2013;6:1631–1642.
52. Sorensen K, Murphy J, Lennard A, et al. Anaplastic large cell
lymphoma in a reconstructed breast using a silicone implant: a UK
case report. J Plast Reconstr Aesthet Surg. 2014;67(4):561–563.
53. Smith TJ, Ramsaroop R. breast implant related anaplastic large cell
lymphoma presenting as late onset peri-implant effusion. Breast.
2012;21:102–104.
54. Olack B, Gupta R, Brooks GS. Anaplastic large cell lymphoma
arising in a saline breast implant capsule after tissue expander
breast reconstruction. Ann Plast Surg. 2007;59:56–57.
55. Newman MK, Zemmel NJ, Bandak AZ, Kaplan BJ. Primary breast
lymphoma in a patient with silicone breast implants: a case report
and review of the literature. J Plast Reconstr Aesthet Surg.
2008;61:822–825.
56. Miranda RN, Aladily TN, Prince HM, et al. Breast implant-
associated anaplastic large-cell lymphoma: long-term follow-up of
60 patients. J Clin Oncol. 2014;32:114–120. Miranda et al. reviewed the
long-term follow-up of 60 breast implant-associated anaplastic large cell
lymphoma (BIA-ALCL) patients. The mean age was 52-years-old (range
28–87 years) with a median of 9 years (range 1–32 years) between
implantation and lymphoma diagnosis. Patients presented with either a
malignant effusion or seroma (70%) or a distinct mass (30%). The  
median overall survival (OS) was 12 years (median follow-up 2 years;
range 0–14 years). A total capsulectomy with implant removal was
performed in 93% of patients. OS and progression-free survival (PFS)
were similar between patients who received and did not receive
chemotherapy (p=0.44 and p=0.28, respectively), suggesting that some
patients may achieve optimal outcomes with an adequate surgical
approach. Patients with a breast mass had a worse rate of OS and PFS
(p=0.052 and p=0.03, respectively). The association of a mass may indicate
either a worse prognosis of a more aggressive variant, more progressed
disease, or perhaps a consequence of inadequate surgical ablation of tumor
infiltration.
57. Hart AM, Lechowicz MJ, Peters KK, et al. Breast implant-associated
anaplastic large cell lymphoma: report of 2 cases and review of the
literature. Aesthet Surg J. 2014;34(6):884–894.
58. Lipworth L, Tarone RE, McLaughlin JK. Breast implants and
lymphoma risk: a review of the epidemiologic evidence through
2008. Plast Reconstr Surg. 2009;123:790–793.
59.
ProductsandMedicalProcedures/ImplantsandProsthetics/
BreastImplants/ucm481899.htm.
59b.  Srinivasa DR, Miranda RN, Kaura A, et al. Global Adverse Event
Reports of Breast Implant-Associated ALCL: An International
Review of 40 Government Authority Databases. Plast Reconstr Surg.
2017;139(5):1029–1039.
59c.  McGuire P, Reisman NR, Murphy DK. Risk Factor Analysis for
Capsular Contracture, Malposition, and Late Seroma in Subjects
Receiving Natrelle 410 Form-Stable Silicone Breast Implants. Plast
Reconstr Surg. 2017;139(1):1–9.
59d.  Australian Therapeutic Goods Administration. Breast implants:
Update on TGA monitoring of anaplastic large cell lymphoma.
<
monitoring-anaplastic-large-cell-lymphoma>.
60. de Jong D, Vasmel WL, de Boer JP, et al. Anaplastic large-cell
lymphoma in women with breast implants. JAMA. 2008;300:2030–
2035. de Jong and colleagues reported an individually matched case
control study from the Netherlands nationwide pathology database. The
pathology database served a total population of approximately nine  
million women. The authors found a positive association for the
development of ALCL in women with breast implants compared to those
without implants, with an odds ratio of 18.2 (95% confidence interval,
2.1–156.8). Based upon this data, the authors estimated an incidence of
0.1–0.3 per 100 000 BIA-ALCL cases for women with prostheses per  
year. This study contradicted a number of prior studies that failed to  
show an association between breast augmentation and risk of lymphoma.
In addition, those prior studies were woefully limited in power and length
of follow-up. This study emphasized the difficulty in determining the
incidence and prevalence of a very rare and recently recognized clinical
entity.
61. Largent J, Oefelein M, Kaplan HM, et al. Risk of lymphoma in
women with breast implants: analysis of clinical studies. Eur J
Cancer Prev. 2012;21:274–280.
62. Brinton LA. The relationship of silicone breast implants and cancer
at other sites. Plast Reconstr Surg. 2007;120(7 suppl 1):94S–102S.
63. Lipworth L, Tarone RE, McLaughlin JK. Breast implants and
lymphoma risk: a review of the epidemiologic evidence through
2008. Plast Reconstr Surg. 2009;123(3):790–793.
64. Beatriz EA, Miranda RN, Rauch GM, et al. Breast implant-
associated anaplastic large cell lymphoma: sensitivity, specificity
and findings of imaging studies in 44 patients. Breast Cancer Res
Treat. 2014;147(1):1–14.
65. Taylor CR, Siddiqi IN, Brody GS. Anaplastic large cell lymphoma
occurring in association with breast implants: review of pathologic
and immunohistochemical features in 103 cases. Appl
Immunohistochem Mol Morphol. 2013;21(1):13–20.
66. Carbone PP, Kaplan HS, Musshoff K, et al. Report of the Committee
on Hodgkin’s Disease Staging Classification. Cancer Res.
1971;31:1860–1861.
67. Sobin LH, Gospadarowicz MK, Wittekind C. TNM Classification
of Malignant Tumors. 7th ed. Hoboken, NJ: Wiley-Blackwell;
2009.
68. Clemens MW, Medeiros LJ, Butler CE, et al. Complete surgical
excision is essential for patients with breast implant-associated
anaplastic large cell lymphoma. J Clin Oncol. 2015:160–168. The
authors evaluated the efficacy of different treatment modalities utilized for
BIA-ALCL in order to determine an optimal treatment approach. A total
of 128 patients were reviewed for pathologic findings, and clinical
follow-up and malignant tissue specimens were centralized for 87 patients
with BIA-ALCL. At a median follow-up of 45 months (range 3–217
months), the median OS after diagnosis of BIA-ALCL was 13 years, and

208.e3
References
the OS rate was 93% at 3 years and 89% at 5 years. Patients with
lymphoma confined by the fibrous capsule surrounding the implant had
better event-free survival (EFS) and OS than patients with lymphoma
spread beyond the capsule (p=0.03). Patients who underwent a complete
surgical excision that included total capsulectomy with breast implant
removal had better OS (p=0.022) and EFS (p=0.014) when compared with
patients who received partial capsulectomy, systemic chemotherapy, or
radiation therapy. Based upon observed disease progression characteristics,
a novel solid tumor TNM (tumor, lymph node, metastasis) staging system
was proposed. The authors concluded that surgical management with
complete surgical excision is essential to achieve optimal EFS in patients
with BIA-ALCL.
69. Hart A, Lechowicz MJ. Breast implant-associated anaplastic large
cell lymphoma: treatment experience in 53 patients. Aesthet Surg J.
2014;34(6):884–894. Hart et al. performed a meta-analysis and identified
53 BIA-ALCL patients. For patients with available clinical data, the
authors noted rates of 17.3% with extracapsular disease and 23.1% with
the presence of a mass. A total of 39.6% of patients were treated with
surgery alone, 9.4% with surgery and radiation, 18.9% with surgery and
chemotherapy, 30.2% with surgery, chemotherapy, and radiation, and
1.9% with chemotherapy alone. At a median follow-up of 15 months
(3.6–90 months), disease recurrence was 28.3%, of which 73.3% were
treated with salvage chemotherapy. BIA-ALCL was attributed to four
patient deaths. Extracapsular disease extension was associated with
increased risk for recurrence (p<0.0001) and patient death (p=0.0008).
This study also found a statistically significant difference in 3- and 5-year
survival rates between patients presenting with and without a mass
(p=0.0308 and p=0.0308, respectively).
70. Brody GS, Deapen D, Clive T, et al. Anaplastic large cell lymphoma
(ALCL): occurring in women with breast implants analysis of 173
cases. Plast Reconstr Surg. 2015;135(3):695–705. Brody and colleagues
recently reported a summary of 79 published patients and 94 previously
unreported cases. The authors report that for all implants where surface
characteristics were known, there was at least one textured device used
within the patient’s surgical history. The authors reconfirm that there  
are no known pure smooth implant cases and importantly note that
BIA-ALCL has been reported in association with all major forms of
implant texturing techniques from current implant manufacturers.  
The authors noted most patients having slow disease progression and  
a good prognosis when adequately treated, but conceded occasional
lymphadenopathy, metastases, and nine attributable deaths.
71. Kim B, Predmore ZS, Mattke S, et al. Breast implant–associated
anaplastic large cell lymphoma: updated results from a structured
expert consultation process. Plast Reconstr Surg Glob Open.
2015;3(1):e296.
72. Younes A, Bartlett NL, Leonard JP, et al. Brentuximab vedotin for
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73. Pro B, Advani R, Brice P, et al. Brentuximab vedotin (SGN-35) in
patients with relapsed or refractory systemic anaplastic large-cell
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2190–2196.
74. Chung KC1, Malay S, Shauver MJ. Economic analysis of screening
strategies for rupture of silicone gel breast implants. Plast Reconstr
Surg. 2012;130(1):225–237.

SECTION II • Reconstructive Breast Surgery
13 
Oncological considerations for
breast reconstruction
Grant W. Carlson
SYNOPSIS
■ In the US 35% of women treated for breast cancer with total
mastectomy receive immediate or early breast reconstruction. The
percentage is higher in young women and those treated in tertiary care
medical centers.
■ Immediate breast reconstruction (IBR) has several advantages: it can
prevent some of the negative psychological and emotional sequelae
seen with mastectomy; the aesthetic results of immediate
reconstruction are superior to those seen after delayed reconstruction;
and it also reduces hospital costs by reducing the number of
procedures and length of hospitalization.
■ IBR has the potential to impact the treatment of breast cancer. It could
affect the delivery of adjuvant therapy and the detection and treatment
of recurrent disease. Chemotherapy and radiation therapy could also
impact the complication rates of reconstruction.
Introduction
Approximately 35% of women treated for breast cancer
with total mastectomy receive immediate or early breast
reconstruction. The percentage is higher in young
women and those treated in tertiary care medical centers.
IBR has several advantages: it can prevent some of the
negative psychological and emotional sequelae seen
with mastectomy; the aesthetic results of immediate
reconstruction are usually superior to those seen after
delayed reconstruction; and it also reduces hospital
costs by reducing the number of procedures and length
of hospitalization. Therefore, IBR has the potential to
impact the treatment of breast cancer. It could affect the
delivery of adjuvant therapy and the detection and
treatment of recurrent disease. In addition, chemother-
apy and radiation therapy could also impact the
complication rates of reconstruction. The oncological
considerations for breast reconstruction are outlined in
this chapter.
Immediate breast reconstruction
impact on survival
There are concerns that breast reconstruction may nega-
tively impact breast cancer survival. Studies have shown
that breast reconstruction does not interfere with the
detection of local recurrences (LRs). Skin and nipple-
sparing mastectomy are increasingly used to improve
the results of breast reconstruction. Despite their rela-
tive surgical conservatism compared to traditional
mastectomy, these techniques have not been associated
with an increase in breast cancer recurrence. Complica-
tions after reconstruction have the potential to delay the
administration of adjuvant therapy and potentially
impact survival.
Agarwal et al. used the SEER cancer registry from
1998 to 2002 and assessed 52 249 patients to evaluate the
breast cancer specific survival of patients treated with
immediate or early delayed breast reconstruction after
mastectomy.1 Demographic covariates included age,
race, marital status, income, education, and county
metropolitan status; oncologic covariates included
tumor stage, histologic grade, lymph node status,
hormone receptor status, receipt of radiation, and uni-
lateral or bilateral mastectomy. Breast reconstruction
patients had significantly lower hazard of death (HR
0.73, p<0.0001) compared to those treated with total
mastectomy alone when controlling for demographic
and oncologic covariates.

