Post-Mastectomy Radiation Therapy...and Breast Reconstruction

Radiation therapy (RT) is a proven and well-accepted modality in treatment (or adjunct treatment) for breast cancer. It is almost always used following lumpectomy, as it significantly reduces the local recurrence rate.

Even following mastectomy, although a definitive procedure for the cancer, may be recommended RT following the mastectomy due to various pathologic findings. Classic indications are:

Certain (aggressive) types of tumors

Tumors 5cm or greater

4 or more positive lymph nodes

Positive (inadequate) margins on specimen

Others, and newer indications, are:

for tumors less than 5cm and 1-3 nodes (+) - include any 3 of the 4: 1-3 nodes (+), LVI, ER (-) tumors, or premenopusal or less than 40 years of age

for tumors less than 5cm and node (-) - include any 3 of the 4: margin less than 2mm, less than 40 years of age

Although a beneficial adjunct for breast cancer in several circumstances, it has also detriments to both the patient as well as plastic surgeon. Above all, treatment for cancer comes before the aesthetics of breast reconstruction, and the proven benefit outweighs the ill-effects of RT. The impact that RT has on the skin, as evidenced by the radiation dermatitis/radiation burn, angiofibrosis, contrcture/fibrosis of the skin, and soft tissue, as well as the healing/infection issues are not favorable.

From the plastic surgery standpoint, these effects are troublesome, especially when dealing with reconstruction. This should be discussed with your plastic surgeon, as it impacts the type of reconstruction you should have. Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation will be needed postoperatively. However, what is not conveyed, is that the above changes may occur and account for some of the breast asymmetry or contractures. Although a "breast conserving" therapy is performed, many women end up seeking a plastic surgeon to assist with these issues, which often times, include the same procedures as if a mastectomy was performed anyhow.

Implant-based reconstruction is not a recommended reconstructive procedure, as already noted in previous posts. The complication rates are markedly increased with often times, poor aesthetic results, let a lone the wound healing, infection, contracture/asymmetry rates, among others. This type of reconstruction usually fairs poorly following RT. There are several studies showing good results following implant-based reconstruction, however. Many times, RT is not known until final pathology returns several days later. If by chance a tissue expander reconstruction was chosen, and RT is later found to be needed for an indication above, I would opt to keep them in, quickly inflate to maximal expansion, then deflate for the RT. Immediately afterwards, quick expansion would be done (e.g., M.D. Anderson protocol). However, exchange for a flap-based reconstruction is always an option if any complications come about during this process.

Radiation after flap-based procedures are significantly better following RT. After a flap procedure (e.g., latissismus, TRAM, or DIEP flap, recruiting well-vascularized tissue from a remote area negates some of the ill-effects that RT has done. There still is a chance for the reconstructed breast to shrink or contract if followed by radiation, but it resists the effects much better than implants. Usually, performing this in a delayed fashion would allow your plastic surgeon to excise all of the affected tissue, and use the flap to reconstruct the defect. This is my preference after, or for known RT. The flap-based reconstructions (e.g., latissimus, TRAM, or notably the DIEP), are excellent options as discussed in previous posts. You may consider delaying your reconstruction for a later date if you know you will be receiving RT postoperatively.

Silicone Implants

Several queries regarding silicone implants have been asked recently in regards to breast reconstruction. Basically, silicone implants have always been able to be used for reconstructive purposes. They were taken off the market for a time period for aesthetic reasons, but re-approved in the last few years for this purpose.

The FDA approved Allergan Corp. and Mentor Corp.'s silicone breast implants and have since returned these devices to the U.S. market. 14 years after the FDA restricted access to the silicone implants, they have been placed back on the market after extensive studies for safety concerns. They were off the market for this reason from 1992 until November 2006.

The approval letter stipulated a number of conditions that the manufacturers needed to satisfy in order to receive FDA final approval to market and sell silicone breast implants in the United States. These letters came after an FDA advisory panel hearing in April 2005, in which the panel heard more than 20 hours of data presentations from the manufacturers and public comment.

Breast augmentation is now the most common aesthetic surgical procedure, according to ASAPS and ASPS statistics. About 380,000 and 58,000 women had breast augmentation and reconstruction, respectively, last year, according to ASPS. Both breast augmentation and reconstruction have been proven in numerous studies to have psychological and physical benefits for women who choose these procedures.

