Preoperative evaluation and planning for breast reconstruction following mastectomy

Introduction

Breast cancer is the most common malignancy in women, and it is estimated that 1 in 8 women (13%) will be diagnosed with invasive breast cancer during their lifetime. Surgery, either breast conservation (lumpectomy and radiation) or mastectomy, is part of the treatment algorithm for breast cancer. Despite equivalent survival, patients with breast cancer are increasingly electing for mastectomy due to a desire for symmetry, reluctance to undergo radiation, and fear of recurrence. Mastectomy is also an option for patients with high-risk, non-invasive pathology such as ductal carcinoma in situ (DCIS), in palliation for patients with advanced disease, or for women with a genetic mutation (e.g. BRCA1 and BRCA2) that predisposes them to a higher lifetime risk of cancer.

Options for reconstruction following mastectomy include autologous breast reconstruction (ABR) such as abdomen-based free tissue transfer, or implant-based reconstruction (IBR). Patient-reported outcomes show that women undergoing bilateral mastectomy and reconstruction achieve a quality of life at least as good as those undergoing breast-conserving therapy. In fact, breast-conserving therapy may be associated with more pain/discomfort in the chest area and poorer sexual well-being. There are increasing efforts to assess patient-reported outcomes to study the impact and effectiveness of breast surgery from the patient perspective, such as the Breast-Q tool.

Preoperative planning is often overlooked, but it plays a major role in breast cancer care. The preoperative consultation should begin with a thorough history not only of the breast cancer diagnosis and treatment thus far, but also of any baseline psychosocial, medical, or surgical history that may influence the treatment plan. A thorough physical examination will also help guide the discussion on reconstructive options, as a very slim patient may not be a suitable candidate for autologous free tissue transfer. Regardless of the reconstructive choice, years of experience has allowed us to better balance patient preferences and risk factors, while always aiming for optimal cosmetic outcomes. It is important to note that the ultimate success is dependent on the involvement of the patient in the entire process and the surgeon’s ability to set realistic expectations. In this chapter we will review key components to a preoperative assessment including oncologic status and treatment options for resection and reconstruction, patient/treatment risk factors, and key features of the physical exam portion.

Breast cancer history and considerations

Patients are often referred to a plastic surgeon by a breast surgeon after a cancer diagnosis and a treatment plan has been made. However, at times, patients may be referred to a plastic surgeon to aid in formulating the treatment plan based on the best reconstructive option. Reviewing the pathologic diagnosis and imaging should precede any discussion on reconstruction. Tumor stage/location influences key decisions such as nipple-preservation during mastectomy, chemotherapy and radiation. Plastic surgeons should also be aware of the risks and benefits of contralateral and nipple-sparing mastectomy.

Stage

Based on women diagnosed with breast cancer from 2009 to 2015, the 5-year relative survival rate is 99% for localized disease, 86% for regional, 27% for distant, and 90% for all stages combined. This data encourages patients with early stage disease to pursue reconstruction. In patients with advanced and metastatic disease, it is becoming more common for these patients to also pursue mastectomy and reconstruction based on advancements in the oncologic management. Regardless of the situation, it is important to seek out the patient’s goals and desires to restore quality of life, while balancing oncologic/other risks and underlying healthcare burden.

Depending on the stage of the breast cancer, the patient may require sentinel lymph node biopsy, axillary dissection, radiation, chemotherapy, and/or hormonal therapy. Chemotherapy may be administered in the neoadjuvant setting or adjuvant setting. Indications for sentinel lymph node (SLN) biopsy include T1–2 invasive breast cancer (tumor size <5 cm) with a clinically negative axilla, DCIS sufficient to require mastectomy, and patients with clinically negative axillary nodes following neoadjuvant chemotherapy. Axillary lymph node dissection is not indicated if there is no evidence of nodal spread or if 1–2 SLNs are positive and with small tumors, but the patient is planning on receiving whole-breast radiotherapy. These recommendations are a result of several randomized controlled trials demonstrating no difference in overall and disease-free survival with appropriate lymph node sampling versus axillary dissection. An in-depth discussion of the benefits of sentinel versus completion axillary lymph node sampling for breast cancer is complex and out of the scope of this chapter, as the management has evolved in recent years. Chemotherapy, in both the neoadjuvant and adjuvant settings, is standard for triple negative tumors, tumor size >0.5 cm, or for pathologically involved lymph nodes. For tumors that are estrogen- or progesterone-receptor positive, most physicians will recommend hormonal therapy, either tamoxifen (selective estrogen receptor modulator) or an aromatase inhibitor, such as anastrozole. Trastuzumab is a monoclonal antibody specifically used for breast cancer that is human epidermal growth factor receptor 2 (HER2/NEU-receptor) positive. Radiation for breast cancer is offered in several cases: after breast-conserving surgery, after a mastectomy if the cancer was larger than 5 cm, when greater than four lymph nodes are involved, when margins are positive for invasive disease, or if cancer has spread to other parts of the body. How these aforementioned treatments influence a patient’s risk factors and options for reconstruction will be discussed later in this chapter.

