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Annals of Plastic Surgery 2012 Levine

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  • Annals of Plastic Surgery 2012 Levine

Outcomes of Delayed Abdominal-Based Autologous Reconstruction Versus Latissimus Dorsi Flap Plus Implant Reconstruction in Previously Irradiated Patients

Steven M. Levine, MD,* Nima Patel, MD, and Joseph J. Disa, MD
Background: Local recurrence after breast conservation therapy is usually managed with salvage mastectomy. Multiple methods of reconstruction are possible, although delayed autologous reconstruction provides the most reliable results.

Methods: We compared complications in delayed abdominal-based [transverse rectus abdominis muscle (TRAM)/deep inferior epigastric perforator (DIEP)] reconstruction with delayed latissimus dorsi plus implant-based reconstruction in previously irradiated breasts. The authors reviewed 133 consecutive cases of delayed breast reconstructions performed in patients who had post-mastectomy radiation therapy and reconstruction with abdominal-based methods (single-pedicle TRAM, supercharged pedicle TRAM, muscle-sparing TRAM free flap, DIEP flap, and superficial inferior epigastric artery flap) or a pedicled latissimus dorsi flap plus implant. Complications for donor and recipient sites were recorded including infection, seroma, hematoma, and partial flap loss.

Results: Seventy-five patients were reconstructed with abdominal-based flaps (37 muscle-sparing TRAMs, 19 pedicled TRAMs, 12 DIEPs, 6 supercharged pedicled TRAMs, and 1 superficial inferior epigastric artery). Their median age was 50 years and mean follow-up was 22.7 months. Three (4.0%) patients required reoperation during the same hospital visit for vascular compromise that resulted in 2 (2.7%) flap failures. Three (4.0%) patients had partial flap loss that ultimately required debridement and primary closure. Seventeen (22.7%) patients had minor complications including seroma, small hematoma, cellulitis, and abdominal bulge. Fifty-six patients were reconstructed with latissimus dorsi flaps plus implants. Their median age was 47 years and mean follow-up was 32 months. Three (5.4%) patients developed infections resulting in implant loss. Four (7.1%) patients had partial flap loss that required debridement and primary closure. Thirteen (23.2%) patients had minor complications including seroma (12 patients) and hematoma (1 patient) that required drainage. Fisher exact test was used to determine statistical significance of complication and failure rates between the 2 types of reconstruction. In patients who had postmastectomy radiation therapy, those with abdominal-based reconstructions had fewer complications compared with latissimus dorsi flap plus implant reconstructions (28.0% vs 30.4%,P= 0.846). Also, fewer reconstructions failed in patients with abdominal-based reconstruction (2.7% vs 5.4%,P= 0.650).

Conclusions: Abdominal-based autologous reconstruction had fewer complications and fewer reconstruction failures than latissimus dorsi flap plus implant reconstructions in patients with postmastectomy radiation therapy in our series; however, these rates were not statistically significant.

Key Words: breast reconstruction, TRAM, DIEP, latissimus dorsi, implant, radiation therapy, breast conservation therapy Radiation therapy is an integral component in the multidisciplinary management of breast cancer, and indications for the use of radiation therapy in the treatment of breast cancer are continually expanding. As a result, the need for plastic surgeons to perform breast reconstruction in patients with a history of breast or chest wall radiation is also increasing. Reconstructive surgeons have a responsibility to guide patients through the breast reconstruction decision-making process. Anecdotal experience is no longer considered sufficient when justifying treatment algorithms, neither to patients nor to insurance providers.

Multiple methods of breast reconstruction are possible in patients who have undergone postmastectomy radiation therapy; although it is generally agreed that delayed autologous reconstruction provides the most reliable results. The goal of the authors’study was to compare complications in delayed abdominal-based transverse rectus abdominis muscle (TRAM)/deep inferior epigastric perforator (DIEP)] reconstruction with delayed latissimus dorsi plus implant-based reconstruction in patients who underwent postmastectomy radiation therapy.

PATIENTS AND METHODS

A prospectively maintained database of all patients treated at Memorial Sloan-Kettering Cancer by the Plastic and Reconstructive Surgery Service was queried to identify patients with a documented history of postmastectomy radiation before breast reconstruction. We limited our search to patients who received abdominal-based breast reconstruction [single-pedicle TRAM (S-P TRAM) flap, supercharged pedicle TRAM (S-C TRAM) flap, free TRAM-sparing (MS-TRAM) flap, DIEP flap, or superficial inferior epigastric artery (SIEA) flap] or latissimus dorsi flap plus implant reconstruction. A retrospective chart review of the patients’ medical records was performed to include patient demographic information, the types of operations performed, and any complications. Complications for donor and recipient sites were recorded including infection, seroma, hematoma, partial flap loss, and complete flap loss. Abdominal-based reconstructions were considered to have failed if the flap had to be removed and replaced with an alternative reconstruction. Latissimus dorsi flaps plus implant reconstructions were considered to have failed if an implant was lost because of extrusion, infection, or rupture or if implantexchange was required because of asevere capsular contracture. This study was approved and carried out under the guidelines set forth by the institutional review board at Memorial Sloan-Kettering Cancer Center.