Silicone implants have been proven safe for reconstructive and augmentation purposes and the research behind these implants are excellent. Overall, excellent results are obtained from such implants with the health concerns already addressed and complications of such should be discussed with your plastic surgeon.

Implant-Based Breast Reconstruction and Recurrent Cancer

Many women are fearful, for obvious reasons, that implants may contribute to cancer recurrence or may hinder detection of any recurrent cancer. Implant-based reconstruction is the most common type of breast reconstruction, even today. Recurrence of cancer is always a concern, and thus, studies were performed to evaluate if implants hindered or lengthened the time of diagnosis of recurrence.

The most notable study reviewed two groups of more than 300 women each - women with immediate breast reconstruction with implants and women without any reconstruction. These took into account patient age and stage of the disease. The recurrence rate of reconstructed patients = 6.8% and without reconstruction = 8.1%. There was no statistical difference in detection or recurrence between these groups. Nearly all (~95%) of all recurrences were detected by physical examination alone, with the rest being found via CT scan. Treatment was not affected by the implants. And, generally, did not require removal of the implant. Only 3 of the 21 women who had recurrence had her implant removed, with 2 of 3 requesting to have it removed.

Breast cancer continues to grow in number along with the reconstructive options available. With the growing knowledge of the reconstructive option, more and more women continue to opt for breast reconstruction. Only a few years ago, breast reconstruction was only conducted in approximately 10% of all women with breast cancer. This number has increased over the past few years alone, mostly due to the fact that women are more informed of this option. Overall, immediate breast reconstruction is still a safe procedure with numerous advantages...and as this study shows, has no impact on the identification of a recurrence or any association towards causing a cancer recurrence.

Recent Mammography Recommendations

Recently, the United States Preventive Services Task Force (USPSTF) has recently released recommendations for screening mammography for women. Their recommendations state that such mammograms should be every other year beginning at age 50yo, instead of the current guidelines of beginning at age 40yo (35yo for high-risk women). Mammography has unquestionably saved many lives, especially in women younger than 50yo. At least 10-20% of all breast cancers are diagnosed in these younger women. Breast cancer in younger women is always a more aggressive tumor, and overall, usually a more deadly tumor, especially when not caught early. When detected early and in its earliest and most treatable stage, the recurrence and survival rate is MUCH lower. Women over 74yo are not given specific guidelines for mammography, as they state that their risk of dying from other medical conditions is far greater than that of breast cancer, despite the fact that breast cancer (1 in every 8 women will develop) clearly increases with age.

The current recommendations by the USPSTF are based on old research from 1992-2001. The medical technology, especially in diagnostics, imaging (including digital mammography and breast MRI, breast cancer research (billions of dollars over the past few years alone, and treatment modalities have made huge advances, which accounts for the massive decrease in mortality rate over these past 8 years from the USPTF quoted studies. Regular mammographic screening began in 1990 - the mortality rate of breast cancer, previously unchanged over the past half century prior, has significantly decreased by mre than 30% since its inception. Clinical breast exams are not recommended prior to mammography, as they state that a clinical exam adds no additional benefit from that given by a mammogram. Lastly, this task force has not made any specific recommendation for monthly self-breast exams. As known, many breast tumors are found by women during self breast exams, prompting earlier medical evaluation, or by an experienced physician who may catch many masses not found by the woman.

The USPSTF has blatantly refused to data and research (and arguably, common sense), when these recommendations were made. No physician of the specialties that should have been involved (breast surgery, radiology, or oncology), had any input on theses recommendations. In fact, the American College of Radiology (ACR) and other Boards still stick to the current guidelines of beginning yearly screening mammograms beginning at age 40yo. Their claims of the "hazzards" of mammograms are unwarranted: discomfort, anxiety from false positives and need for possible surgery/treatment, and radiation exposure. Undoubtedly, a life saved from early detection far outweighs any of these concerns. Discomfort and anxiety is overshadowed by catching a breast cancer in its earliest stage. The radiation exposure from a mammogram is minimal. In fact, the radiation given off from the earth itself is much greater. The money saved by not performing mammograms between ages 40-49 will most likely be the opposite effect - with the more aggressive treatments, surgery, and battling of late-stage breast cancer will cost much more in money, time, and lives lost. This potential money savings in health care does not make sense as evidenced by current research and data/statistics in breast cancer research. My fear is that women that can afford to pay out-of-pocket for mammograms at an earlier age will get them and those who don't have these means will ultimately suffer. Saving women's lives and detecting/treating breast cancer at its earliest stages should be of utmost importance. The ACR still supports monthly self-breast exams, yearly physician breast exams, and annual screening mammograms beginning at age 40yo (age 35yo in high-risk women) - these are the best modalities that we have today.