Nipple-sparing mastectomy

Patients with breast cancer are increasingly selecting nipple-sparing mastectomy (NSM) when possible ( Box 17.1 ) . NSM is an option for patients wishing to preserve their nipple–areolar complex (NAC) and skin envelope at the time of mastectomy, but only if certain criteria are met ( Fig. 17.1 ). Indications include a solitary tumor located greater than 2 cm from the nipple, size smaller than 5 cm, HER2/NEU-receptor negative, and without evidence of lymphovascular invasion. Ultimately, the nipple can be saved if disease is absent from the ducts underlying it and for patients undergoing prophylactic mastectomy. Contraindications include patients with more aggressive breast cancers such as inflammatory type or high histologic grade, involvement of the NAC, bloody nipple discharge, multifocal/multicentric disease, and tumor size >5 cm. Studies have demonstrated an acceptably low rate of locoregional and distant metastasis following NSM in women with breast cancer. A recent long-term follow-up study of 944 patients who underwent NSM and immediate breast reconstruction for invasive breast cancer from 2003 to 2015 in Korea demonstrated a 5-year cumulative incidence of cancer recurrence at the NAC of 3.5%. As previously discussed, variables predictive of cancer recurrence in this cohort included multifocality or multicentricity, negative hormone receptor or HER2 positive subtype, high histologic grade, and an extensive intraductal component. Importantly, there was no significant difference in the distant metastasis-free or overall survival in patients with and without recurrence of cancer at the NAC.

NSM may lead to improved aesthetic outcomes when compared with skin-sparing mastectomy (SSM) alone in patients undergoing reconstruction. Bailey and colleagues observed significant improvement in quality of life following NSM and breast reconstruction, specifically with regards to Satisfaction and Outcome and Satisfaction with Breasts domains of the BREAST-Q. NSM is also associated with higher psychosocial and sexual well-being when compared with SSM and nipple reconstruction. Several patient and reconstructive factors may increase risk for complications following NSM, including partial or total nipple necrosis that has been reported in up to 20% of patients undergoing NSM. Importantly, nipple necrosis does not always result in complete loss, and partial necrosis can be managed conservatively with oftentimes very acceptable outcomes. Although tissue expander, single-stage, direct-to-implant (DTI) and ABR are all safe options for breast reconstruction following NSM, recent data suggests that complications appear to be greater with DTI and ABR techniques. Periareolar/circumareolar and transareolar incisions are associated with the highest rate of nipple necrosis, whereas the inframammary incision is relatively well-tolerated. Host-related risk factors for nipple necrosis include body mass index (BMI), age over 45, tobacco use, preoperative radiation, incision type, flap thickness and breast size (C cup or larger). However, distance between the sternal notch and NAC and degree of breast ptosis has not been shown to impact complication rates following NSM. A prospective cohort study of patients undergoing NSM noted increased post-reconstructive breast volumes when an inframammary incision is used versus a lateral radial incision, but that a lateral radial incision leads to greater patient satisfaction and psychosocial well-being. With all of the above considered, it is as important to inform patients who are not undergoing NSM that there are still options for nipple reconstruction and tattoo, which could similarly lead to high satisfaction ( Fig. 17.2 ).

Contralateral prophylactic mastectomy

The rate of contralateral prophylactic mastectomy (CPM) has more than doubled over the last decade in the US. The decision to undergo CPM at the time of unilateral mastectomy is complex, but is largely patient-driven ( Fig. 17.3 ). Unsurprisingly, CPM has been shown to increase short-term healthcare costs; however, additional studies are needed to determine the potential for cost-savings long-term if patients no longer require revisional or balancing procedures. CPM rates are highest among Caucasians, patients with higher socioeconomic status, with private insurance, and treated at high-volume centers. Younger patient age is considered one of the strongest factors associated with increasing CPM rates. Other commonly cited reasons for CPM include MRI at the time of diagnosis, increased use of genetic testing, and availability of immediate breast reconstruction.

