INTRODUCTION
According to the National Cancer Institute, breast cancer is the second most
common type of cancer, after non-melanoma skin cancer, among women in Brazil and
in the world. An estimated 59,700 new cases of breast cancer occurred each year
of the 2018-2019 biennium in Brazil, with an estimated risk of 56.33 cases per
100,000 women. The disease accounts for approximately 25.2% of new cancer cases
recorded worldwide1.
Multiple factors are involved in the etiology of breast cancer, including age at
first menstruation of <12 years; menopause after 55 years; women who have
never become pregnant or never had children (nulliparity); first pregnancy after
30 years; use of certain contraceptives and hormone replacement therapy in
menopause, especially for prolonged periods; exposure to ionizing radiation;
consumption of alcoholic beverages; hypercaloric diets; sedentary lifestyle; and
genetic predisposition (due to genetically transmitted mutations in certain
transmitted genes, mainly the two high-risk genes, BRCA1 and BRCA2)1.
Owing to its high incidence, this cancer is a major concern, especially because
of the psychological and social impacts on women’s health. In an attempt to
reduce the negative feelings triggered by the disease and mastectomy, to improve
self-esteem, and to make up for the lack of breasts, many women opt for surgical
reconstruction. It is a safe procedure that does not increase the risk of
recurrence or interfere in the detection of the disease, and does not lead to
delays of adjuvant therapies. The effectiveness of several surgical procedures
that use conservative techniques, neighborhood flaps, alloplastic materials, and
pedicled and microsurgical myocutaneous flaps have been described2,3.
With the emergence of genetic testing for BRCA1 and BRCA2 for risk
stratification, the frequency of contralateral prophylactic mastectomy is
increasing considerably in patients who had undergone mastectomy for unilateral
cancer. Besides genetic tests, other factors can contribute to the
implementation of prophylactic mastectomy, including multiple mammographic
changes, multicentric precursor lesions, difficulty in screening due to dense
breasts, and high anxiety of patients4.
OBJECTIVE
The objective of this study was to analyze the cases of breast reconstruction
after mastectomy for breast cancer, performed over a period of 16 years at the
author’s private clinic, by identifying the age of patients, types of surgery
performed (technique used and laterality), complications, presence of risk
factors of complications, and evolution of the procedures over time.
METHODS
This retrospective longitudinal observational study was conducted by reviewing
the medical records of patients who underwent breast reconstruction after
mastectomy for breast cancer between January 2002 and December 2017. The
following data were collected: age, type of breast reconstruction performed
(technique used and whether unilateral or bilateral), and postoperative
complications. Data on the presence of risk factors of complications
(comorbidities, smoking, obesity, and radiotherapy) were also collected in the
patients’ charts from October 2007.
All the surgeries were performed by the same plastic surgeon in 5 hospitals
located in the city of Brasilia (DF).
This research project followed the legal procedures according to resolution
196/96 of the National Health Council regarding research involving human beings
and was conducted in accordance with the principles of the Declaration of
Helsinki.
RESULTS
From January 2002 to December 2017, 586 mastectomized breast cancer patients
underwent breast reconstruction. The mean age of the patients was 54.37 years,
ranging from 27 to 80 years. Breast reconstruction was performed with a
transverse rectus abdominis myocutaneous (TRAM) flap in 160 patients, with
conservative techniques (local and neighborhood flaps) in 107, with a latissimus
dorsi myocutaneous flap (LDMF) in 156, with prostheses in 113 (16 with a larger
pectoral muscle flap extended with a lower pedicle dermofat flap and 41 with
superior and subcutaneous flaps mixed lower a subcutaneous flap covering the
implant), and secondarily in 50 (those that required a new reconstruction due to
failure of the first procedure; Figures 1
to 8).
Figure 1 - The number of patients who underwent breast reconstruction
between January 2002 and December 2017, in accordance with the
technique. LDMF, latissimus dorsi myocutaneous flap; TRAM,
transverse rectus abdominis myocutaneous flap.
Figure 1 - The number of patients who underwent breast reconstruction
between January 2002 and December 2017, in accordance with the
technique. LDMF, latissimus dorsi myocutaneous flap; TRAM,
transverse rectus abdominis myocutaneous flap.
Figure 2 - Unilateral breast reconstruction with a TRAM flap.
A, B and C: Preoperative
aspect; D, E and F:
Postoperative aspect.
Figure 2 - Unilateral breast reconstruction with a TRAM flap.
A, B and C: Preoperative
aspect; D, E and F:
Postoperative aspect.