210
SECTION II
CHAPTER 13 • Oncological considerations for breast reconstruction
Access to breast reconstruction is a surrogate marker
for quality of breast cancer care, so these results are not
surprising. Patients in cancer centers are more likely to
be referred to plastic surgeons and undergo more
aggressive treatment and surveillance in follow-up.
There is also a selection bias that large multi-institutional
cancer registries, like the SEER registry, cannot over-
come. These registries do not collect data on patient
comorbidities that impact the selection process of who
receives breast reconstruction. Healthier people are
more committed to their medical care and are more
likely to undergo breast reconstruction and ultimately
have a better survival.
The effects of the stress of surgery including anesthe-
sia, blood loss, and opioid use may impact cancer pro-
gression. Reconstructive surgeries, especially using
autologous tissue, are longer operations with greater
blood loss and postoperative pain. Studies are needed
that examine the impact of different reconstructive
techniques on breast cancer survival.
Immediate breast reconstruction and
local recurrence of breast cancer
Skin sparing and nipple sparing mastectomy
Skin sparing mastectomy (SSM) has markedly improved
the aesthetic results of IBR (Fig. 13.1). Preservation of
the native skin envelope and the inframammary fold
reduces the amount of tissue necessary for reconstruc-
tion.2 Breast symmetry can often be achieved without
operating on the contralateral breast and the periareolar
incisions are inconspicuous under clothes.
A
Fig. 13.1  Skin sparing mastectomy and immediate transverse rectus andominis
musculocutaneous flap (TRAM) flap breast reconstruction.
B
Table 13.1  Published series of local recurrence of breast cancer after skin sparing and non-skin sparing mastectomy
Author
Follow-up
(Months)
SSM
(N)
LR in SSM
(%)
Non-SSM
(N)
LR in Non-SSM
(N)
Newman et al.85
50
437
6.2
437
7.4
Carlson et al.3
41.3
187
4.8
84
9.5
Kroll et al.4
72
114
7.0
40
7
Simmons et al. 5
15.6–32.4
77
3.9
154
3.2
Rivadeneira et al.86
49
71
5.6
127
3.9
Medina-Franco et al.87
73
176
4.5
-
-
Carlson et al.10
64.6
565
5.5
-
-
Slavin et al.88
44.8
51
3.9
-
-
Toth et al.89
51.5
50
0
-
-
Spiegel et al.90
117.6
221
4.5
-
-
Foster et al.91
49.2
25
4.0
-
-
LR, local recurrence; SSM, skin sparing mastectomy.
There have been concerns that skin, nipple, and
inframammary fold preservation reduces the effective-
ness of total mastectomy. There is a large body of evi-
dence that LRs after SSM are comparable to non-skin
sparing mastectomy (Table 13.1).3–5 Care must be taken,
however, in patients with superficial cancers or diffuse
ductal carcinoma in situ (DCIS) to assure adequate
surgical margins.

211
Immediate breast reconstruction and local recurrence of breast cancer
involvement. Larger, more ptotic breasts are not good
candidates for the procedure. Nipple elevation cannot
be achieved without preservation of a dermoglandular
pedicle, which impacts the completeness of mastectomy.
The ideal candidate for an NSM has small to moderate
sized breasts with minimal ptosis.
Detection of local recurrence after
breast reconstruction
The role of postreconstruction imaging after the treat-
ment of breast cancer remains controversial. There is a
paucity of data that addresses the issue, and there are
no established guidelines.7 The incidence of LR of breast
cancer is related to tumor stage. Most LRs after total
mastectomy are in the skin and subcutaneous tissue and
are readily detected by physical examination.8 A flap or
implant could potentially delay the discovery of chest
wall recurrences.
Systemic relapse is not inevitable following LR, espe-
cially after the treatment of DCIS.9,10 This argues that
early detection of LRs may have a potential survival
impact. All forms of mastectomy leave residual breast
tissue, and the differences are in terms of the microscopic
breast tissue left behind in the skin and inframammary
fold, which is largely preserved after SSM. Torresan
et al. evaluated residual glandular tissue in the skin
flaps that would have been preserved after SSM.11
They found that 60% contained residual glandular
tissue and it correlated with skin flap thickness.
Nipple-sparing mastectomy (NSM) is growing in
popularity because of its perceived aesthetic benefits
(Fig. 13.2). Patient satisfaction with nipple areolar recon-
struction following SSM can be disappointing.6 Data
regarding the oncological safety of NSM is hampered
by small sample size, varying indications and surgical
techniques, and short follow-up (Table 13.2). There are
limited oncological and reconstructive indications for
performing NSM. Large tumors and those located in the
central breast have an increased incidence of nipple
Fig. 13.2  Nipple sparing mastectomies and immediate implant reconstruction via inframammary fold incisions.
(A,B) Preoperative appearance. (C,D) Postoperative appearance.
A
B
C
D
Table 13.2  Published series of nipple areolar complex
recurrence after therapeutic nipple sparing mastectomies
Author
Year
N
Median
follow-up
(months)
NAC
recurrence
Petit et al.92
2005
579
41
0%
Sacchini et al.93
2006
68
24.6
0%
Paepke et al.94
2008
94
34
0%
Babiera et al.95
2010
53
15
0%
Kim et al.96
2010
152
60
1.3%
Jensen et al.97
2011
77
60.2
0%
Peled et al.98
Lohsiriwat et al.99
2012
152
45
0%
Lohsiriwat et al.99
2012
861
50
1.3%
Sakurai et al.100
2013
788
78
3.7%
NAC, nipple areolar complex.

212
SECTION II
CHAPTER 13 • Oncological considerations for breast reconstruction
autologous tissue reconstruction are mammographi-
cally similar to that of primary tumors (Fig. 13.4).20,21
Proponents of surveillance mammography feel that
screening breast cancer patients with autologous recon-
structions can detect non-palpable recurrences before
clinical examination.
Helvie et al. evaluated surveillance mammography in
113 patients after TRAM flap reconstruction.22 Six
patients underwent biopsy for suspicious mammo-
graphic findings, and two LRs were detected. Two
patients in the study group went on to develop recur-
rences that were detected by physical examination.
There was one false negative mammogram resulting in
a sensitivity of 67% and specificity of 98% for surveil-
lance mammography after TRAM flap reconstruction.
There is a paucity of data regarding the efficacy of
MRI of the breast following autogenous breast recon-
struction.23,24 Breast MRI has been shown to clearly
delineate autogenous flaps from residual mammary
adipose tissue. The absence of contrast medium uptake
during breast MRI precludes recurrent carcinoma to a
high probability. Fat necrosis in a TRAM flap will show
early postoperative contrast enhancement, but this
resolves within 6–12 months. Rieber et al. evaluated
MRI of the breast in the follow-up of 41 patients who
had undergone autogenous tissue breast reconstruc-
tion.25 MRI was able to distinguish flaps from surround-
ing residual breast tissue in all cases. It excluded disease
recurrence in four patients with suspicious mammo-
graphic or sonographic findings, and returned false
positive findings in three cases.
The potential indications for postreconstruction
imaging include patients with close surgical margins
The completeness of mastectomy is important in the
treatment of DCIS because most cases of recurrence
represent unexcised residual disease. Several authors
have reported LR of DCIS treated by SSM and IBR.9,12,13
They found that the majority of LRs were invasive carci-
nomas. This suggests that postreconstruction mammog-
raphy can have a role in the early detection of recurrences
prior to the development of invasive carcinoma.
Physical examination of implant reconstruction is
relatively easy. There is minimal soft tissue covering the
implant except along the inframammary fold and in the
axillary tail. Deep chest wall recurrences are extremely
unlikely because the implants are placed in the submus-
cular plane. Conventional mammographic evaluation
has limited utility because the implants obscure soft
tissue visualization. MRI, which has been used exten-
sively to evaluate the integrity of silicone gel implants,
may have a role in the selective surveillance after
implant reconstruction.14–17
The sensitivity of physical examination of autologous
reconstruction is lower than that seen with implant
reconstruction. Deep chest wall recurrences often avoid
detection until symptoms develop. Autologous recon-
struction causes less impairment of mammographic
tissue visualization.18 Benign mammographic findings
after transverse rectus abdominis myocutaneous
(TRAM) flap reconstruction include fat necrosis, lipid
cysts, calcifications, lymph nodes, and epidermal inclu-
sion cysts (Fig. 13.3).19 Breast cancer recurrences in
Fig. 13.3  Mammographic appearance of fat necrosis after TRAM flap
reconstruction.
Fig. 13.4  Mammographic appearance of local recurrence after TRAM flap
reconstruction.

213
Immediate breast reconstruction and adjuvant therapy
therapy. Studies comparing onset of chemotherapy
after IBR and control group treated with mastectomy
alone have failed to show significant differences.29–32
Alderman et al. examined the impact of breast recon-
struction on the administration of adjuvant chemo-
therapy. Data from eight National Comprehensive
Cancer Network institutions was used. They found that
IBR did not result in the omission of adjuvant chemo-
therapy, but there was a modest but statistically signifi-
cant delay in the time to administration.32 The authors
concluded that this short delay would not impact
survival.
Wound complications after IBR must be treated
aggressively to remove necrotic, potentially infected
tissue. Patients with clean, open wounds can receive
chemotherapy with minimal compromise in wound
healing. These patients must be followed closely to
detect early signs of infection.
and patients with diffuse DCIS treated by SSM. Its
routine use after autologous reconstruction after SSM
for invasive carcinoma warrants further study. The low
detection rate and specificity does not justify the routine
use of MRI in the follow-up of patients postreconstruc-
tion. MRI is most useful in patients with abnormal
findings on physical examination or mammography
and ultrasound. It is also helpful to delineate the extent
of local disease recurrence.
Treatment of local recurrence after
breast reconstruction
Surgical options following LR after breast reconstruc-
tion depend on the location and number of metastatic
deposits and previous treatment. Imaging of the recon-
structed breast and body scans are necessary to delineate
the extent of tumor involvement (see Fig. 13.4). Isolated
LRs can be treated with removal of as much recon-
structed tissue as necessary to achieve negative margins.
Adjuvant chest wall radiation is usually administered
(Fig. 13.5).
In cases of implant reconstruction, it may be neces-
sary to remove a portion of the implant capsule neces-
sitating implant removal in most cases. Howard et al.
reviewed 16 cases of LR after TRAM flap reconstruc-
tion.26 Eight recurrences occurred in the skin and were
detected on physical examination. Eight recurrences
occurred in the chest wall and were symptomatic, being
detected on physical examination or diagnostic imaging.
Twelve were felt amenable to surgical resection, and
three required removal of the entire TRAM flap.
Immediate breast reconstruction and
adjuvant therapy
Chemotherapy
There are concerns that IBR may delay the administra-
tion of adjuvant chemotherapy. A survey of 376 consul-
tant breast surgeons in the UK and Ireland found that
the majority (57%) preferred delayed reconstruction
because of these concerns.27 Breast reconstruction does
have a high complication rate especially in patients
that are obese, smoke tobacco, or have a history of chest
wall irradiation. Alderman et al. performed a multi-
institutional study of complication rates after tissue
expander or TRAM flap reconstruction.28 They reported
a 52% complication rate, with major complications
occurring in 30% of patients.
It seems logical that the high complication rate of IBR
could potentially delay the administration of adjuvant
A
Fig. 13.5  (A) Preoperative and (B) postoperative appearance of local breast cancer
recurrence in a left TRAM flap treated by wide local excision and radiation.
B

214
SECTION II
CHAPTER 13 • Oncological considerations for breast reconstruction
positive lymph nodes. Radiotherapy reduced LRR
(2p<0.000 01), overall recurrence (RR 0.67, 2p=0.000 09),
and breast mortality (RR 0.78, 2p=0.01) in this group.
Improvements in breast screening, lymph node analy-
sis, and better system therapy have resulted in lower
absolute risks of recurrence than are seen in the older
studies analyzed, which could lower the impact of
PMRT. Many centers currently recommend PMRT
for patients with early breast cancer. This policy
has increased the complexity of planning breast recon-
struction in patients who potentially have nodal
involvement. In patients with stage III breast cancer, the
best policy may be to perform delayed breast recon-
struction. There are two concerns when administering
PMRT after IBR: technical difficulties with radiation
delivery and negative effects of radiation on the aes-
thetic outcome.
Impact of breast reconstruction on the
administration of radiotherapy
The chest wall is the single most important target to
receive radiation. The majority of LRR are seen in the
chest wall only and not the LNs. The sites at greatest
risk are the skin overlying the tumor bed and the mas-
tectomy scar. There are technical problems related to
irradiation of the reconstructed breast. Distortion of the
chest wall anatomy means that radiotherapy portals
need to be modified. The treatment is more difficult,
particularly irradiating the internal mammary lymph
nodes (IMLNs). This may require changing the depth of
tangential fields resulting in an increased volume of
irradiated lung or heart. The steeply sloping medial
contour from inflated expanders may produce problems
with field matching resulting in a less precise junction
and underdosing of the area under the junction. This
adversely affects electron dosimetry and increases the
negative effects of PMRT as a result of the higher energy
beam requirements and tangential irradiation of the
skin surface.
Chen et al. performed a survey of radiation oncolo-
gists with regard to the treatment of breast cancer in
women who have had breast reconstruction.41 A total of
358 radiation oncologists responded, and 57% of them
felt reconstruction challenged their ability to deliver
effective breast radiation. With regard to patients with
tissue expander reconstruction, 60% preferred treating
moderately filled implants with 150–250 cc rather than
completely deflated or fully inflated implants. The
reason given was to minimize the dose to the heart
and lungs.
The routine treatment of IMLNs is controversial. All
of the randomized trials that showed a survival benefit
Patients with locally advanced, stage III breast cancer
are generally treated with chemotherapy followed by
total mastectomy and adjuvant radiation. The 5-year
survival rate is 50–80%, and patients with a poor
response to chemotherapy have an especially bad prog-
nosis. It may be preferable to delay reconstruction until
after mastectomy and adjuvant radiation in these
patients. This avoids the potential problems from radia-
tion delivery and the adverse effects of postmastectomy
radiation therapy (PMRT) on immediate reconstruction.
These issues will be discussed in detail later in this
chapter.
There is conflicting data regarding the impact of neo-
adjuvant chemotherapy on complications after IBR.
Mehrara et al. found that neoadjuvant chemotherapy
was an independent predictor of overall complications
in free flap breast reconstruction.33 Zweifel-Schlatter
et al. compared 47 patients undergoing immediate free
flap breast reconstruction after neoadjuvant chemo-
therapy with 52 patients who did not receive preopera-
tive therapy, and found no delay in beginning adjuvant
therapy.34 The use of neoadjuvant chemotherapy did not
impact wound complications or delay adjuvant radia-
tion therapy.
Radiation
Rationale for postmastectomy radiotherapy
The goals of postmastectomy radiotherapy are to opti-
mize locoregional control and improve survival. Studies
have shown that extensive lymph node involvement,
large tumor size (≥5 cm), tumor lymphovascular inva-
sion, and positive margins predispose to locoregional
recurrence (LRR) after total mastectomy for breast
cancer. Randomized trial and a meta-analysis have
shown that PMRT can reduce this risk by approximately
67%.35–37 Locoregional recurrences and systemic recur-
rence should not be considered as separate events. An
improvement in locoregional control of breast cancer
directly effects the development and spread of subclini-
cal tumor deposits.
Two randomized trials have shown a survival benefit
for postmastectomy radiotherapy in patients with 1–3
metastatic lymph nodes.38,39 These studies were criti-
cized because the high rate of regional failure in the
non-irradiated group was felt to be the result of inade-
quate axillary surgery and the use of non-anthracycline
based chemotherapy. A meta-analysis by the Early
Breast Cancer Trialists’ Collaborative Group has pro-
vided strong evidence supporting the use of postmas-
tectomy radiotherapy.40 The group studied the results of
22 trials of PMRT conducted between 1964 and 1986 and
noted that 1133 women had axillary dissection and 1–3