Acellular dermal matrix - breast reconstruction applications

The use of the acellular dermal matrix has grown in its applications and use in plastic & reconstructive procedures, and growing. It has truly been a remarkable addition for breast reconstruction.

The acellular dermal matrix is a tissue that is specially-prepared, which comes from cadaveric skin. It has been processed in such a way that the basement membrane and cellular matrix remain intact, while removing all other cellular components that may lead to both rejection and infection. Packages as a sterile tissue product, due to its preparation, the chance of acquiring viruses and such is nearly absent.

Its applications for breast reconstruction alone include its use in tissue expander/implant reconstruction, to act as a "hammock" at the inferior portion of the breast for which the implant lies within. This creates a natural "sling" which mimics the ptosis (sag) of the breast, while supporting it in place. By suturing this matrix to its exact position of the breast margins, the plastic surgeon is able to precisely recreate an excellent contour for your breast, especially at the inferior, medial, and lateral positions. This also minimizes migration of the implant, as sometimes seen with "bottoming out" inferiorly or its displacement into the axilla (armpit). In addition to its increased aesthetic results, the acellular dermal matrix provides additional coverage over your implant. This is especially useful in those instances of dehiscence (your incision opening up), thus protecting the implant from exposure, and threatening its necessity for removal. Furthermore, in cases where the overlying mastectomy flaps are thin or damaged, leading to partial flap necrosis, the tissue matrix again provides a coverage over your implant, which can heal over time or a graft placed over the are or simply closed. Lastly, the additional coverage lessens implant visibility and palpability and is a great adjunct for revisionary breast surgery. The use of this matrix, along with the advantages listed above, has reduced the time of the reconstructive portion of the procedure as well. There is less pectoralis muscle retraction and eliminates the need to raise any other surrounding muscles in order to achieve complete implant coverage.

Additional benefits seen with the acellular dermal matrix are numerous. There has been a significantly decreased incidence (almost none) of capsular contracture around the implant at the area of the tissue matrix. Reasons are unknown as of yet, but contracture has been a huge problem in cases of implants used for reconstruction and augmentation. Also, there are tissue regeneration properties of the matrix in which rather than inciting a scarring response, the dermal matrix begins a regenerative process in which it acts as a biologic scaffold and unbelievably, vessels incorporate into matrix and the surrounding cells differentiate into surrounding tissue that it is incorporated into (an amazing concept).

Overall, the use of the acellular dermal matrix in breast reconstruction has been revolutionary. Its applications for tissue expander reconstruction, possibility to use in immediate implant reconstruction (going directly to implants rather than the use of a tissue expander first), revisionary breast surgery, capsular contracture complications, and nipple reconstruction have been great.

Perforator flaps/Microsurgery

Flap reconstruction offers an autologous (your own tissue) reconstruction, and gives many of the benefits described in earlier posts, such as a soft and "natural" breast mound. Such flaps also are much better for those with a history of radiation, or those who will ultimately require postoperative radiation therapy following mastectomy. Autologous tissue flaps for breast reconstruction offer the best options for these purposes, until the possibility of reconstruction with stem cells becomes a reality. The conventional autologous flap reconstruction requires sacrificing a muscle to reconstruct the breast, either the latissimus dorsi or rectus abdominis muscle. Although popular and reliable procedures to accomplish the goal of breast reconstruction, some of the expected outcomes that coincide are increased pain and seroma formation, along with functional deficits, weakness, and increased rates of hernias/bulges in the areas where the muscle was taken.