Figure 3 - Bilateral breast reconstruction with a TRAM flap. A,
B and C: Preoperative aspect;
D, E and F: Postoperative
aspect.
Figure 3 - Bilateral breast reconstruction with a TRAM flap. A,
B and C: Preoperative aspect;
D, E and F: Postoperative
aspect.
Figure 4 - Unilateral breast reconstruction with a LDMF flap.
A: Preoperative aspect; B:
Postoperative aspect; C: Marking for reconstruction of
the nipple areola complex; D: Final postoperative
aspect; E: Preoperative marking and dorsal region
donor; F: Postoperative appearance of the dorsal region
donor.
Figure 4 - Unilateral breast reconstruction with a LDMF flap.
A: Preoperative aspect; B:
Postoperative aspect; C: Marking for reconstruction of
the nipple areola complex; D: Final postoperative
aspect; E: Preoperative marking and dorsal region
donor; F: Postoperative appearance of the dorsal region
donor.
Figure 5 - Bilateral breast reconstruction with a LDMF. A:
Preoperative aspect; B: Postoperative aspect;
C: Marking for nipple-areola complex
reconstruction; D: Final postoperative aspect;
E: Preoperative marking and dorsal region donor;
F: Postoperative appearance of the dorsal region
donor.
Figure 5 - Bilateral breast reconstruction with a LDMF. A:
Preoperative aspect; B: Postoperative aspect;
C: Marking for nipple-areola complex
reconstruction; D: Final postoperative aspect;
E: Preoperative marking and dorsal region donor;
F: Postoperative appearance of the dorsal region
donor.
Figure 6 - Breast reconstruction with a prosthesis. A:
Preoperative aspect; B: Preoperative marking;
C and D: Intraoperative aspect of the
superior pectoralis minor flap and mixed inferior subcutaneous flap
covering the implant; E: Immediate postoperative
aspect; F: Late postoperative aspect.
Figure 6 - Breast reconstruction with a prosthesis. A:
Preoperative aspect; B: Preoperative marking;
C and D: Intraoperative aspect of the
superior pectoralis minor flap and mixed inferior subcutaneous flap
covering the implant; E: Immediate postoperative
aspect; F: Late postoperative aspect.
Figure 7 - Breast reconstruction with a prosthesis. A:
Preoperative aspect; B: Preoperative marking;
C and D: Intraoperative aspect of the
flap from the greater pectoral muscle, extended with a dermofat flap
of the inferior pedicle covering the implant; E:
Immediate intraoperatively mounted breast; F:
Postoperative aspect.
Figure 7 - Breast reconstruction with a prosthesis. A:
Preoperative aspect; B: Preoperative marking;
C and D: Intraoperative aspect of the
flap from the greater pectoral muscle, extended with a dermofat flap
of the inferior pedicle covering the implant; E:
Immediate intraoperatively mounted breast; F:
Postoperative aspect.
Figure 8 - Breast reconstruction with a prosthesis. A:
Preoperative aspect; B: Preoperative marking;
C and D: Postoperative appearance with
capsular contracture; E and F:
Postoperative appearance after a second correction of the capsular
contracture.
Figure 8 - Breast reconstruction with a prosthesis. A:
Preoperative aspect; B: Preoperative marking;
C and D: Postoperative appearance with
capsular contracture; E and F:
Postoperative appearance after a second correction of the capsular
contracture.
The TRAM procedures performed were unilateral in 72 patients (43 immediate and 29
late) and bilateral in 88 (74 immediate, 5 late, and 9 immediate on one side and
late on the other). The LDMF procedures performed were unilateral in 40 patients
(30 immediate and 10 late) and bilateral in 116 patients (106 immediate, 6 late,
and 4 immediate on one side and late on the other; Figure 9).
Figure 9 - Types of breast reconstruction performed between January 2002 and
December 2017. LDMF, latissimus dorsi myocutaneous flap; TRAM,
transverse rectus abdominis myocutaneous flap.
Figure 9 - Types of breast reconstruction performed between January 2002 and
December 2017. LDMF, latissimus dorsi myocutaneous flap; TRAM,
transverse rectus abdominis myocutaneous flap.
Before October 2007, the percentage of patients who underwent bilateral
surgeries, including a TRAM flap and LDMF, was 30%, which increased to 83.3%
from then on (Figure 10). The
reconstructions were performed with a TRAM flap and LDMF flap, respectively, in
32% and 12% of the patients from 2002 to 2006; in 25.73% and 25.14% from 2007 to
2011; and in 16.45% and 43.67% from 2012 to 2017. During the whole study period,
64.55% and 35.44% of the patients respectively underwent bilateral and
unilateral breast reconstructions with a TRAM flap and LDMF.