215
Immediate breast reconstruction and adjuvant therapy
multicenter study that evaluated patient reported
outcomes for implant-based breast reconstruction with
or without radiation using the Breast-Q.50 The Breast-
Q is a validated patient-reported outcome measure
(PROM) designed to quantify a patient’s experience
in terms of postsurgical satisfaction and health-related
quality-of-life (QOL) after breast surgery and recon-
struction. It can provide patients and providers with
important information to assist in decision-making with
regard to breast reconstruction. The questionnaire was
completed by 633 patients after implant reconstruc-
tion: 414 did not receive radiation, and 219 received
radiation (preoperative radiotherapy 47, postoperative
radiotherapy 172). Patients that received postoperative
radiotherapy had a significant reduction in all domains
(satisfaction with breasts, satisfaction with outcome,
psychosocial well-being, sexual well-being, and phys-
ical well-being) in a univariate analysis. Patients that
received radiation were younger and had higher rates
of axillary dissection and chemotherapy. Multivariate
analysis confirmed the negative impact of radiotherapy
on the satisfaction with breasts domain (p=0.03) when
adjusted for patient and treatment factors. The authors
hypothesize that this may be a reflection of radiation
side effects including capsular contracture and fibrosis.
They conclude that the potential decrease in patient
satisfaction after irradiation of implant reconstruc-
tion should be part of the informed decision-making
process.
These results confirmed the findings of a similar
study using the Breast-Q by Eriksson et al.47 They also
found that radiotherapy significantly impacted all
questionnaire domains when administered in the setting
of implant reconstruction. These authors also reported
the impact of radiotherapy on reconstructive failure: no
radiotherapy 6%, preoperative radiotherapy 25%, and
postoperative radiotherapy 15% (p<0.001). Patients with
reconstructive failure were not included in the question-
naire analysis. Eriksson noted that a large majority of
women who were successfully reconstructed would
choose breast reconstruction again regardless of whether
they received radiation or not. They concluded that
autologous reconstruction should be considered in the
setting of radiotherapy, especially in previously irradi-
ated patients. The reported high satisfaction rates
showed that implant-based reconstruction is not contra-
indicated in the setting of radiotherapy.
There are many patients who do not desire or are not
candidates for autologous reconstruction. It is incum-
bent upon the treating surgeon to provide the patient
with accurate information so that she can make an
informed decision with regard to implant reconstruc-
tion in the setting of radiation therapy.
of PMRT in node positive patients used IMLN irradia-
tion.35,36,40 The results of retrospective studies examining
IMLN irradiation specifically are conflicting. It is the
single greatest predictor of high heart and lung doses in
patients with implant-based reconstruction whether
unilateral or bilateral reconstruction is performed and
is a risk factor for cardiac toxicity. Long-term results of
randomized trials will hopefully answer this important
question with regard to IMLN irradiation.
Motwani et al. examined the effect of immediate
autologous breast reconstruction on the technical deliv-
ery of PMRT.42 Two radiation oncologists reviewed
radiotherapy plans in 110 patients. These were compared
to matched controls that had mastectomy alone. A quali-
tative scoring system was used that evaluated chest wall
coverage, treatment of the IMLN chain, minimization of
lung exposure, and avoidance of the heart. They found
that patients having immediate breast reconstruction
had compromise of their radiation therapy plans com-
pared to that of the control group. If coverage of the
IMLNs was eliminated, the risk of compromise was
significantly reduced. The authors suggested that in
patients with locally advanced breast cancer, the option
for delayed reconstruction should be considered.
Several studies from other centers that do not rou-
tinely treat IMLNs have shown excellent chest wall
coverage, local control, and acceptable doses to the
heart and lungs.43–45 Interpretation of these studies is
hampered by different radiation techniques being used
for reconstruction patients compared to matched con-
trols without reconstruction.
Immediate implant-based reconstruction in the
setting of postmastectomy radiotherapy
There is increasing level III data indicating that radia-
tion increases surgical morbidity after implant-based
breast reconstruction.46–49 Lam et al. reviewed 12 studies
involving 1853 patients to examine the impact of PMRT
on immediate two-stage implant reconstruction.49
Postreconstruction radiotherapy of the tissue expander
resulted in a significantly higher overall reconstructive
failure compared to controls (29.3% vs. 5%, p<0.000 01).
Barry and Kell in a meta-analysis of 11 studies found
that patients receiving PMRT after implant reconstruc-
tion had a significantly increased risk of complications
(OR=4.2, 95% CI: 2.4–7.2) compared to those that did
not receive radiation.46 Autologous reconstruction was
associated with less morbidity (OR=0.21, 95% CI: 0.1–0.4)
in the setting of PMRT.
The impact of radiation therapy on implant breast
reconstruction from the patients’ perspective is
less well documented. Albornoz et al. performed a

216
SECTION II
CHAPTER 13 • Oncological considerations for breast reconstruction
epigastric perforator (DIEP) flap reconstruction.55 They
examined 30 DIEP flaps that received PMRT compared
to a control group of 30 non-irradiated DIEP flaps. They
reported a 23.3% incidence of fat necrosis in the radiated
group vs. 0% incidence in the control group. Radiation
fibrosis was seen in 56.7% of cases with 5 (16.7%) requir-
ing surgical revision.
Spear et al. reviewed 171 pedicled TRAM flaps in 150
patients to determine the effect of radiation therapy.56
This was the first study that critically evaluated
the cosmetic effects of radiation therapy on TRAM flap
reconstruction. Radiation, whether administered before
or after reconstruction, had a negative impact on the
aesthetic appearance, symmetry, contracture, and hyper-
pigmentation of the flap reconstruction. This was based
on the evaluation of postoperative photographs by
blinded judges. There was a two-fold increase in the
incidence of fat necrosis in the post-TRAM flap group
compared to a control group. The authors recommended
that TRAM flap reconstruction be postponed in patients
who will receive postmastectomy radiotherapy.
Delayed-immediate breast reconstruction
MD Anderson Cancer Center advocates a two-stage
approach to “delayed-immediate breast reconstruction”
in patients who may potentially receive PMRT to avoid
potential complications and interference with radiation
delivery.57 Stage I consists of performing a SSM with
insertion of a subpectoral tissue expander that is filled
to the appropriate volume in an attempt to preserve the
skin envelope. After review of the permanent pathologi-
cal analysis, if PMRT is not required, patients undergo
IBR. In patients who require PMRT, the expander is
deflated to provide a flat surface for radiotherapy. After
its completion, the expander is re-inflated and the skin
envelope expanded. This second staged is a form of
delayed skin preserving reconstruction.
An animal study has shown that partial deflation of
a tissue expander exacerbated the adverse effects of
radiation, as evidenced by a reduction in epidermal
thickness, an increase in seroma formation, and an
increase in capsular thickness compared to a study
group that received radiation to a fully inflated
expander.58 MD Anderson Cancer Center performed a
5-year review of 47 patients with stage III breast cancer
who underwent delayed-immediate breast reconstruc-
tion.59 The overall expander loss occurred in 15 patients
(32%), including 9 (22%) during re-inflation after PMRT.
Timing of delayed reconstruction after PMRT
In performing autologous delayed breast reconstruc-
tion, the optimum delay to allow the acute effects of
Radiation impact on TRAM flap reconstruction
The body of evidence in the literature has shown that
radiation therapy increases the risk of TRAM flap com-
plications and negatively impacts the aesthetic out-
comes. Early work showed that chest wall radiation
increased the risk of complications after delayed pedicled
TRAM flap reconstruction.51 Overall, a history of chest
wall irradiation resulted in a statistically significant
increase in both fat necrosis and flap necrosis. Bipedicle
TRAM flap reconstruction showed a reduced risk of
these complications, arguing that improved blood
supply can overcome some of the effects of radiation.
Williams et al. reviewed 19 cases of pedicled TRAM
flap irradiation.52 Complication rates were compared to
delayed TRAM flaps performed after the administration
of radiation and a control group of TRAM flap recon-
struction alone. The overall flap complication rate is the
same whether radiation was administered before or
after reconstruction. Ten patients (52.6%) demonstrated
postirradiation changes to the TRAM flap and 6 required
surgical interventions (31.6%).
Carlson et al. performed a retrospective review of 199
patients undergoing 232 pedicled TRAM flap recon-
structions to identify patients who received radiother-
apy.53 Patients were stratified into 5 groups by the use
and timing of radiation as well as the timing of the
reconstruction. Blinded reviewers assessed the overall
aesthetic appearance. The incidence of flap complica-
tions was 34.2% in the immediate non-irradiated group,
10.7% in the delayed non-irradiated group, 44% in the
post-TRAM radiation group, 60% in the immediate pre-
TRAM radiation group, and 33% in the delayed pre-
TRAM radiation group (p=0.010). Patients who had
immediate TRAM flap reconstruction and did not
receive radiation had a better global aesthetic outcome
(p<0.001) than the other 4 groups. The aesthetic outcome
was similar whether radiation was administered pre- or
post-TRAM flap reconstruction.
Tran et al. compared immediate and delayed free
TRAM flap reconstruction in patients receiving PMRT.54
The study groups included 32 immediate and 70 delayed
TRAM flaps. The incidence of early complications did
not differ between the groups. However, the incidence
of late complications (fat necrosis, volume loss, or flap
contracture) was significantly higher in the immediate
reconstruction group. Nine patients (28%) in the imme-
diate group required an additional flap to correct dis-
torted contours. The authors concluded that in patients
who need PMRT, TRAM flap reconstruction should be
delayed until radiation therapy is completed.
A paper by Rogers and Allen has demonstrated
similar deleterious effects of radiation on deep inferior