Perforator flaps have come to the forefront of plastic & reconstructive surgery due to their decreased morbidity, decreased recuperation time, and increased aesthetic results. This is due in part since they are muscle-sparing procedures, which subsequently maintain muscle function and do not have any morbidity associated with sacrificing of muscles, such as those described previously. Since these types of flaps are technically challenging and more complex, microsurgical expertise is required and as such, very few plastic surgeons in the United States are skilled enough to perform these perforator flaps successfully. In addition to the elaborate dissection of these flaps, albeit tedious, the flap must be reanastomosed under a microscope to blood vessels in the nearby recipient site.

Although a poplar procedure elsewhere in the world, patients in the U.S. often must travel far to find a surgeon capable of performing these perforator flaps, such as the DIEP, SIEA, SGAP, TUG, or ALT flap (DIEP - abdominal skin/tissue only; SIEA - abdominal skin/tissue only; SGAP - buttock skin/tissue only; TUG - groin skin/tissue only; ALT - lateral thigh skin/tissue only). These flaps spare muscle and are arguably the best reconstructive options that we have today. To find a surgeon near you who perform such free tissue transfer breast reconstructions, see the links provided to the right.

Breast reconstruction does not delay treatment for your cancer, if necessary, such as chemotherapy or radiation therapy. Literature shows no increase in recurrence rate or survival rate nor any decreased ability to diagnose such cancers. n fact, the most recent literature has even shown a decreased recurrence rate with immediate breast reconstruction. With all of this in mind, as well as knowing the the superior aesthetic results that are associated with immediate breast reconstruction (reconstruction performed at the same time as your mastectomy), I recommend discussing all of your breast reconstruction options with a plastic surgeon who specializes in breast reconstruction before your mastectomy procedure...please refer to my earliest posts on breast reconstructive options and understanding all of your options.

Part IV: Flap-based reconstruction - DIEP flap

DIEP flap

The use of microsurgery and perforator flaps, such as the DIEP flap, is the newest and state of the art technique for plastic & reconstructive surgery today, including breast reconstruction. Very few plastic surgeons perform this technique due to its complexity, time, and skill involved, but such reconstruction arguably provides the best aesthetic outcome with less morbidity, since only perforating vessels are utilized and muscle is not sacrificed for the flap reconstruction, for those women who are candidates for this unique procedure. However, it is a very popular technique elsewhere in the world and by those few surgeons who perform it in the United States. It is a procedure that has been refined through my fellowship training, and one in which women throughout the United States consult for to perform this innovative type of breast reconstruction, such as the DIEP flap.

Like the conventional TRAM flap procedure, the perforator flap DIEP breast reconstruction offers the advantages such as those offered by the TRAM flap, however, without the sacrifice of the rectus abdominis muscle - only the excess skin and fat from your lower abdominal wall is harvested for the flap...the muscle is left intact on your abdominal wall. This gives the distinct advantage of a completely autologous breast reconstruction, without need for an implant. In addition, since it is a muscle sparing procedure where the rectus abdominis muscle is not sacrificed, your abdominal wall integrity is maintained, leaving a much lower chance of bulges or hernias after the procedure than the TRAM flap.

The flap and its blood vessels are then disconnected entirely from the body, and the entire flap is then relocated to its new location in the breast area as a free tissue transfer. Its corresponding blood vessels are then reattached to blood vessels in the nearby area, using microsurgical techniques. Afterwards, the entire flap may be turned, twisted, or inset in the best position possible to contour a new breast for you. The conventional pedicled TRAM flap is limited in its insetting since it remains attached to its muscle insertion and blood supply superiorly.

Much like a tummy tuck, your abdominal incision will be sutured closed, first by repairing the abdominal wall, then by suturing your incision, leaving a single incision at the lower abdomen, hidden within your bikini line. To finish the closure, your umbilicus (belly button) will be brought out through a small incision, and sutured at its normal anatomic location.

General guidelines:

· Hospitalization: 5-7 days

· Advantages: Same as for the TRAM flap, but decreased hernia/bulge risk due to the fact that the muscle is spared and abdominal wall integrity maintained

· Disadvantages: Same as for the TRAM flap; complex procedure; abdominal wall integrity maintained (minimal hernia/bulge risk – much less than conventional TRAM flap)