Figure 10 - Analysis of the type of TRAM flap and LDMF (unilateral or
bilateral) according to period performed. LDMF, latissimus dorsi
myocutaneous flap; TRAM, transverse rectus abdominis myocutaneous
flap.
Figure 10 - Analysis of the type of TRAM flap and LDMF (unilateral or
bilateral) according to period performed. LDMF, latissimus dorsi
myocutaneous flap; TRAM, transverse rectus abdominis myocutaneous
flap.
One or more types of complications occurred in 203 patients (34.64%) who
underwent operation, with a total of 335 complications (Table 1) and some patients presented with more than one type
of complication. Most patients presented complications that were treated on an
outpatient basis without the need for surgical review. The analysis of risk
factors in the last 293 patients who underwent operation (from October 2007 to
December 2017) revealed that 35 patients had obesity (body mass index [BMI],
>30 kg/m2), 29 were smokers, 32 had
received radiotherapy, and 111 presented comorbidities (diabetes, hypertension,
and hypothyroidism). In this group, 116 patients (39.59%) had some
complications, of whom 80 (68.9%) had at least one risk factor (Figure 11). Of the 29 smokers, 58.62%
presented complications.
Table 1 - Complications and intercurrences.
Complications |
n |
% |
Seroma |
84 |
25.07 |
Necrosis of the remaining breast skin |
47 |
14.0 |
Liponecrosis |
37 |
11.0 |
Dehiscence |
33 |
9.85 |
Partial flap necrosis |
31 |
9.25 |
Hematoma |
20 |
5.97 |
Infection |
19 |
5.67 |
Capsular contracture (including postoperative
radiotherapy)
|
18 |
5.40 |
Partial necrosis of the nipple-areola complex
(NAC)
|
9 |
2.70 |
Necrosis of the navel |
8 |
2.40 |
Abdominal bulging |
8 |
2.40 |
Mondor's disease |
7 |
2.09 |
Atelectasis |
5 |
1.50 |
Pulmonary thromboembolism |
3 |
0.90 |
Asymmetry |
2 |
0.60 |
Deep venous thrombosis |
1 |
0.30 |
Acute renal failure |
1 |
0.30 |
Obstructive acute abdomen |
1 |
0.30 |
Pneumonitis |
1 |
0.30 |
Total |
335 |
100 |
Table 1 - Complications and intercurrences.
Figure 11 - Number of complications according to the presence or absence of
risk factors in the last 293 patients who underwent operation.
Figure 11 - Number of complications according to the presence or absence of
risk factors in the last 293 patients who underwent operation.
DISCUSSION
Breast reconstruction is an essential part of breast cancer treatment. Several
breast reconstruction techniques are available, and the choice of the best
technique is influenced by several factors related to oncological treatment such
as staging, the need for radiotherapy, the type of mastectomy, and laterality
(unilateral or bilateral), and patient-related factors such as BMI,
comorbidities, presence of donor areas for autologous reconstruction,
preference, expectation in relation to the result, and lifestyle 5. The choice of the technique to be used
must be specific to the patient and in accordance with the experience of the
plastic surgeon.
In the last 10 years of the study period, an increase in the number of bilateral
surgeries performed was observed, although the disease was unilateral, due to
the interest of patients to undergo contralateral prophylactic surgery. With the
emergence of genetic testing for risk stratification, the frequency of
contralateral prophylactic mastectomy is increasing exponentially.
In addition to the genetic tests, other factors can contribute to the
implementation of prophylactic mastectomy, including multiple mammographic
changes, multicentric precursor lesions, difficulty in screening due to dense
breasts, and high patient anxiety6.
In the present study, from 2002 to September 2007, 30% of reconstructions with a
TRAM flap and LDMF were bilateral, and this rate was 83.33% from October 2007 to
December 2017. From the moment of the treatment of the primary cancer, >10%
of women treated will subsequently develop cancer in the contralateral breast,
which may emerge up to 30 years after the initial treatment7.
The efficacy of prophylactic mastectomy depends on the ability to remove a large
part of the breast tissue, leaving the flap with a minimum viable thickness. The
development of cancer in the residual tissue has been reported with an incidence
ranging from 1% to 9%8. The effectiveness
of the contralateral prophylactic mastectomy in patients treated for breast
cancer is estimated at 96%9. In the study
of Hartmann et al.6, the reduction in the
risk of developing breast cancer in patients who undergo prophylactic mastectomy
was close to 90%.