217
Contralateral prophylactic mastectomy
decade document a more than doubling of the inci-
dence of CPM.65 The potential drivers of this trend
are many, but in general they stem from a percep-
tion held by patients, the medical community, and
the general public that there is a risk of subsequent
primary breast cancer. Some risk factors are better
understood than others. For instance, heritable genetic
mutations substantially heighten the risk of a contra-
lateral primary breast cancer, but indeterminate find-
ings on MRI or certain histopathology have unknown
implications.
Younger age has been widely demonstrated to
increase the likelihood of electing for CPM.66–72 Among
women with early stage disease, younger women face
a longer life expectancy and thus a longer window
in which to develop a second primary breast cancer.
On the other hand, younger women with very early
presenting cancers may be more likely to harbor a
predisposing genetic mutation, which clearly confers
an increased risk of a subsequent cancer to the oppo-
site breast and may motivate the pursuit of CPM. It
is also known that younger women are more likely
to pursue postmastectomy breast reconstruction in
general.2–4 Some have postulated that better symmetry
and a superior aesthetic outcome can be achieved with
bilateral breast reconstruction, which may make
some women more accepting of a contralateral
procedure.
Women of racial minorities are less likely to choose
CPM, a trend that likely reflects cultural preferences and
socioeconomic differences.67,69–71,73 A family history of
breast cancer was a strong predictor of prophylactic
mastectomy.66,69,72,74,75 Furthermore, a family history
consisting of multiple first-degree relatives is among the
indications for prophylactic mastectomy put forward by
the Society of Surgical Oncology.76
The use of MRI in the diagnostic workup of a breast
cancer increases the use of CPM by two- to three-
fold.69,74,77 Sorbero et al. propose two mechanisms for
this association.77 Firstly, women imaged by MRI are
more likely choose mastectomy over breast conserving
surgery, which introduces the option of CPM that a
subset of women will take. Secondly, indeterminate
findings in the contralateral breast, some of which will
necessitate further breast biopsies, generate uncertainty
and distress for the patient and perhaps even their
surgeon, which then spurs a decision for CPM.
Occult breast cancer is discovered in approximately
5% of CPM specimens.75,78 While these lesions may
have been identified on surveillance imaging and
effectively treated, most evidence points to an overall
improvement in disease-free survival following CPM,
at least among women at high risk, such as those with
PMRT to resolve appears to be 6–12 months. Baumann
et al. reviewed their experience with delayed free TRAM
flap reconstruction after PMRT to determine the impact
of timing on surgery complications.60 In total, 189
patients were identified and stratified into 2 groups:
reconstruction performed less than 12 months from
PMRT and reconstruction performed after 12 months.
They found that complications were decreased in the
longer delay group including total flap loss and re-
operation. Momoh et al. reviewed their experience with
100 patients having delayed free flap reconstruction
after PMRT and found no difference in complication
rates whether the operation was performed early (within
6 months) or delayed (greater than 6 months after
PMRT).61
Breast reconstruction after failed
breast conservation
Breast conservation therapy (BCT) is the treatment of
choice for most early stage breast cancers. Despite sur-
vival rates equivalent to total mastectomy, BCT is
associated with a 0.5% per year risk of in breast recur-
rence over 20 years. The primary treatment after failed
breast conservation is total mastectomy. Reconstruction
in this setting is poorly understood and presents a
unique set of challenges.
There is a rise in data indicating that the complication
rates of implant-based IBR are increased in the setting
of preoperative radiotherapy. Mastectomy skin flap
necrosis, capsular contracture, and reconstructive failure
have all been well documented.47,62–64 Cordeiro et al.
found the aesthetic grades to be lower in patients having
immediate tissue expander reconstruction after failed
breast conservation.62 Hirsch et al. reviewed their expe-
rience with immediate tissue expander reconstruction
after breast conservation.63 They found a 29.6% (21/71)
rate of explantation with the rates being similar during
the first stage (tissue expander) and the second stage
(permanent implant placement).
Good results can be achieved with implant-based
reconstruction after failed breast conservation, but the
patients must be counseled on the increased risk of
complications (see Fig. 13.1). The literature provides no
data on how time after breast conservation affects the
results of immediate tissue expander reconstruction.
Contralateral prophylactic mastectomy
Women diagnosed with breast cancer increasingly elect
to undergo a contralateral prophylactic mastectomy
(CPM) at the time of breast cancer treatment. Data
from a large national registry spanning most of the last

218
SECTION II
CHAPTER 13 • Oncological considerations for breast reconstruction
The considerable added morbidity of prophylactic
mastectomy has been demonstrated in other series.75,82–84
Miller et al. reviewed a single institution experience of
600 patients treated by total mastectomy (unilateral 391,
CPM 209).83 When adjusting for confounding variables
(age, BMI, smoking, diabetes, reconstruction, and radia-
tion), patients undergoing CPM were 1.5 times more
likely to have any operative complication (p=0.029) and
2.7 times more likely to have a major complication
(p=0.004) when compared with patients undergoing
unilateral mastectomy.
The incidence of CPM has risen dramatically over
recent years. Women who choose CPM are more often
young, white, and have a family history of breast cancer.
Failure of breast conservation and pursuit of postmas-
tectomy breast reconstruction are other contributing
factors. Reconstructive trends in this cohort, namely the
prevalence of immediate implant-based reconstruction,
are mirrored by national trends among all patients who
undergo mastectomy. As the incidence of CPM contin-
ues to increase, the outcomes of this procedure must be
critically assessed. The added morbidity appears to be
substantial.
a strong family history or hormone receptor negative
cancer.77,79,80
Nationwide data on breast reconstruction demon-
strates an overall increase in IBR, as well as a significant
increase in the use of breast implants.81 The increasing
proportion of women who undergo CPM is undoubt-
edly a substantial contributor to these trends. The ben-
efits of prophylactic mastectomy must be weighed
against the added morbidity of a second procedure,
which in the vast majority of cases involves not only
mastectomy but also reconstruction. Because the proce-
dure is elective and the breast is healthy, patients and
even clinicians may underestimate the potential risks.
Crosby et al. examined immediate postmastectomy
bilateral reconstruction for an index cancer combined
with a CPM in 497 patients.82 The findings showed that
154 patients developed a complication in the reconstruc-
tion, and 42 patients (27.3%) developed a complication
in the prophylactic side. In implant reconstruction, they
found a 22.5% complication rate in the index breast and
a 19.2% risk of a complication in the prophylactic breast.
The risk of having a complication in both breasts was
11.1%.
1. Agarwal J, Agarwal S, Pappas L, et al. A population-based study of
breast cancer-specific survival following mastectomy and
immediate or early-delayed breast reconstruction. Breast J.
2012;18(3):226–232. Large population based study using the SEER
database of over 52 000 breast cancer patients. Regression analysis showed
that IBR had no impact on breast cancer survival.
3. Carlson GW, Bostwick J 3rd, Styblo TM, et al. Skin-sparing
mastectomy. Oncologic and reconstructive considerations. Ann Surg.
1997;225(5):570–575, discussion 575-578. A large retrospective review
comparing the outcomes of non-skin sparing and skin sparing
mastectomies in the treatment of breast cancer.
8. Langstein HN, Cheng MH, Singletary SE, et al. Breast cancer
recurrence after immediate reconstruction: patterns and
significance. Plast Reconstr Surg. 2003;111(2):712–720, discussion
721-722. Review of 39 local recurrences after IBR. The majority of local
recurrences occurred in the skin and subcutaneous tissue.
32. Alderman AK, Collins ED, Schott A, et al. The impact of breast
reconstruction on the delivery of chemotherapy. Cancer.
2010;116(7):1791–1800. Multi-institutional study that found IBR did not
lead to omission of chemotherapy but was associated with a modest delay
in initiating treatment.
40. EBCTCG, McGale P, Taylor C, et al. Effect of radiotherapy after
mastectomy and axillary surgery on 10-year recurrence and
20-year breast cancer mortality: meta-analysis of individual
patient data for 8135 women in 22 randomised trials. Lancet.
2014;383(9935):2127–2135. Landmark meta-analysis that examines
the impact of postmastectomy radiotherapy on breast cancer  
survival.
47. Eriksson M, Anveden L, Celebioglu F, et al. Radiotherapy in
implant-based immediate breast reconstruction: risk factors,
surgical outcomes, and patient-reported outcome measures in a
large Swedish multicenter cohort. Breast Cancer Res Treat.
2013;142(3):591–601. Study that evaluates the impact of postmastectomy
radiotherapy on surgical morbidity and patient reported outcomes after
immediate implant-based reconstruction.
62. Cordeiro PG, Snell L, Heerdt A, et al. Immediate tissue expander/
implast breast reconstruction after salvage mastectomy for cancer
recurrence following lumpectomy/irradiation. Plast Reconstr Surg.
2012;129(2):341–350. This text highlights that implant-based
reconstruction after failed breast conservation has poorer aesthetic
outcomes for patients without a history of radiation.
67. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast
reconstruction: part 2. The influence of changing mastectomy
patterns on reconstructive rate and method. Plast Reconstr Surg.
2013;131(3):320e–326e. Review of the National Inpatient Sample database
showing the increase in implant-based breast reconstruction and the use of
contralateral prophylactic mastectomy.
98. Peled AW, Foster RD, Stover AC, et al. Outcomes after total
skin-sparing mastectomy and immediate reconstruction in 657
breasts. Ann Surg Oncol. 2012;19:3402–3409. Single institution
experience with nipple sparing mastectomies that highlights changes in
technique to reduce complication rates.
Access the complete reference list online at

218.e1
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35. Overgaard M, Jensen MB, Overgaard J, et al. Postoperative
radiotherapy in high-risk postmenopausal breast-cancer patients
given adjuvant tamoxifen: Danish Breast Cancer Cooperative
Group DBCG 82c randomised trial. Lancet.
1999;353(9165):1641–1648.
36. Ragaz J, Olivotto IA, Spinelli JJ, et al. Locoregional radiation
therapy in patients with high-risk breast cancer receiving adjuvant
chemotherapy: 20-year results of the British Columbia randomized
trial. J Natl Cancer Inst. 2005;97(2):116–126.
37. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of
differences in the extent of surgery for early breast cancer on local
recurrence and 15-year survival: an overview of the randomised
trials. Lancet. 2005;366(9503):2087–2106.
38. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and
chemotherapy in node-positive premenopausal women with breast
cancer [see comments]. N Engl J Med. 1997;337(14):956–962.
39. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative
radiotherapy in high-risk premenopausal women with breast
cancer who receive adjuvant chemotherapy. Danish Breast Cancer
Cooperative Group 82b Trial [see comments]. N Engl J Med.
1997;337(14):949–955.
40. EBCTCG, McGale P, Taylor C, et al. Effect of radiotherapy after
mastectomy and axillary surgery on 10-year recurrence and

