INTRODUCTION
Since Hartrampf introduced it for the first time, in 1982, the transverse rectus
abdominis myocutaneous (TRAM) flap with a transverse skin island has become one
of the most popular breast reconstruction techniques1.
The surgical options currently available for breast reconstruction involve the
use of autologous tissue, alone and in combination with implants, or the use
of
prostheses and/or expanders only. The choice is based individually on the
characteristics and preferences of patients, the indication of adjuvant
therapies, and the experience of the physician2.
The use of radiotherapy (RT) in the treatment of breast cancer reduces the risk
of locoregional recurrence and provides increased survival, and may be used in
combination with surgery as an adjuvant postoperative treatment3,4.
Radiotherapy is an integral part of the multidisciplinary approach for breast
cancer. The recent literature has highlighted the significant role of RT in
high- and intermediate-risk patients. However, the combination of RT with
reconstruction in post-mastectomy patients continues to be a matter of
controversy3,4.
It is generally well accepted that radiation negatively influences the results of
breast reconstruction with implants. In the longer term, however, the effects
of
radiation on the outcome of breast reconstruction with autologous tissue are
still unclear3.
OBJECTIVE
The objective of this study was to evaluate the postoperative complications in
patients who underwent breast reconstruction (immediate and late) with a TRAM
flap and statistically correlate these complications with the presence or
absence of RT.
METHODS
A retrospective survey was conducted of the medical records of 424 patients who
underwent breast reconstruction after mastectomy for the treatment of breast
cancer. Of the patients, 126 underwent immediate or late breast reconstruction
with a TRAM flap between 2004 and 2011. We analyzed the presence or absence of
RT and postoperative complications in the immediate and late
reconstructions.
Complications were divided into minor (hematoma, seroma, epidermolysis,
dehiscence, and localized infection that are not related to RT) and major
(complete or partial flap necrosis and localized steatonecrosis, defined as fat
calcifications that do not compromise the skin, measuring up to 3 cm on clinical
examination). In this study, RT was considered related to the onset of major
complications. Possible complications in the donor area were not accounted for
in this survey.
The patients were divided into 3 groups as follows: 1) patients who underwent
only immediate or late reconstruction with a TRAM flap without RT (TRAM alone
group), 2) patients who underwent mastectomy with immediate breast
reconstruction followed by RT (TRAM→RT group), and 3) patients who
underwent mastectomy + RT and, subsequently, late breast reconstruction
(RT→TRAM group). Each group was evaluated for the presence and absence of
minor and major complications.
All the reconstructions were performed by a single plastic surgeon, always using
the same surgical technique and accompanied during this period by the same
surgeon. A vacuum drain was used in the breast and abdomen in all the patients.
The medications and postoperative guidelines were all standardized. Closure of
the abdomen was always performed with a Prolene mesh. Smokers and patients who
had undergone the first phase of the reconstruction by other medical staff were
excluded.
The chi-square and Games-Howel statistical tests were applied, and the results
were considered significant when the p value was <0.05.
RESULTS
Of the 126 patients whose medical records were evaluated, 92 who underwent breast
reconstruction with the TRAM technique were selected for the study (after
application of the exclusion criteria). The following 3 patient groups were
analyzed: without radiation (n = 47), with radiation after TRAM flap
reconstruction (n = 27), and with radiation before TRAM flap reconstruction (n
=
18). The patients included in the study were between 35 and 80 years of age
(mean [SD]: 55.81 [9.162] years). The body mass index (BMI) was between 23 and
35 kg/m2 (mean [SD]: 28.16 [3.387] kg/m2). The groups were
considered homogeneous regarding age (p = 0.123) and BMI
(p = 0.775), as shown in table 1. The mean follow-up period of the patients was 20
months.
Table 1 - Descriptive Statistics based on Age and BMI of Patients.
|
Minimum |
Maximum |
Mean |
Standard Deviation |
Sig. ANOVA between Groups |
BMI |
23 |
35 |
28.16 |
3.387 |
0.123 |
Age |
35 |
80 |
55.81 |
9.162 |
0.775 |
Table 1 - Descriptive Statistics based on Age and BMI of Patients.
The surgical technique used was the ipsilateral reconstruction with a TRAM flap
in 98.9% of the cases. One patient underwent contralateral reconstruction
because the patient had a Kocher incision on the same side of the mastectomy
(1.1%). Three patients underwent microsurgical free TRAM flap
reconstruction.
For the analysis, the complications were divided into two types, minor (not
related to RT) and major (may be related to RT). The incidences of these types
of complications were determined to assess if the presence of RT and its effects
before and after reconstruction influenced the incidence of minor and major
complications, as shown in Table 2.
Table 2 - Number of Patients with Bilateral Reconstruction per Group.
|
|
Group |
Sig. Kruskal-Wallis |
|
|
Without Radiation |
With Radiation after TRAM |
With Radiation before TRAM |
|
|
N |
% |
N |
% |
N |
% |
|
Bilateral |
Yes |
6 |
12.8 |
4 |
14.8 |
0 |
0 |
0.250 |
No |
41 |
87.2 |
23 |
85.2 |
18 |
100 |
|
Total |
47 |
100 |
27 |
100 |
18 |
100 |
|
Table 2 - Number of Patients with Bilateral Reconstruction per Group.
The incidence of major complications was higher in the groups with RT after TRAM
flap reconstruction (29.6%) (Figure 1) than
in the other groups (without RT, 23.4% (Figure 2) and with RT before TRAM flap reconstruction, 5.6%) (Figure 3). However, the differences among the
groups were not statistically significant in the chi-square test. Multiple
comparisons were made among the groups (Games-Howel test), and no significant
difference was found at a significance level of 5%.