Secondary or rescue reconstruction, defined as complete revision of a previous
reconstruction in the event of unsatisfactory outcome or failure of the
surgery10, was performed in 50
patients. In 88% of the cases, a myocutaneous flap, TRAM flap, and LDMF were
used, which demonstrates that these flaps are well indicated in these cases, as
they provide healthy and well-vascularized tissue to a previously manipulated
area. Furthermore, on the basis of the numbers shown, over the years, LDMF has
been increasingly used in reconstructions in comparison with the TRAM flap.
Treatment of breast cancer used to be mutilating, involving large surgeries that
remove large amounts of skin and even muscle. Therefore, the use of TRAM flaps
is important in reconstructions that require a considerable volume of tissue to
cover the defect of the mastectomy, provided that they have sufficient abdominal
adipose tissue9.
With the development of skin-saving mastectomy and the increase in the number of
immediate reconstructions performed, in addition to the improvement of the
quality of silicone implants, the use of breast reconstruction with a TRAM flap,
a surgery of higher morbidity and with disadvantages such as abdominal hernias
and bulging, has decreased, and reconstructions with a LDMF and direct implant
have increased9.
In the 586 patients who underwent breast reconstruction, the extended pectoralis
major flap with an inferior dermofat pedicle covering the silicone implant was
used in 16 patients (2.73%). This flap is used to lengthen the submuscular
pocket. This flap can only be used after joint analysis by the mastologist
because it retains a small amount of breast tissue of the lower quadrants. After
the concordance of the mastologist to retain this tissue, the location of the
tumor, the presence of microcalcifications or other diseases in this region, and
the nutritional viability of the flap should be analyzed.
The technique described by Cosac et al.4
provides for an appropriate pocket for the placement of the implant, without
excessive tension, with alleviation of projection in the upper and lower poles,
and with lower tendency for cephalic migration of the implant. In addition, it
presents a minimal risk of prosthesis extrusion, in cases of necrosis or
dehiscence, due to the interposition of tissue between the implant and the skin.
Besides the excellent aesthetic results, use of the proposed flap does not
involve donor site morbidity, prolonged recovery, muscle weakness, nor the use
of grafts, being an alternative technique in selected patients4.
In 41 patients (6.99%), breast reconstruction was performed with a prosthesis
pocket with a superior retropectoral flap and lower mixed subcutaneous cavity.
This technique, described by Cosac et al.9, involves making an arcuate incision in the breast, extending from the
lateral end to the medial part of the submammary sulcus. The entire lower base
of the breast skin is kept intact, and the dermofat flap should have a minimum
thickness of 1.5 to 2 cm. After mastectomy, the plastic surgeon constructs the
flap of the pectoralis major muscle, and the implant, after its inclusion, is
covered by this muscle in its upper two-thirds and by the dermofat flap in its
lower one-third.
This technique results in a single arched scar, which leads to a less
stigmatizing aspect. Patient recovery is rapid, with a lower perception of
postoperative pain. One of the great advantages of this technique is the
presence of a thinner flap, without glandular tissue, which favors greater
oncological safety9.
The rate of complications observed in the present study (34.64%) is in agreement
with the reported data11. Complications
range from 15% to 45%, according to the type of surgery performed, and increase
with risk factors (obesity, smoking, comorbidities, and radiotherapy)4, as observed in this study. Not all
complications compromise the final result or require new interventions such as
seroma, which is responsible for 25.07% of the complications, in patients with
outpatient or expectant treatment, rarely implying any permanent
complications.
The presence of smoking is associated with a significant increase in the
incidence rates of flap necrosis and other complications11. In the group of the last 293 reconstructions studied,
the rate of complications in smokers was 58.62%, which is significantly higher
than the overall complication rate of 33.41%.
CONCLUSION
The individualization of patients is key to the success of breast reconstruction.
Each reconstructive technique has its indications, advantages, and limitations,
which should be widely discussed with the patient to obtain the best possible
result. The choice of technique also depends on the surgeon’s experience and
relationship with the mastology team. We emphasize the need for a
multidisciplinary, tuned, well-trained, and qualified surgical team, each
working in their area of expertise but synergistically to achieve the best
possible surgical outcome.
In this study, an increase in the number of bilateral surgeries performed was
observed in recent years, which is attributed to the increase in the number of
prophylactic mastectomies performed in contralateral breasts, which can reduce
the risk of cancer and facilitate establishment of breast symmetry, with more
harmonious results. In recent years, we also observed an increase in the number
of reconstructions using the myocutaneous flap of the latissimus dorsi muscle
compared with that with the transverse rectus abdominis myocutaneous flap, and a
significant increase in the number of reconstructions with silicone
implants.