218.e2
SECTION II
CHAPTER 13 • Oncological considerations for breast reconstruction
20-year breast cancer mortality: meta-analysis of individual
patient data for 8135 women in 22 randomised trials. Lancet.
2014;383(9935):2127–2135. Landmark meta-analysis that examines the
impact of postmastectomy radiotherapy on breast cancer survival.
41. Chen SA, Hiley C, Nickleach D, et al. Breast reconstruction and
post-mastectomy radiation practice. Radiat Oncol. 2013;8:45.
42. Motwani SB, Strom EA, Schechter NR, et al. The impact of
immediate breast reconstruction on the technical delivery of
postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys.
2006;66(1):76–82.
43. Koutcher L, Ballangrud A, Cordeiro PG, et al. Postmastectomy
intensity modulated radiation therapy following immediate
expander-implant reconstruction. Radiother Oncol.
2010;94(3):319–323.
44. Liljegren A, Unukovych D, Gagliardi G, et al. No difference in
dose distribution in organs at risk in postmastectomy radiotherapy
with or without breast implant reconstruction. Radiat Oncol.
2014;9:14.
45. Ohri N, Cordeiro PG, Keam J, et al. Quantifying the impact of
immediate reconstruction in postmastectomy radiation: a large,
dose-volume histogram-based analysis. Int J Radiat Oncol Biol Phys.
2012;84(2):e153–e159.
46. Barry M, Kell MR. Radiotherapy and breast reconstruction: a
meta-analysis. Breast Cancer Res Treat. 2011;127(1):15–22.
47. Eriksson M, Anveden L, Celebioglu F, et al. Radiotherapy in
implant-based immediate breast reconstruction: risk factors,
surgical outcomes, and patient-reported outcome measures in a
large Swedish multicenter cohort. Breast Cancer Res Treat.
2013;142(3):591–601. Study that evaluates the impact of postmastectomy
radiotherapy on surgical morbidity and patient reported outcomes after
immediate implant-based reconstruction.
48. Ho A, Bovill E, Macadam S, et al. Post-mastectomy radiation
therapy after immediate two-stage tissue expander/implant breast
reconstruction: a UBC perspective. Plast Reconstr Surg. 2014.
49. Lam TC, Hsieh F, Boyages J. The effects of postmastectomy
adjuvant radiotherapy on immediate two-stage prosthetic breast
reconstruction: a systematic review. Plast Reconstr Surg.
2013;132(3):511–518. Meta-analysis of 12 studies and 1853 patients that
showed postmastecomy radiotherapy after two-staged prosthetic breast
reconstruction resulted in an 18.6% reconstrutive failure rate compared
to a 3.1% failure rate for a control group not receiving radiation.
50. Albornoz C, Matros E, McCarthy C, et al. Implant based
reconstruction and radiation: a multicenter analysis of long-term
health-related quality of life and satisfaction. Ann Surg Oncol. 2014.
51. Watterson PA, Bostwick J 3rd, Hester TR Jr, et al. TRAM flap
anatomy correlated with a 10-year clinical experience with 556
patients. Plast Reconstr Surg. 1995;95(7):1185–1194.
52. Williams JK, Carlson GW, Bostwick J 3rd, et al. The effects of
radiation treatment after TRAM flap breast reconstruction. Plast
Reconstr Surg. 1997;100(5):1153–1160.
53. Carlson GW, Page AL, Peters K, et al. Effects of radiation therapy
on pedicled transverse rectus abdominis myocutaneous flap breast
reconstruction. Ann Plast Surg. 2008;60(5):568–572.
54. Tran NV, Chang DW, Gupta A, et al. Comparison of immediate
and delayed free TRAM flap breast reconstruction in patients
receiving postmastectomy radiation therapy. Plast Reconstr Surg.
2001;108(1):78–82.
55. Rogers NE, Allen RJ. Radiation effects on breast reconstruction
with the deep inferior epigastric perforator flap. Plast Reconstr
Surg. 2002;109(6):1919–1924, discussion 1925-1926.
56. Spear SL, Ducic I, Low M, et al. The effect of radiation on pedicled
TRAM flap breast reconstruction: outcomes and implications. Plast
Reconstr Surg. 2005;115(1):84–95.
57. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate
breast reconstruction. Plast Reconstr Surg. 2004;113(6):1617–1628.
58. Celet Ozden B, Guven E, Aslay I, et al. Does partial expander
deflation exacerbate the adverse effects of radiotherapy in
two-stage breast reconstruction? World J Surg Oncol. 2012;10:44.
59. Kronowitz SJ, Lam C, Terefe W, et al. A multidisciplinary protocol
for planned skin-preserving delayed breast reconstruction for
patients with locally advanced breast cancer requiring
postmastectomy radiation therapy: 3-year follow-up. Plast Reconstr
Surg. 2011;127(6):2154–2166.
60. Baumann DP, Crosby MA, Selber JC, et al. Optimal timing of
delayed free lower abdominal flap breast reconstruction after
postmastectomy radiation therapy. Plast Reconstr Surg. 2011;127(3):
1100–1106.
61. Momoh AO, Colakoglu S, de Blacam C, et al. Delayed autologous
breast reconstruction after postmastectomy radiation therapy: is
there an optimal time? Ann Plast Surg. 2012;69(1):14–18.
62. Cordeiro PG, Snell L, Heerdt A, et al. Immediate tissue expander/
implast breast reconstruction after salvage mastectomy for cancer
recurrence following lumpectomy/irradiation. Plast Reconstr Surg.
2012;129(2):341–350. This text highlights that implant-based
reconstruction after failed breast conservation has poorer aesthetic
outcomes for patients without a history of radiation.
63. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of tissue
expander/implant breast reconstruction in the setting of
prereconstruction radiation. Plast Reconstr Surg.
2012;129(2):354–361.
64. Lin KY, Johns FR, Gibson J, et al. An outcome study of breast
reconstruction: presurgical identification of risk factors for
complications. Ann Surg Oncol. 2001;8(7):586–591.
65. Habermann EB, Abbott A, Parsons HM, et al. Are mastectomy
rates really increasing in the United States? J Clin Oncol.
2010;28(21):3437–3441.
66. Arrington AK, Jarosek SL, Virnig BA, et al. Patient and surgeon
characteristics associated with increased use of contralateral
prophylactic mastectomy in patients with breast cancer. Ann Surg
Oncol. 2009;16(10):2697–2704.
67. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S.
breast reconstruction: part 2. The influence of changing
mastectomy patterns on reconstructive rate and method. Plast
Reconstr Surg. 2013;131(3):320e–326e. Review of the National
Inpatient Sample database showing the increase in implant-based  
breast reconstruction and the use of contralateral prophylactic
mastectomy.
68. Chagpar AB, Studts JL, Scoggins CR, et al. Factors associated with
surgical options for breast carcinoma. Cancer.
2006;106(7):1462–1466.
69. King TA, Sakr R, Patil S, et al. Clinical management factors
contribute to the decision for contralateral prophylactic
mastectomy. J Clin Oncol. 2011;29(16):2158–2164.
70. Tuttle TM, Habermann EB, Grund EH, et al. Increasing use of
contralateral prophylactic mastectomy for breast cancer patients: a
trend toward more aggressive surgical treatment. J Clin Oncol.
2007;25(33):5203–5209.
71. Tuttle TM, Jarosek S, Habermann EB, et al. Increasing rates of
contralateral prophylactic mastectomy among patients with ductal
carcinoma in situ. J Clin Oncol. 2009;27(9):1362–1367.
72. Yi M, Hunt KK, Arun BK, et al. Factors affecting the decision of
breast cancer patients to undergo contralateral prophylactic
mastectomy. Cancer Prev Res (Phila). 2010;3(8):1026–1034.
73. Elmore L, Myckatyn TM, Gao F, et al. Reconstruction patterns in a
single institution cohort of women undergoing mastectomy for
breast cancer. Ann Surg Oncol. 2012;19(10):3223–3229.
74. Chung A, Huynh K, Lawrence C, et al. Comparison of patient
characteristics and outcomes of contralateral prophylactic
mastectomy and unilateral total mastectomy in breast cancer
patients. Ann Surg Oncol. 2012;19(8):2600–2606.
75. Pinell-White XA, Kolegraff K, Carlson GW. Predictors of
contralateral prophylactic mastectomy and the impact on
breast reconstruction. Ann Plast Surg. 2014;72(6):S153–
S157.
76. Position Statement on Prophylactic Mastectomy. 2007.
77. Sorbero ME, Dick AW, Beckjord EB, et al. Diagnostic breast
magnetic resonance imaging and contralateral prophylactic
mastectomy. Ann Surg Oncol. 2009;16(6):1597–1605.
78. Goldflam K, Hunt KK, Gershenwald JE, et al. Contralateral
prophylactic mastectomy. Predictors of significant histologic
findings. Cancer. 2004;101(9):1977–1986.

218.e3
References
79. Boughey JC, Hoskin TL, Degnim AC, et al. Contralateral
prophylactic mastectomy is associated with a survival advantage
in high-risk women with a personal history of breast cancer. Ann
Surg Oncol. 2010;17(10):2702–2709.
80. Brewster AM, Bedrosian I, Parker PA, et al. Association between
contralateral prophylactic mastectomy and breast cancer outcomes
by hormone receptor status. Cancer. 2012;118(22):5637–5643.
81. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S.
Breast reconstruction: increasing implant rates. Plast Reconstr Surg.
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82. Crosby MA, Garvey PB, Selber JC, et al. Reconstructive outcomes
in patients undergoing contralateral prophylactic mastectomy.
Plast Reconstr Surg. 2011;128(5):1025–1033.
83. Miller ME, Czechura T, Martz B, et al. Operative risks associated
with contralateral prophylactic mastectomy: a single institution
experience. Ann Surg Oncol. 2013.
84. Osman F, Saleh F, Jackson TD, et al. Increased postoperative
complications in bilateral mastectomy patients compared to
unilateral mastectomy: an analysis of the NSQIP database. Ann
Surg Oncol. 2013;20(10):3212–3217.
85. Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment,
and outcome of local recurrence afterskin-sparing mastectomy and
immediate breast reconstruction. Ann Surg Oncol.
1998;5(7):620–626.
86. Rivadeneira DE, Simmons RM, Fish SK, et al. Skin-sparing
mastectomy with immediate breast reconstruction: a critical
analysis of local recurrence. Cancer J. 2000;6(5):331–335.
87. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated
with local recurrence after skin-sparing mastectomy and
immediate breast reconstruction for invasive breast cancer. Ann
Surg. 2002;235(6):814–819.
88. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy
and immediate reconstruction: oncologic risks and aesthetic results
in patients with early-stage breast cancer. Plast Reconstr Surg.
1998;102(1):49–62.
89. Toth BA, Forley BG, Calabria R. Retrospective study of the
skin-sparing mastectomy in breast reconstruction. Plast Reconstr
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90. Spiegel AJ, Butler CE. Recurrence following treatment of ductal
carcinoma in situ with skin-sparing mastectomy and immediate
breast reconstruction. Plast Reconstr Surg. 2003;111(2):706–711.
91. Foster RD, Esserman LJ, Anthony JP, et al. Skin-sparing
mastectomy and immediate breast reconstruction: a prospective
cohort study for the treatment of advanced stages of breast
carcinoma. Ann Surg Oncol. 2002;9(5):462–466.
92. Petit JY, Veronesi U, Luini A, et al. When mastectomy becomes
inevitable: the nipple-sparing approach. Breast. 2005;14(6):527–531.
93. Sacchini V, Pinotti JA, Barros AC, et al. Nipple-sparing
mastectomy for breast cancer and risk reduction: oncologic or
technical problem? J Am Coll Surg. 2006;203(5):704–714.
94. Paepke S, Schmid R, Fleckner S, et al. Subcutaneous mastectomy
with conservation of the nipple-areola skin: broadening the
indications. Ann Surg. 2009;250(2):288–292.
95. Babiera G, Simmons R. Nipple-areolar complex-sparing
mastectomy: feasibility, patient selection, and technique. Ann Surg
Oncol. 2010;17(suppl 3):245–248.
96. Kim HJ, Park EH, Lim WS, et al. Nipple areola skin-sparing
mastectomy with immediate transverse rectus abdominis
musculocutaneous flap reconstruction is an oncologically safe
procedure: a single center study. Ann Surg. 2010;251(3):493–498.
97. Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mastectomy
in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol.
2011;18(6):1665–1670.
98. Peled AW, Foster RD, Stover AC, et al. Outcomes after total
skin-sparing mastectomy and immediate reconstruction in 657
breasts. Ann Surg Oncol. 2012;19:3402–3409. Single institution
experience with nipple sparing mastectomies that highlights changes in
technique to reduce complication rates.
99. Lohsiriwat V, Martella S, Rietjens M, et al. Paget’s disease as a
local recurrence after nipple-sparing mastectomy: clinical
presentation, treatment, outcome, and risk factor analysis. Ann
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100. Sakurai T, Zhang N, Suzuma T, et al. Long-term follow-up of
nipple-sparing mastectomy without radiotherapy: a single center
study at a Japanese institution. Med Oncol. 2013;30(1):481.

SECTION II • Reconstructive Breast Surgery
14 
Preoperative evaluation and planning
for breast reconstruction following
mastectomy
John Y.S. Kim and Nima Khavanin
SYNOPSIS
■ The specific details of an individual patient’s preoperative context can
optimize shared decision-making and yield better reconstructive
outcomes while concomitantly managing patient expectations.
■ Preoperative evaluation for breast reconstruction generally includes
understanding a patient’s oncologic status, treatment plan, past
medical and surgical history, medications, anatomy, and postoperative
expectations.
■ A patient’s oncologic history will guide important decisions including
eligibility for nipple-sparing mastectomy as well as the need for
chemoradiation.
■ Perioperative medication management plays an important role in
decreasing the risk for adverse events, and decisions to continue or
withhold specific medications should be made on a case-by-case
basis.
■ Risk calculators convert a patient’s demographic information and
comorbidities into an individualized measure of risk, facilitating patient
education and shared decision-making.
Introduction
The surgical management of breast cancer requires
a multidisciplinary approach that involves medical
oncologists, radiologists, pathologists, breast/oncologic
surgeons, and reconstructive surgeons. This integration
is especially germane for breast reconstruction patients
since there are diverse technique choices available, each
with its attendant profile of risks and benefits. The
specific details of an individual patient’s preoperative
context can optimize shared decision-making and yield
better reconstructive outcomes while concomitantly
managing expectations. Accordingly, in this chapter
we will review current literature on how patient and
disease factors, including pre-reconstruction radiation,
chemotherapy, patient anatomy, medications, and
comorbidities, play into medical, surgical, and cosmetic
outcomes following breast reconstruction.
Patient history
A detailed patient history should focus on a patient’s
oncologic history and treatment plan, relevant medical
and surgical history, and risk factors that may affect
wound healing and/or reconstructive outcomes.
Oncologic status and treatment plan
A patient’s stage is not only an important predictor of
life expectancy but also the need for neoadjuvant or
adjuvant chemoradiation. Details such as tumor size
and location can affect a patient’s candidacy for nipple-
sparing mastectomy, and information on cancer type,
e.g., inflammatory cancer, can affect the extent of skin
resection and consequent need for soft-tissue coverage.
The magnitude of the oncologic problem can also dictate
a decision to potentially delay reconstruction if there is
limited life expectancy or if the urgency of adjuvant
treatment mandates a deferral of potentially complex
reconstructive procedures.
Stage
As a prognostic factor, cancer stage is among the most
important predictors of a patient’s long-term cancer
survival. Recent SEER (Surveillance, Epidemiology, and
End Results) statistics demonstrate nearly 100% 5-year
survival rates for Stage 0 or I, 93% for stage II, 72%
for stage III, 22% for stage IV.1 This data often plays
an important role in a woman’s decision between