With regards to oncologic benefit of CPM, to our knowledge, there are no prospective studies that demonstrate an advantage. Reported pros of undergoing CPM include avoidance of future screening mammograms and resulting biopsies therefore decreasing related patient anxiety, improved symmetry with reconstruction, and decreased risk of contralateral breast cancer. However, additional surgery increases the risk of operative complications, increases operative time, and further decreases sensation along the chest wall. One study demonstrated that bilateral abdomen-based ABR did not increase the risk of major postsurgical complications such as flap loss or postoperative thrombosis compared with unilateral reconstruction. However, the bilateral group did have higher rates of minor surgical and postoperative medical complications, such as extremity deep venous thrombosis. There is also the possibility that CPM may delay time to surgical resection and adjuvant treatments. Position statements have been used to guide patients contemplating CPM. Surgeons should discourage CPM if patients are at a high risk for complications (e.g. smoking and comorbidities), have a high risk of recurrent/distant disease, and potentially those with stage IV disease. Updated National Comprehensive Cancer Network (NCCN) guidelines discourages prophylactic mastectomy except for high-risk genetic/familial circumstances.

Conversely, the reconstructive literature suggests that there is a potential quality-of-life benefit to choosing CPM that cannot be overlooked. The Mastectomy Reconstruction Outcomes Consortium (MROC) assessed postoperative morbidity and patient-reported outcomes in women 18 years of age and older with a diagnosis of unilateral in situ or invasive breast cancer undergoing breast reconstruction. Those opting for CPM with bilateral IBR experienced significantly improved satisfaction with breasts as measured by the BREAST-Q, as well as reduced anxiety about future cancer occurrences compared to those undergoing unilateral reconstruction. In ABR, bilateral reconstruction results in significantly higher quality-of-life satisfaction scores at more than 3 years when compared with unilateral reconstruction; however, these patients report lower scores of abdominal well-being. For patients undergoing bilateral reconstruction, procedure-type (IBR vs. ABR) has no impact on patient satisfaction scores, although patients with ABR have improved satisfaction scores following unilateral mastectomy.

Patient counseling should ensure that patients are making informed decisions while assessing risks and benefits of CPM. Not surprisingly, breast surgeons may not offer or even discuss CPM until the plastic surgeon reviews this option with patients. In fact, like patients, some physicians lack knowledge about CPM. There is also a known discordance between the patients’ and physicians’ beliefs regarding the benefits of CPM. Nevertheless, increasing physician and patient education is critical in order to ultimately better align the patient’s decision with their goals.

Reconstructive options

The implementation of the Women’s Health and Cancer Rights Act in 1998 required payers to provide benefits for mastectomy-related services that included all stages of reconstruction and procedures aimed to restore breast symmetry. Even still, some women are unaware of breast reconstruction options and insurance benefits, and this has led some states to mandate for proper education about reconstructive options and/or referral to a reconstructive surgeon after diagnosis. Patients should be well informed of the general risks of any breast reconstructive procedure, including wound healing issues, infection, seroma, failure, and the need for future revisional surgeries.

Reconstruction may be performed at the time of mastectomy (immediate) or after a period of delay (delayed), usually after completion of adjuvant radiation. Patients should know that immediate reconstruction does not usually result in time delays for the delivery of adjuvant treatments. Common reasons for choosing immediate reconstruction include obviating the need for a separate operative/anesthetic procedure for reconstruction and avoiding any psychosocial consequences of the mastectomy defect in the interim period. If patients are not suitable candidates for immediate reconstruction based on oncologic or medical reasons, a delayed approach is usually recommended. Delaying reconstruction is also an option when the mastectomy skin flaps are unfavorable or ischemic following the mastectomy to allow the skin flaps to demarcate or prove viable prior to proceeding with reconstruction. In fact, delayed reconstruction may decrease complication rates, while achieving similar clinical and patient-reported outcomes to immediate reconstruction. Regardless of the reconstructive method, in patients undergoing bilateral mastectomy with reconstruction, no subsequent mammography screenings are necessary. Our general algorithm for choosing between the various aforementioned techniques is included in Algorithm 17.1 .

Algorithm 17.1

Senior author’s preferred general reconstructive algorithm. ABR: autologous breast reconstruction; IBR: implant-based reconstruction; SSM: simple sparing mastectomy; CPM: contralateral prophylactic mastectomy; DTI: direct-to-implant reconstruction. *The decision to proceed with contralateral prophylactic mastectomy is based on the patient’s wishes.