The techniques used in breast reconstruction are effective and safe alternatives,
with acceptable complication rates. The presence of risk factors such as
obesity, smoking, comorbidities, and radiotherapy, resulted in a higher rate of
complications. The surgeon should be aware of all the details, including a
well-performed preoperative assessment, correct indication for surgery, and
rigorous postoperative follow-up.
COLLABORATIONS
OMC
|
Analysis and/or data interpretation, final manuscript approval,
realization of operations and/or trials.
|
ACC
|
Analysis and/or data interpretation, conception and design study,
data curation, writing - review & editing.
|
RCSD
|
Analysis and/or data interpretation.
|
RSCC
|
Analysis and/or data interpretation.
|
SVS
|
Analysis and/or data interpretation.
|
AAD
|
Analysis and/or data interpretation.
|
JPPCF
|
Analysis and/or data interpretation.
|
JCD
|
Final manuscript approval.
|
REFERENCES
1. Brasil. Ministério da Saúde. Instituto Nacional de Câncer José
Alencar Gomes da Silva (INCA). Estimativa 2018: incidência de câncer no Brasil /
Instituto Nacional de Câncer José Alencar Gomes da Silva. Coordenação de
Prevenção e Vigilância. Rio de Janeiro: INCA; 2017.
2. Malata CM, McIntosh SA, Purushotham AD. Immediate breast
reconstruction after mastectomy for cancer. Br J Surg. 2000;87(11):1455-72. DOI:
https://doi.org/10.1046/j.1365-2168.2000.01593.x
3. Hu E, Alderman AK. Breast reconstruction. Surg Clin North Am.
2007;87(2):453-67. DOI:
https://doi.org/10.1016/j.suc.2007.01.004
4. Cosac OM, Costa LA, Barros APGSH. Reconstrução mamária bilateral com
retalhos pediculados. In: Melega JM, Viterbo F, Mendes FH, eds. Cirurgia
plástica: os princípios e a atualidade. Rio de Janeiro: Guanabara Koogan; 2011.
p. 732-42.
5. Nahabedian MY. Factors to consider in breast reconstruction. Womens
Health (Lond). 2015;11(3):325-42. DOI:
https://doi.org/10.2217/WHE.14.85
6. Hartmann LC, Schaid DJ, Woods JE, Crotty TP, Myers JL, Arnold PG, et
al. Efficacy of bilateral prophylactic mastectomy in women with a family history
of breast cancer. N Engl J Med. 1999;340(2):77-84. PMID: 9887158 DOI:
https://doi.org/10.1056/NEJM199901143400201
7. Broët P, de la Rochefordière A, Scholl SM, Fourquet A, Mosseri V,
Durand JC, et al. Contralateral breast cancer: annual incidence and risk
parameters. J Clin Oncol. 1995;13(7):1578-83. PMID: 7602346 DOI:
https://doi.org/10.1200/JCO.1995.13.7.1578
8. van Geel AN. Prophylactic mastectomy: the Rotterdam experience.
Breast. 2003;12(6):357-61. DOI:
https://doi.org/10.1016/S0960-9776(03)00136-X
9. Cosac OM, Ribeiro I, Moura LG, Soares DAS, Daher LMC, Galdino MCA,
et al. Reconstrução mamária com loja de retalho retropeitoral superior e
subcutâneo misto inferior. Rev Bras Cir Plást.
2018;33(2):166-73.
10. Tuttle TM, Jarosek S, Habermann EB, Arrington A, Abraham A, Morris
TJ, et al. Increasing rates of contralateral prophylactic mastectomy among
patients with ductal carcinoma in situ. J Clin Oncol. 2009;27(9):1362-7. DOI:
https://doi.org/10.1200/JCO.2008.20.1681
11. Stucky CC, Gray RJ, Wasif N, Dueck AC, Pockaj BA. Increase in
contralateral prophylactic mastectomy: echoes of a bygone era? Surgical trends
for unilateral breast cancer. Ann Surg Oncol. 2010;17(Suppl 3):330-7. DOI:
https://doi.org/10.1245/s10434-010-1259-x
1. Hospital das Forças Armadas, Brasília, DF,
Brazil.
2. HOSPITAL DAHER LAGO SUL, BRASÍLIA, DF,
BRAZIL.
Corresponding author: Ognev Meireles Cosac, SMDB
Conjunto 32, Lote 02, Casa A. Lago Sul, Brasilia, DF, Brazil. Zip Code:
71680-320. E-mail: ognev@terra.com.br
Article received: January 21, 2019.
Article accepted: February 10, 2019.
Conflicts of interest: none.