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CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
Relatively little reconstructive data exists on this rare
cohort.10 In the largest study to date,9 59 women, all of
whom received chemotherapy and radiation, under-
went 52 delayed and 7 immediate autogenous recon-
structions. Complications occurred in nearly 36% of
patients, with one total flap loss.
Special case: nipple-sparing mastectomy
As its name suggests, nipple-sparing mastectomy (NSM)
preserves the nipple and areola, in addition to the
typical mastectomy skin flap, allowing for potentially
improved cosmetic outcomes.11 Generally, NSM is only
indicated in carefully selected patients, particularly
those undergoing mastectomy for prophylactic reasons
or those with smaller, unifocal lesions a reasonable
distance away from the nipple areolar complex.12–14
Other variables favoring this potential approach include
negative axillary node involvement, negative lympho-
vascular involvement, no extensive intraductal compo-
nent, grade 1 or 2 tumor, HER2/neu negativity, and ER/
PR positivity. Contraindications include inflammatory
breast cancer, clinical involvement of the nipple areolar
complex, nipple retraction, Paget’s disease, bloody
nipple discharge, and multicentricity (Table 14.2).15,16
Retrospective studies of nipple pathology in patients
with nipple removal have demonstrated subclinical
nipple involvement rates ranging from 0 to 58% depend-
ing on the tumor size and location, multicentricity, and
lymph node positivity among other variables.11 These
data have led researchers to develop oncologic criteria
for NSM including peripheral tumor location, size
under 2–5 cm, and a tumor to nipple distance greater
than 2 cm.17 Using similar patient selection criteria, local
Table 14.1  Factors in the evaluation for postmastectomy
radiation12–16
Indications
• Locally advanced disease – T4 tumor
• T3 tumor with evidence of node involvement upon pathology
• Margins positive for invasive disease upon pathology
• Tumor of any size with 4+ involved nodes
Possible indications
• T1–2 disease & 1–3 involved nodes
• T3N0
• DCIS identified at the surgical margin
• Node negative, triple negative breast cancer
DCIS, ductal carcinoma in situ.
Table 14.2  Criteria for nipple-sparing mastectomy
Indications11–18
Contraindications
• Tumor location >2 cm from
the nipple
• Negative axillary nodes
• No lymphovascular
involvement
• No extensive intraductal
component
• Tumor grade 1 to 2
• HER2/neu negative
• Tumor size <2–5 cm*
• ER/PR positive*
• Inflammatory breast cancer
• Clinical involvement of the
nipple areolar complex
• Nipple retraction
• Paget’s disease
• Bloody nipple discharge
• Multicentricity
• HER2/neu positive
• Tumor grade 3
Supporting factors
• No prior breast surgery or radiation
• Young, <45 years old
• Non-smoker
• No adjuvant radiation
*Ongoing topics of research
breast-conserving therapy and mastectomy, as well as
her decision on whether or not to pursue reconstruction.
Recently, trends in mastectomy for early-stage breast
cancer increased to 37.8% in 2011, with 36.4% of these
patients electing to undergo reconstruction.2 Although
patients with early disease (stage I or carcinoma in situ)
are more likely to undergo reconstruction,3,4 some
centers report no association between cancer stage and
reconstruction rates,5 and this relationship likely varies
across institutions.
Cancer stage is also one of many variables, including
tumor size, margins, nodal involvement, and tumor
histology, that factors into the decision regarding post-
mastectomy radiation and systemic chemotherapy.
Indications for postmastectomy radiotherapy are pre-
sented in Table 14.1. The possibility of adjuvant and
neoadjuvant therapies can affect both the timing and
even modality of reconstruction and should be reviewed
with every patient.
Special case: inflammatory breast cancer
Inflammatory breast cancer is an aggressive form of
cancer marked by the classic finding of peau d’orange
and a relatively poor prognosis.6 These cancers may
require aggressive surgical resection in addition to
chemotherapy and irradiation, and have a relatively
high recurrence rate.7,8 Reconstruction in this setting
can be particularly challenging as the diffuse skin and
lymphatic involvement can require extensive resection
of the breast, chest wall, and skin, resulting in an
extensive mastectomy defect. Furthermore, the need
for radiotherapy increases the rate of poor patient
outcomes. While some surgeons consider inflamma-
tory breast cancer a relative contraindication to recon-
struction, others note the utility of autogenous flaps in
helping to provide durable, vascularized coverage over
the chest wall in anticipation of postmastectomy
radiation.9,10

221
Patient history
patient’s particular regiment. The most recent regiments
from the National Comprehensive Cancer Network
guidelines are presented in Tables 14.3 and 14.4. Despite
these systemic effects, the use of adjuvant chemotherapy
after immediate breast reconstruction has been consis-
tently demonstrated to be safe with regards to the
risk of surgical complications, wound healing issues,
and reconstructive failure.32–34 Even in the setting of
cancer recurrence rates of 1–12% have been noted at
follow-ups of 13–66 months, respectively,11 and some
authors even advocate for further expanding these
inclusion criteria.18 A recent systematic review and
meta-analysis found the pooled nipple areolar complex
cancer recurrence rate to be 0.9%, compared to a 4.2%
recurrence rate in the skin flap beyond the nipple areolar
complex.16
In addition to the risk of cancer recurrence in the
nipple, NSM creates an added reconstructive–aesthetic
conundrum in that patients expect that the nipple will
be preserved, which is not always the case. In fact, nipple
necrosis rates with NSM range from 1 to 9.7% for partial
necrosis, and 0 to 7.9% for total necrosis.11 From a recon-
structive standpoint, a number of variables, including
active smoking, patient age, BMI, preoperative radia-
tion, incision type, flap thickness, and breast size, have
been identified as risk factors for nipple necrosis.19–22
Full-thickness periareolar incisions for mastectomy
access have been consistently demonstrated to increase
the rate of nipple necrosis compared to alternatives,
whereas an inferolateral inframammary fold incision is
relatively well-tolerated.20,23,24 Another study found that
a C or larger bra cup size is associated with a 34% nipple
necrosis rate (32% partial necrosis, 2% total necrosis)
compared to a 6% nipple necrosis rate (all partial necro-
sis) with an A or B bra cup size (p = 0.003).21 Although
theoretically a concern, the degree of breast ptosis and
the distance between the sternal notch and the nipple
areolar complex has not been shown to impact complica-
tion rates following NSM.22 Similarly, the use of a bio-
prosthetic sling or concurrent axillary/nodal surgery is
not associated with greater rates of nipple necrosis.21
Chemotherapy
Neoadjuvant chemotherapy is well established in breast
cancer and can reduce the tumor burden in the breast
and axilla, allowing for less extensive surgical opera-
tions.25 As many of these agents are cytotoxic, they may
theoretically increase a patient’s risk for complications
such as infection or wound healing issues.26 However,
multiple large cohort studies and meta-analyses have
not demonstrated association between neoadjuvant
chemotherapy and infection, skin necrosis, seroma,
unplanned return to the operating room, or reconstruc-
tive failure.27–29
Adjuvant chemotherapy similarly plays a crucial role
in improving disease recurrence and overall survival in
breast cancer,30,31 and has been extensively studied with
regards to its association with reconstructive outcomes.
Many chemotherapeutic agents have well-documented
systemic side effects involving the heart, lungs, kidneys,
and liver, among others that will vary depending on a
Table 14.3  Neoadjuvant/adjuvant chemotherapy regimens for
HER2-negative invasive breast cancer
Preferred regimens
• Dose-dense AC (doxorubicin/cyclophosphamide) followed by
paclitaxel ever 2 weeks
• Dose-dense AC (doxorubicin/cyclophosphamide) followed by
paclitaxel weekly
• TC (docetaxel and cyclophosphamide)
Other regimens
• Dose-dense AC (doxorubicin/cyclophosphamide)
• AC (doxorubicin/cyclophosphamide) every 3 weeks
• FAC/CAF (fluorouracil/doxorubicin/cyclophosphamide)
• FEC/CEF (cyclophosphamide/epirubicin/fluorouracil)
• CMF (cyclophosphamide/methotrexate/fluorouracil)
• AC (doxorubicin/cyclophosphamide) followed by docetaxel
every 3 weeks
• AC (doxorubicin/cyclophosphamide) followed by weekly
paclitaxel
• EC (epirubicin/cyclophosphamide)
• FEC/CEF (cyclophosphamide/epirubicin/fluorouracil) followed
by docetaxel or weekly paclitaxel
• FAC (fluorouracil/doxorubicin/cyclophosphamide) followed by
weekly paclitaxel
• TAC (docetaxel/doxorubicin/cyclophosphamide)
(Modified from the NCCN Guidelines version 2.2015 for Invasive Breast Cancer.)
Table 14.4  Neoadjuvant/adjuvant chemotherapy regimens for
HER2-positive invasive breast cancer
Preferred regimens
• AC (doxorubicin/cyclophosphamide) followed by paclitaxel +
trastuzumab ± pertuzumab
• TCH (docetaxel/carboplatin/trastuzumab) ± pertuzumab
Other regimens
• AC (doxorubicin/cyclophosphamide) followed by docetaxel +
trastuzumab ± pertuzumab
• Docetaxel + cyclophosphamide + trastuzumab
• FEC (cyclophosphamide/epirubicin/fluorouracil) followed by
docetaxel + trastuzumab + pertuzumab
• FEC (cyclophosphamide/epirubicin/fluorouracil) followed by
paclitaxel + trastuzumab + pertuzumab
• Paclitaxel + trastuzumab
• Pertuzumab + trastuzumab + docetaxel followed by FEC
(cyclophosphamide/epirubicin/fluorouracil)
• Pertuzumab + trastuzumab + paclitaxel followed by FEC
(cyclophosphamide/epirubicin/fluorouracil)
(Modified from the NCCN Guidelines version 2.2015 for Invasive Breast Cancer.)

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CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
demonstrated a 40% absolute reduction in the risk of
keloid development when compared to placebo.45 With
respect to safety, SERMs are largely considered low risk.
However, tamoxifen has been associated with grade 2+
subcutaneous fibrosis when administered with con-
comitant radiotherapy,46 as well as increased risk of
venous thromboembolic disease, particularly in older
women during their first 2 years after exposure.47 The 5
year risk for venous thromboembolism in tamoxifen
patients has been reported as 1.2%, compared to 0.5%
within the control arm.47
Fewer studies to date have addressed the effects of
relatively new biologic agents on surgical outcomes.
The VEGF inhibitor bevacizumab has been associated
with multiple wound complications, including dehis-
cence, ecchymosis, surgical site bleeding, and infec-
tions.48 However, its evidence in breast reconstruction is
currently limited. Golshan et al.49 reviewed data on 13
patients with triple negative breast cancer undergoing
mastectomy with immediate reconstruction, 5 of which
received cisplatin alone (3 transverse rectus abdominis
myocutaneous [TRAM] flaps and 2 expander/implant)
and 8 cisplatin plus bevacizumab (2 TRAMs and 6
expander/implant). Of these, 4 patients (50% total, 66%
of expander/implant reconstructions) in the bevaci-
zumab plus cisplatin cohort experienced reconstructive
failure after tissue expander placement with AlloDerm.
To date, no studies have been published on the effects
of HER2/neu pathway inhibitors, trastuzumab or lapa-
tinib, on breast reconstruction outcomes.
Radiotherapy
For many patients with extensive nodal involvement,
locally advanced breast cancers, or those undergoing
breast conserving therapy, external beam radiation is a
routine part of a multimodal treatment plan that has
been shown to decrease loco-regional disease recurrence
and even overall survival (Table 14.5).50–52 Radiation
exposure does, however, lead to fibrosis as well as
expander/implant-based breast reconstruction, adju-
vant chemotherapy affected neither the timing of
expander inflation nor surgical complication rates,
including seroma, infection, or skin necrosis.35
Concomitantly, concerns that immediate breast recon-
struction may delay the initiation of adjuvant chemo-
therapy have been largely refuted.5,36–38 The largest study
to date, including 3643 patients, concluded that while
immediate reconstruction resulted in a modest but sig-
nificant overall delay, it was unlikely to be clinically
significant and did not lead to frank omission of chemo-
therapy.39 Nonetheless, it is important to carefully coor-
dinate the surgical plan with potential delays in mind.
For example, patients with multiple risk factors for
wound healing complications may benefit from modali-
ties that offer the lowest risk of wound healing problems
in order to facilitate transition to adjuvant therapy.
Although the optimal timing of mastectomy, reconstruc-
tion, and adjuvant chemotherapy is an active topic of
research, a significant survival benefit has been demon-
strated with the initiation of chemotherapy even as late
as 44 days40 to 12 weeks41 postoperatively.
Hormonal and biologic therapies
Targeted hormonal and biologic therapies have also
emerged as important parts of the oncologic armamen-
tarium in treating of breast cancer, with varying degrees
of evidence on their impact on breast reconstruction
outcomes. Estrogen has been understood to promote
cutaneous wound healing via signaling through epider-
mal estrogen receptors.42 Selective estrogen receptor
modulators (SERMs) including tamoxifen and raloxi-
fene have demonstrated similar accelerated cutaneous
wound healing properties in an in vivo mouse model.43
In an in vitro study of human fibroblasts, however,
tamoxifen delayed cell proliferation, growth factor
production, and consequently wound healing, but did
improve scar formation.44 A randomized controlled trial
of tamoxifen in patients with a history of keloids
Table 14.5  Impact of postmastectomy radiotherapy on oncologic outcomes
Citation
Follow-up
time
No. of
patients
Nodal
status
Locoregional recurrence
Overall survival
PMRT
No PMRT
PMRT
No PMRT
Overgaard et al.,
1999
10 yr
135
N0
3%
17%
82%
70%
1061
1–3N +
7%
30%
62%
54%
51
≥4N +
14%
42%
32%
20%
Katz et al., 2000
10 yr
132
N0
6%
23%
56%
55%
794
1–3N +
6%
31%
55%
44%
448
≥4N +
11%
46%
24%
17%
Truong et al., 2005
20 yr
183
1–3N +
9%
20%
61%
53%
112
≥4N +
17%
41%
30%
16%
PMRT, postmastectomy radiotherapy