Figure 1 - A: Preoperative image; B: Postoperative
image of breast reconstruction with TRAM flap bilaterally followed
by radiotherapy in the left breast.
Figure 1 - A: Preoperative image; B: Postoperative
image of breast reconstruction with TRAM flap bilaterally followed
by radiotherapy in the left breast.
Figure 2 - A: Preoperative image; B: Postoperative
image of breast reconstruction with TRAM flap in the right breast;
C: Postoperative image of the breast after the
second reconstruction phase without radiotherapy.
Figure 2 - A: Preoperative image; B: Postoperative
image of breast reconstruction with TRAM flap in the right breast;
C: Postoperative image of the breast after the
second reconstruction phase without radiotherapy.
Figure 3 - Late TRAM flap. A: Postoperative image after
radiotherapy; B: Postoperative image of breast
reconstruction with TRAM flap; C: Postoperative image
of the breast after the second reconstruction phase.
Figure 3 - Late TRAM flap. A: Postoperative image after
radiotherapy; B: Postoperative image of breast
reconstruction with TRAM flap; C: Postoperative image
of the breast after the second reconstruction phase.
Similarly, we found no evidence of statistically significant differences among
the groups for minor complications, although a higher incidence was observed
among the patients with RT before TRAM flap reconstruction (38.9%) than among
those who had no RT (21.3%) and had post-TRAM flap reconstruction RT (29.6%).
The multiple comparisons with the Games-Howel test also showed no significant
differences between the groups. Figures 4
and 5 illustrate these results.
Figure 4 - Incidence of major complications per group.
Figure 4 - Incidence of major complications per group.
Figure 5 - Incidence of minor complications per group.
Figure 5 - Incidence of minor complications per group.
DISCUSSION
Adjuvant RT improves the prognosis of patients with advanced breast cancer, whose
risk of locoregional recurrence is >25-30%2. The American Society for Therapeutic Radiology and Oncology and
the American Society of Clinical Oncology recommend post-mastectomy RT for
patients with advanced disease (T3 or T4 tumors) or patients who underwent
levels I, II, and/or III axillary emptying and had at least four positive
axillary lymph nodes.
However, the role of adjuvant radiotherapy in the treatment of patients with T1
or T2 tumors and 1-3 positive axillary lymph nodes is controversial2. Adjuvant RT in patients with locoregional
disease is generally not recommended for women with tumors of <5 cm in
diameter and negative axillary lymph nodes4,5.
Obesity and smoking are the most important factors that interfere with the final
result with regard to complications6. In
our study, smoking was an exclusion factor, and BMI was homogeneous among the
3
groups.
According to Jugenburg et al.5, RT
administered before or after breast reconstruction has the potential to
negatively affect the form, symmetry, and pigmentation, and to increase the
incidence of contractures in reconstructed breasts. In our study, the breasts
reconstructed with TRAM and irradiated before or after reconstruction were not
adversely affected by RT.
Some authors reported that the association between reconstruction with a TRAM
flap and RT, regardless of the sequence of these procedures, produced a similar
rate of complications and aesthetic results7. Williams et al.8
demonstrated no significant difference in the overall incidence of complications
between the irradiated groups, either before or after reconstruction (31%
vs. 25%, p = 0.749). In our sample,
similar results were observed. On the other hand, other authors reported a
higher incidence of late complications in the immediate reconstruction group
than in the late reconstruction group9,10.
In 2001, researchers from M. D. Anderson published a retrospective study that
compared complication rates between patients who underwent immediate
reconstruction with a TRAM flap before RT and those who underwent late
reconstruction after RT. The incidence of early complications did not differ
significantly between the two groups. However, the incidence of late
complications (steatonecrosis, loss of flap volume, and flap contracture) was
significantly higher in the immediate reconstruction group (87.5%
vs. 8.6%; p < 0.001)3,11.
The present study shows that although late complications are more prevalent in
the immediate reconstruction group, the difference between the groups is not
statistically significant.
CONCLUSION
In this study, adjuvant RT was not a potentiating factor of complications in the
patients who underwent immediate reconstruction with a TRAM flap after
mastectomy. Moreover, no statistically significant difference was found in the
occurrence of minor and major complications among the different patient
groups.
COLLABORATIONS
MCC
|
Analysis and/or interpretation of data; final approval of the
manuscript; conception and design of the study; completion of
surgeries and/or experiments; writing the manuscript or critical
review of its contents.
|
MSB
|
Analysis and/or interpretation of data; final approval of the
manuscript; writing the manuscript or critical review of its
contents.
|
JPPCF
|
Analysis and/or interpretation of data; writing the manuscript or
critical review of its contents.
|
DBP
|
Statistical analyses; final approval of the manuscript.
|
RCJ
|
Writing the manuscript or critical review of its contents.
|
BPE
|
Writing the manuscript or critical review of its contents.
|
DMCC
|
Writing the manuscript or critical review of its contents.
|
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1. Sociedade Brasileira de Cirurgia Plástica, São
Paulo, SP, Brazil.
2. Hospital Daher, Brasília, DF,
Brazil.
Corresponding author: Marina de Souza
Borgatto
SMHN Quadra 02, Bloco C, Edifício Dr. Crispim, Sala 1315
Brasília, DF, Brazil Zip Code: 70710-149
E-mail: mborgatto@yahoo.com.br
Article received: March 31, 2013.
Article accepted: May 17, 2018.
Conflicts of interest: none.