Statistical AnalysisDescriptive statistics were reported as number and percents of patients or means with ranges. Fisher exact test with 2 tails was reported for comparison of binary variables. The significance level was set at an > of 0.05. Stata statistical software was used for analysis (StataCorp, College Station, TX)

RESULTS

A total of 131 patients were identified who underwent either abdominal-based autologous breast reconstruction or latissimus dorsi plus implant breast reconstruction in a period ranging from July 1999 through February 2011. Seventy-five patients were reconstructed with abdominal-based flaps (37 muscle-sparing TRAMs, 19 pedicled

TRAMs, 12 DIEPs, 6 supercharged pedicled TRAMs, and 1 SIEA). Their median age was 50 years and mean follow-up was 22.7 months. Three (4.0%) patients (2 MS-TRAMs and 1 S-P TRAM) required reoperation during the same hospital visit for vascular compromise, that resulted in 2 (2.7%) (1 MS-TRAM and 1 S-P TRAM) flap failures. Three (4.0%) patients (1 MS-TRAM and 2 S-P TRAMs) had partial flap loss that ultimately required debridement and primary closure. Seventeen (22.7%)patients had minor complications including seroma, small hematoma,,cellulitis, and abdominal buldge.

Fifty-six patients were reconstructed with latissimus dorsi flaps plus implants. Their median age was 47 years and mean follow-up was 32 months. Three (5.4%) patients developed infections that resulted in implant loss. Four (7.1%) patients had partial flap loss that required debridement and primary closure. Thirteen (23.2%) patients had minor complications including seroma (12 patients) and hematoma (1 patient) that required drainage.

Fisher exact test was used to determine statistical significance of complication and failure rates between the 2 types of reconstruction. In patients who had undergone postmastectomy radiation, patients with abdominal-based reconstructions had fewer complications compared with latissimus dorsi flap plus implant reconstructions (28.0% vs 30.4%, P= 0.846). Also, fewer reconstructions failed in patients with abdominal-based reconstruction (2.7% vs 5.4%, P=0.650)

DISCUSSION
Radiation therapy sequelae include microvascular occlusion and direct cellular damage of the local tissue that can persist for several decades. These long-lasting effects translate into chronic skin thickening, decreased pliability, and decreased wound healing potential. For these reasons, there is virtually no debate that the most reliable and, therefore, safest results in breast reconstruction after breast radiation therapy involve the use of autologous tissue. Autologous tissue introduces healthy tissue, devoid of radiation changes to the radiation-scarred bed. The surgeon can transplant healthy, non-radiated tissue to the previously irradiated chest either alone or in conjunction with alloplastic material.

In the past, multiple studies have demonstrated high complication rates in breast reconstruction in previously irradiated patients treated without autogenous tissue. Forman et al looked at a series of patients whowere treated with salvage mastectomy after failing breast conservation therapy. At 5 years, 60% of reconstructions had experienced a complication or an unfavorable result. Dickson and Sharpe reported a 70% complication rate in a similar series.

In this current study, we sought to compare the complication rates between abdominal-based autologous reconstruction and latissimus dorsi plus implant reconstruction in patients who underwent postmastectomy radiation therapy. Our rationale for investigating this question is to be able to provide the most comprehensive picture on risks, benefits, and alternatives of the various types of breast reconstruction options that we offer patients. Ultimately, donor site preferences and personal opinions on the use of an implant device might sway a patient in 1 direction or another; however, complication profiles between abdominal-based autologous reconstruction and latissimus dorsi flaps plus implant reconstruction, would add another important dimension to this decision. Further, we included all abdominal-based flaps (S-P TRAM, S-C TRAM, MS-TRAM, DIEP, or SIEA) in 1 group because of our imperfect ability to predict which flap will ultimately be used for reconstruction. As preoperative imaging techniques advance and surgeons comfort with using them increases, we will be able to better stratify specific abdominal flap complication profiles.

CONCLUSIONS

Reconstructing the irradiated breast will continue to present challenges to plastic surgeons. Although no single approach is most appropriate for all patients, we continue to believe that autologous tissue-based reconstruction provides the most reliable reconstruction. We demonstrate that both abdominal-based autologous reconstruction and latissimus dorsi plus implant reconstruction are acceptable forms of breast reconstruction in patients who have undergone post-mastectomy radiation therapy. In our series, abdominal-based autologous reconstruction had fewer complications and fewer reconstruction failures than latissimus dorsi flap plus implant reconstructions in patients who underwent postmastectomy radiation therapy; however, these rates were not statistically significant.