223
Patient history
reconstruction in the setting of an irradiated field.64
Nonetheless, these patients are generally still at an
increased risk for complications, particularly fat necro-
sis, when compared to a cohort that is never irradiated.65–68
A recent meta-analysis of reconstructive outcomes in
this cohort demonstrated a 10% wound healing compli-
cation rates, 10% fat necrosis rates, 4% infection rate, 2%
hematoma rate, and 4% seroma rate.69 Of the 1011 total
flap reconstructions performed on an irradiated field
within the meta-analysis, the pooled flap loss rate was
only 1% and partial flap necrosis rate 6%.69 Overall,
autologous reconstruction of previously irradiated chest
is widely considered the safest and most reliable option
and should be encouraged in patients willing to undergo
a flap-based procedure.
Mantle radiation for lymphoma
Historically, the pattern of radiation for Hodgkin’s
lymphoma has covered lymph nodes in the neck, medi-
astinum, and axilla, and was referred to as “mantle
radiation” because of its similarity to the distribution
covered by a mantle.70 Mantle radiation differs from
postmastectomy radiation in that it focuses on the
mediastinal lymph nodes; patients present with targeted
area of irradiated tissue on the medial portion of the
breast while the central and lateral portions generally
remain healthy.70 The overall dose of radiation is also
typically less, ranging from 35–44 Gy compared to
60 Gy in whole-breast radiation.70
Only two case series of 23 total patients have been
reported of breast reconstruction following mantle
radiation.70,71 Overall, eleven patients developed one or
more complications, including 5 with mastectomy flap
necrosis, 5 severe capsular contractures (1 grade IV, 4
grade III), 6 cellulitis, 4 seroma, 1 hematoma, and 1
chronic breast pain. Four patients undergoing initial
expander/implant reconstruction required implant
removal and salvage with an autologous tissue flap.
Although these patients may not demonstrate signifi-
cant radiation-induced changes to the skin,70,71 physi-
cians must remain cognizant of the increased risk in this
unique cohort.
Postoperative radiation
The final determination regarding postmastectomy
radiation is generally made only after a thorough evalu-
ation of tumor and lymph node specimens by pathology.
While there is some institutional and physician varia-
tion in treatment protocols, some current indications for
postmastectomy radiotherapy generally include locally
advanced tumors with positive nodes or positive surgi-
cal margins (see Table 14.1). In these treated patients,
benefits include significant reductions in long-term
vascular and structural compromise of the skin and
underlying tissues, putting patients at an increased risk
of complications and poor aesthetic outcomes.53 The
best method for integrating breast reconstruction and
radiation remains controversial and is an active area of
ongoing research.
Preoperative radiation – prosthetic reconstruction
Patients with a history of radiation exposure generally
present in one of two ways: immediate reconstruction
after failed breast conserving therapy or delayed recon-
struction following postmastectomy radiotherapy. One
study of 76 patients comparing these two cohorts – in
the setting of expander/implant reconstruction – did
not identify any significant differences in outcomes
between the two.54
When compared to those with no radiation exposure,
patients undergoing prosthetic reconstruction in a previ-
ously irradiated field are at an increased risk for multiple
complications including capsular contracture, wound
dehiscence, implant extrusion, re-operation, and recon-
structive failure.55–60 Severe capsular contracture rates in
the setting of prior radiotherapy can be as high as 20%
at 10 years; compared to patients without any radiation
exposure, the risk is increased 3.3- and 7.2-fold in one-
and two-stage implant reconstruction, respectively.56
Overall, this increased risk of complications manifests
itself in relatively low rates of successful reconstruction,
with reports as low as 60% in two-stage procedures.54 In
this cohort, nearly 56% of explantations or conversions
to a flap occurred after tissue expander insertion, and
44% following expander/implant exchange. The most
common underlying reasons included infection, pain or
tightness, prosthesis exposure, or poor cosmesis.54
Despite conflicting early results within the literature,
the deleterious effects of prior radiation are largely
believed to decrease patient satisfaction and aesthetic
outcomes in the setting of prosthetic reconstruction. A
2006 study of 315 expander/implant reconstruction
found very good or excellent surgeon-reported aesthetic
results in 55.1% of patients with prior irradiation, good
results in 24.1%, fair in 17.2%, and poor in 3.4%, with
no significant difference when compared to those whore
never irradiated (p = 0.225).61 More recently, however,
multiple studies of patient collected data using the vali-
dated BREAST-Q (Reconstruction Module) have dem-
onstrated a significantly negative effect on satisfaction
with breast appearance as well as overall health-related
quality of life.62,63
Preoperative radiation – autologous reconstruction
Because of concerns regarding the deleterious effect of
radiation, many have historically favored autologous

224
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CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
celecoxib, have minimal effects on platelet function,
but appear to have deleterious cardiovascular effects
instead.83 In general, many surgeons similarly recom-
mend discontinuing NSAIDs, including selective COX-2
inhibitors, one to two weeks prior to surgery, although
in a healthy individual, ibuprofen’s effect on platelet
function appears to normalize within 24 hours.84
Oral contraceptives
Oral contraceptives are a widespread class of medica-
tion used to both prevent pregnancy and treat a number
of gynecologic conditions. Their prevalence makes them
a leading cause of thromboembolic events in young
women, with baseline rates as high as 0.1% that only
further increase in the setting of surgery and an active
malignancy.85,86 Most surgeons recommend discontinu-
ing birth control pills 4–6 weeks prior to surgery so that
estrogen/progestin levels may return to physiologic
levels. It is important to remind patients that other
methods of contraception should be used to prevent
unwanted pregnancies through at least the first week
after resuming the medication.
Glucocorticoids
Patients on corticosteroids must balance their benefit in
treating the disease process against the risks of immu-
nosuppression, increased protein catabolism, and poor
wound healing.87
Generally, the human body produces 10–12 mg of
cortisol daily. This number increases to approximately
25–50 mg/day with moderate stress, and 75–150 mg/
day with major stress, returning to baseline within 24–48
hours of the inciting event.87 With patients on chronic
steroid therapy, decision-making surrounding the pos-
sibility of a suppressed hypothalamic–pituitary–adrenal
axis is generally guided by the duration and dosing
leading up to the operation.88–90 Patients who have taken
steroids for less than three weeks, or who are on chronic
alternate-day therapy, are unlikely to have a suppressed
axis and may continue their usual dose. Alternatively,
patients taking greater than a dose equivalent of 20 mg
of prednisone for three or more weeks will require
greater doses perioperatively. Those on a dose equiva-
lent to 5–20 mg of prednisone for greater than 3 weeks
can either undergo testing or receive an empiric postop-
erative glucocorticoid burst.
Past surgical history
A focused surgical history in the breast reconstruction
patients must include details of all prior surgical proce-
dures, particularly those involving the breast, abdomen,
or other potential donor sites.
loco-regional recurrence and overall survival rates
(see Table 14.5). The optimal management of breast
reconstruction in the setting of anticipated post-
mastectomy radiation is somewhat controversial with
some promulgating an immediate conversion to implant
prior to radiation, and others advocating a delayed
approach.54,57,72,73 For those considering autologous
reconstruction, there is also the variant known as the
“delayed-immediate” approach wherein the expander
is placed deliberately in advance of anticipated radiation
to hold and preserve the native skin envelope and
volume until after radiation when definitive autologous
(or prosthetic) reconstruction can be performed.74–76 A
traditional alternative in this setting is to delay the
reconstruction altogether until after radiation, in which
case an autologous reconstruction will almost certainly
be necessary.
Medications
A complete medication history should include all over-
the-counter and herbal/alternative drugs, in addition to
prescription medications. In this section we will review
the evidence for some of the most common medications
that a reconstructive surgeon may encounter.
In general, medications associated with withdrawal
syndromes should be continued or tapered as needed
in the perioperative period. Oral medications may be
substituted for a transdermal, transmucosal, or intrave-
nous form in order to compensate for impaired absorp-
tion secondary to decreased gastrointestinal function or
decreased oral intake.
Aspirin/NSAIDs
Aspirin irreversibly inhibits platelet cyclooxygenase,
increasing perioperative blood loss and the risk for
hemorrhagic complications.77,78 Despite potential bene-
fits with regards to minimizing cardiovascular compli-
cations, the POISE-2 trial found that in patients
undergoing non-cardiac surgery aspirin increases bleed-
ing risk without any improvement in cardiovascular
outcomes or overall mortality.79 In breast reconstruction,
the hematoma rate increases to 9.2% in patients on
aspirin compared to 4.7% in the control group.80
Although its plasma half-life is only 20 minutes, the
irreversible effects of aspirin may take up to 10 days to
resolve. In general, most patients taking aspirin mono-
therapy benefit from holding their doses for one to two
weeks prior to surgery.81
Other nonsteroidal anti-inflammatory drugs (NSAIDs)
exhibit reversible inhibition of cyclooxygenase isoforms
resulting in a similar antiplatelet effect and increased
risk for bleeding.82 Selective COX-2 inhibitors, including

225
Patient history
data allow surgeons to characterize a patient’s indi-
vidual risks for complications, facilitating patient edu-
cation and perioperative decision-making. Below we
discuss the effect of common comorbidities on patient
outcomes.
Diabetes mellitus
Diabetes mellitus is itself an end result of a variety of
metabolic processes, which can be largely classified
into two distinct processes: type 1, insulin-dependent
diabetes and type 2 diabetes. Regardless of the under-
lying process, diabetes has been traditionally associ-
ated with a number of systemic effects including
peripheral artery disease, microvascular disease, neu-
ropathy, and immune compromise.113 Over 100 cyto-
logic factors have been identified that may lead to
increased wound healing complications in diabetes.114
More recently, a number of studies are beginning to
explore potential differences in the adverse effects of
insulin-dependent, type 1 diabetes and type 2 diabetes
– potentially as a surrogate for effects of both short
and long-term glycemic control.115
One recent study using a nationwide patent registry
found an increased risk of wound complications in
diabetics on univariate analysis (4.6% vs. 9.8%, p <
0.001), that went away upon adjusting for potential
confounding variables, including obesity, which is
often associated with type 2 diabetes as a part of the
larger “metabolic syndrome”.116 A handful of smaller
studies have recapitulated this finding in smaller,
single-center cohorts, demonstrating no increase in
wound complications or reconstructive failure in dia-
betics.117,118 The largest study on this topic to date,
including nearly 30 000 patients, found a small but
significant increased risk of overall complication,
including wound complications, in diabetics undergo-
ing autologous reconstruction; this effect was a greater
in insulin-dependent, type 1 diabetics than in type 2
diabetics.115
It is important to note that these studies are all limited
in that they are retrospective in nature and potentially
influenced by selection bias. Also, a history of diabetes
does not necessarily suggest poor glycemic control,
particularly since the Surgical Care Improvement Project
(SCIP) guidelines have recommended postoperative
blood glucose ≤200 mg/dL on postoperative days one
and two.119 Although additional studies are indicated to
better characterize the risks associated with diabetes
mellitus following breast reconstruction, the effect of
poor glycemic control on wound complications is gener-
ally well accepted.113,114 Proper medical management of
a patient’s diabetes leading up to and following breast
reconstruction should be emphasized.
Breast surgery
It has been estimated that over 2 million women in the
United States have undergone augmentation mamma-
plasty, with another 300 000 procedures being performed
each year.91 When faced with breast reconstruction, this
cohort has demonstrated a predilection for implant-
based procedures, either alone or with a latissimus dorsi
flap.92–95 This preference is, at least in part, due to their
willingness to receive implants as well as their relatively
low BMIs, with less soft tissue available for flaps.92,96
Complication rates following reconstruction in this
cohort do not appear to be affected by the location of
the previous implants or the reconstructive procedure
(i.e., direct to implant vs. expander/implant),96 and are
largely the same as complication rates for the general
population.97,98 Only one small study found a significant
difference driven largely by capsular contracture, which
the authors hypothesize may be a result of residual
biofilm or capsule from the previous augmentation.96
Nonetheless, patient satisfaction rates with their recon-
struction have been noted to be greater in patients with
a history of augmentation.92
Abdominal surgery
Abdominal scars of all types (e.g., subcostal, Pfannen-
stiel, midline laparotomy, etc.) may devascularize por-
tions of an abdominal flap compromising its survival99
and increasing donor site morbidity.26,100,101 In order to
counteract any potential flap unreliability, strategies to
improve abdomen-based flap perfusion, including sur-
gical delay, flap design modifications, and microvascular
augmentation of flap perfusion may be indicated.102–106
With careful planning, DIEP flaps have been success-
fully reported in patients with vertical or short-transverse
scars from prior intra-abdominal surgery99 as well as
Pfannenstiel incisions.107
A history of abdominoplasty is particularly concern-
ing as the perforators supplying the tissue flaps have
been previously transected during the undermining
and resection of the upper abdominal flap. Although a
handful of small studies have noted the ingrowth
of new perforators through the rectus abdominis,
allowing for successful abdominal flap reconstruc-
tion,99,108–110 prior abdominoplasty should be considered
a relative contraindication to abdominally-based breast
reconstruction.
Comorbidities
Knowledge of a patient’s medical comorbidities facili-
tates patient-centered discussions regarding the optimal
timing and modality of reconstruction. Combined with
a nomogram60 or individual risk calculator111,112 these

226
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CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
although elevated, both overall complication and recon-
structive failure rates remain acceptable, and expander/
implant reconstruction should be offered along with
autologous procedures to all women who are interested,
regardless of their BMI.143,144
One of the major cosmetic challenges in this cohort
stems from difficulties in achieving large volumes and
ptosis in reconstructed breasts, particularly in the setting
of unilateral reconstruction. One study of 262 patients
found that obese patients undergoing an expander/
implant procedure had an odds ratio of 0.14 for aesthetic
satisfaction when compared to normal weight individu-
als.141 In these patients the use of acellular dermal matrix
or other bioprosthetic slings may facilitate the accom-
modation of large expanders or implants, and allow for
the recreation of a more natural-appearing inferior pole
projection and ptosis similar to the pre-mastectomy
state.145–147
In addition to providing ample tissue for the recon-
struction of large, ptotic breasts, flap reconstruction
provides the added benefit of excising excess soft tissue
from potential donor sites including the abdomen, inner
thigh, and buttocks. In this high-risk cohort, however,
traditional TRAM flaps may decrease upper abdominal
strength, particularly in bilateral reconstructions.148
Muscle-sparing TRAMs and perforator flaps149–151
present attractive alternatives with significantly less
abdominal wall morbidity (<5% incidence of abdominal
weakness) and excellent overall results (<2% flap failure)
in the hands of an experienced surgeon.152
Connective tissue disease
Although no clear link has been demonstrated between
connective tissue disease (CTD) and breast cancer, their
relative commonality makes it likely for reconstructive
surgeons to encounter this challenging cohort of
patients.153,154 Many CTD patients develop severe reac-
tions to radiotherapy likely mediated by a TGF-β
response to radiation and the reactivation of quiescent
disease155 that drives tissue fibrosis, often manifesting as
a late tissue response.156 Interestingly, this reaction is
more common with radiotherapy for breast cancer than
other malignancies and is most prevalent in patients
with scleroderma and systemic lupus erythematosus.157
Although this concern does not preclude breast conser-
vation and whole breast radiotherapy, many women
with CTD seek to avoid radiotherapy and opt for a
mastectomy with or without reconstruction instead.157
In general, a combination of disruptions in the TGF-β
pathway, autoantibodies against collagen or other
structural molecules, vasculopathy or disorders of
angiogenesis, and the effects of anti-inflammatory or
immune-modulating drugs all increase the risks of
Smoking
Smoking exerts a variety of well-understood negative
effects on wound healing, microvascular blood flow,
and oxygen delivery, increasing the risk for wound
complications and their downstream sequelae follow-
ing breast reconstruction.60,120–126 Particularly following
autogenous reconstruction, smoking can increase rates
of flap necrosis and donor site complications, such that
many surgeons suggest excluding smokers from candi-
dacy for such procedures.126–128
Interestingly, the adverse effects of smoking may
persist even after quitting. One study of 227 TRAMs
demonstrated a step-wise decrease in postoperative
complication rates between current smokers, ex-smokers
(quit within the past 12 months), and non-smokers.126
More recently, an analysis of nearly 12 000 patients dem-
onstrated a 2.46-times increase in the odds of flap loss in
former smokers when compared to never smokers,
regardless of the particular reconstructive procedure.111
Additional studies are required to clarify these still
controversial findings129 and better characterize the true
effect of former smoking on patient outcomes.
All smokers seeking consultation for breast recon-
struction should be strongly urged to quit at least 3–4
weeks prior to their operations in order to reduce the
occurrence of complications.130 For patients who are
concerned of relapse, nicotine replacement therapy has
been demonstrated to increase smoking cessation rates
by 50–70% without any added risk of wound healing
complications.130–132
Obesity
Breast reconstruction in obese patients is a challenging
procedure as these patients are not only prone to increased
complication rates compared to non-obese patients,133–138
but their relatively large and ptotic breasts can be aes-
thetically difficult to reconstruct, particularly in the
setting of a unilateral procedure. Obesity exerts its nega-
tive effects on surgical outcomes via two broad categories
of mechanism. The first involves the direct effects of a
patient’s body habitus on the surgical procedure, and the
second the comorbid conditions with which obesity
is strongly associated. These include coronary artery
disease, diabetes, obstructive sleep apnea, hypertension,
hyperlipidemia, microvascular disease, abdominal wall
hernias, and venous disease, among others.139
The use of tissue expander/implant reconstruction in
this cohort remains a contentious issue. The increased
risk of reconstructive failure and patient dissatisfaction
with aesthetic results140,141 has led some surgeons to
advocate for the use of autologous breast reconstruction
in obese patients.142 Nonetheless, others argue that

227
Physical examination
significantly increased risk of venous thromboembolism
(VTE).168 The increased risk of postoperative VTE has
been reported to range between 5- and 20-fold in these
patients,169 and may be increased even further in rela-
tively prolonged autologous procedures.170
Of particular interest to the breast reconstruction
patient is the potentially increased risk for anastomotic
thrombosis and flap loss in hypercoagulable patients
undergoing microsurgical reconstruction. Only a handful
of small studies and case reports have explored this topic
to date.171–174 The largest series includes 100 patients
undergoing free tissue transfer, of which 11 tested posi-
tive for pathologic heterozygous factor V Leiden muta-
tion.171 Although this study failed to identify a significant
correlation between the thrombophilic disorder and flap
failure secondary to thrombotic occlusion, their analyses
were significantly underpowered to detect a difference in
such a rare complication. A number of other, recent
studies have demonstrated flap failure rates close to 15%
in hypercoagulable patients,172,173,175 much greater than
the 1–2% typically seen in contemporary series of free
tissue transfers.176
Ultimately, the majority of patients safely undergo
free flap breast reconstruction, and the odds are that
many undiagnosed patients have, and will continue to
do so, as well. Nonetheless, the strong likelihood of an
increased risk is enough for some surgeons to recom-
mend against free tissue transfer in these patients,172,174
promoting the use of prosthetic or pedicled flap recon-
struction. Still, others will cautiously offer free tissue
transfer along with the administration of therapeutic
anticoagulation with the understanding of an increased
risk for flap loss.173,177,178
At the other end of the spectrum, the presence of a
bleeding disorder puts patients at an increased risk of
developing a potentially life-threatening bleed or hema-
toma. One study of over 16 000 breast reconstructions
identified a history of bleeding disorders as a risk factor
for both major medical and surgical complications,
demonstrating the utility of this information in periop-
erative risk stratification and decision-making.116 When
a bleeding disorder is known or suspected, the most
crucial step is accurate diagnosis and treatment in order
to prevent a potentially life-threatening perioperative
bleed.179 Preoperative screening, however, is not cur-
rently indicated in patients with a negative history and
physical examination.180,181
Physical examination
The specific details of the physical exam as relevant to
each reconstructive procedure will be reviewed in its
respective chapter. In general, the physical exam should
wound dehiscence in CTD patients.158 Additionally, in
some patients secondary conditions including antiphos-
pholipid syndrome may result in a hypercoagulable
state and increased risk of venous thromboembolism.159
Other complications of interest include persistent
seroma, particularly at the donor site for autologous
reconstructions, and even delayed hematoma forma-
tion, believed to be secondary to platelet abnormali-
ties.158 To date, only small case series have been published
on breast reconstruction in this high-risk cohort, and the
true risk for complications remains to be determined.
Respiratory disease
For patients with a history of underlying lung pathol-
ogy, normal perioperative pulmonary physiology
may prove to be enough of a burden to drive the devel-
opment of postoperative pulmonary complications.
Particularly after operations exceeding 2.5 hours,160
postoperative diaphragmatic dysfunction, pain, and
splinting drive a reduction in lung volumes that may
persist for up to 1 week in these patients.161
A known history of COPD increases the risk of postop-
erative pulmonary complications by 2.7- to 6-fold.162 One
large study using data from the National Surgical Quality
Improvement Program registry found that COPD is
associated with an adjusted odds ratio of 1.71 for postop-
erative pneumonia, 1.54 for unplanned re-intubation,
and 1.45 for failure to wean from the ventilator.163 Despite
this increased risk, there does not appear to be a single
prohibitive level of pulmonary function below which
surgery is absolutely contraindicated in this popula-
tion.164,165 Only a handful of studies have specifically
explored the effect of COPD on breast reconstruction and
found similar relationships with major complications
and delays in reconstruction.166 Nonetheless, the risks
and benefits of surgery, and potentially multiple opera-
tions in the context of breast reconstruction, must be
weighed carefully on an individual basis.
Unlike COPD, despite initial beliefs that patients with
underlying asthma experienced greater rates of pulmo-
nary complications, more recent studies have failed to
demonstrate a link between well-controlled asthma and
adverse outcomes. That said, optimal medical manage-
ment of a patient’s asthma should be emphasized before
moving forward with an elective operation.167
Bleeding/clotting disorders
At either end of the spectrum, disorders of the body’s
natural response to endothelial damage and clot forma-
tion may predispose the breast reconstruction patient to
a number of potentially serious complications. Throm-
bophilia is the manifestation of a wide range of heredi-
tary or acquired conditions that places patients at a

228
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CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
superiorly to below the midcostal margins inferiorly.
Arms may be positioned either at the side, on the hips,
or behind the lower back, and common views include
anteroposterior (AP), lateral, and oblique images.
Although conditions may vary based on the setting and
available equipment, DiBernardo et al.184 recommend
positioning the patient in front of a suitable background
and using a 50 mm lens at a distance of 3 feet and with
a reproduction ratio of 1 : 12 in order to obtain high
quality and standardized photographs. A medium
blue or 18% gray background has been suggested in
order to provide the best skin tones without affecting
exposure.
Markings
The preoperative markings vary from one procedure to
the next and will be discussed in detail within each
procedure’s respective chapter. General landmarks on
the breast are depicted in Fig. 14.1 and include the posi-
tion of the inframammary fold, midline, and mastectomy
incision, among others. Donor site markings may
include the anatomic boundaries of the flap, incision
sites, the anticipated course of the vascular pedicle, and
potential Doppler marking.
include basic vital signs, including height, weight
and BMI, in addition to a detailed examination of the
breasts and potential donor sites for autologous
reconstruction.
The breast examination should focus on a number of
factors including the position of the inframammary fold
and nipple, asymmetries, skin thickness and quality,
scars, and an axillary exam. This information can help
determine a patient’s aesthetic goals, particularly in
unilateral reconstructions, and clarify the role of poten-
tial symmetry procedures at the time of reconstruction.
Additionally, measurements of the sternum to the
nipple, nipple to the inframammary fold, and the base
diameter of the breast are taken to facilitate implant
selection. Other findings such as the overall size of the
mass, clinically positive lymph nodes, nipple inversion
or discharge, Paget’s disease, or peau d’orange will
affect a patient’s candidacy for NSM and/or post-
mastectomy reconstruction, and should be incorporated
into the discussion of reconstructive modality.
For patients considering autologous breast recon-
struction, a variety of donor sites including the abdomen,
buttocks, thigh, and back should be examined closely
with an eye towards adequate volume for reconstruc-
tion. Previous scars following abdominal or pelvic
surgery are discussed earlier in this chapter and should
be noted as a potential source of damage to the vascu-
lature and incisional hernias.
Preoperative photographs
Pre- and postoperative photography is now the standard
of care in breast reconstruction, facilitating documenta-
tion, collaboration, patient education, and research.
Reviewing photographs with a patient during the
initial consultation shifts the conversation from a one-
sided discussion – a surgeon talking to the patient – into
a collaborative environment in which the surgeon talks
with the patient about what they can expect,182 although
care must be taken to avoid the implication of a guar-
anteed result.183 Postoperatively, photographs allow
patients and surgeons alike to more objectively assess
results vis-à-vis expected outcomes, guiding the need
for additional surgeries and/or symmetry procedures.
Moreover,
systematically
reviewing
postoperative
images over time can even allow surgeons to track and
study the evolution of their practice, promoting quality
improvement and evidence-based decision-making.
Images of the breast can vary significantly based on
their framing as well as the patient’s configuration, and
a systematic approach is critical in obtaining high
quality, standardized images. The borders should extend
from above the suprasternal notch in the lower neck
Fig. 14.1  Example of preoperative markings for breast reconstruction. Landmarks
and measures of interest include (A) the midline, (B) sternal notch to nipple areolar
complex, (C) nipple to inframammary fold (IMF) distance, (D) breast width, (E)
projection of the IMF onto the midline and IMF offset, (F) the inframammary fold,
and (G) the lateral border of the torso. The red lines represent potential mastectomy
incisions: (H) circular and (J) elliptical periareolar incisions are common
approaches to skin-sparing mastectomy with autologous and prosthetic
reconstruction, respectively, whereas an inferolateral inframammary fold incision (K)
is commonly used in nipple-sparing mastectomy.
G
A
B
B
J
E
E
K
H
D
F
C
C