Breast conservation therapy (BCT) is a common treatment option for woman with breast cancer. After large trials demonstrated equivalent long-term survival for mastectomy and BCT,1,2 the National Institutes of Health championed it as the preferred surgical treatment for patients with early stage breast cancer.3 As a result of those landmark trials, more women in the United States are treated with breast conservation than mastectomy (61.6% vs 38.4%).4 However, although BCT is believed to better preserve a breast cancer patient’s body image relative to mastectomy,5 the incidence of unfavorable aesthetic results are not insignificant, ranging from 20% to 30%.6–8 The addition of oncoplastic techniques at the time of lumpectomy is an effort to minimize these poor cosmetic results that has recently gained popularity.9
The extent of the deformity after BCT varies widely. It can range from simple volume asymmetry with preserved shape to complete shape distortion, dislocation of the nipple areolar complex, radiation fibrosis, skin retraction, and telangiectasias.6,10,11 The type of reconstruction necessary depends on the extent of the deformity and the quality of the breast skin. The purpose of this study is to review our experience with various types of reconstruction used to correct BCT deformities in an attempt to understand the treatment options and critically evaluate their outcomes.
All patients who underwent surgical correction of a BCT deformity by the senior author between 2003 and 2012 were included in this series. Patients with previous partial breast reconstruction were excluded.
Data on patient demographics, comorbidities, tumor size and pathology, and cancer stage, where applicable, were retrospectively collected from hospital and clinic records. Obesity was defined as a body mass index greater than 30 kg/m2, and overweight defined as a body mass index between 25 and 30. Preoperative photographs were reviewed to classify each breast deformity using the Fitoussi classification system (Table 1).11 In this classification scheme, pure asymmetry is differentiated from 4 levels of progressively more severe deformity. Hospital records were queried for the surgical technique, complications, and the need for revisional procedures. The reconstructive procedures were stratified into: (1) minor local procedures (scar revisions, fat grafting); (2) implant augmentation; (3) autologous tissue transfer; (4) mastopexy or reduction; and (5) contralateral mastopexy or reduction only.
Patient satisfaction was measured using the Breast Q reconstruction questionnaire, a validated survey instrument developed by the Memorial Sloan-Kettering Cancer Center.12 The aesthetic outcome was assessed by a panel of blinded reviewers who judged postoperative photographs based on breast size, shape, symmetry, scar quality, position of the nipple areola complex, and overall cosmesis. The rating scale ranged from 1 to 7, with 7 being the most positive.
Outcomes reflecting surgical complications, patient satisfaction, and esthetic results were compared across the levels of deformity and categories of reconstructive techniques.
Continuous variables (e.g., mean aesthetic rating) were compared across the deformity severity classes and reconstructive categories using analysis of variance. Differences across categorical variables (e.g., development of a complication) were assessed using the χ2 test. A P value less than 0.05 was considered statistically significant in all cases.
Sixty-three patients underwent surgical correction of a BCT deformity during the decade reviewed and were included in this series. Their mean age was 55 years (range, 23–72 years), and an average of more than 5 years had lapsed since their oncologic surgery (range, 1–17 years). The most common pathology was invasive ductal carcinoma (41.3%, n = 26), followed by unknown pathology (23.8%, n = 15), and ductal carcinoma in situ (15.9%, n = 10). Among malignant tumors that had staging data available, the majority (61%) were stage 0 or 1, with most invasive tumors measuring less than 2 cm (T1, 60%). Patient comorbidities included hypertension (38%, n = 24), obesity (31%, n = 20), smoking (9.5%, n = 6), and diabetes mellitus (9.5%, n = 6).
The BCT defect was most often located in the upper outer quadrant of the breast (n = 36, 61%). The remaining defects were evenly distributed in the other breast quadrants. The average follow-up was 29 months.
Fifty-one preoperative photos were available for classification by Fitoussi’s scheme. The classification breakdown included 6% grade 1, 37% grade 2, 45 % grade 3, and 12% grade 4. No patients had the maximal grade 5 deformity.
The most common reconstruction performed was bilateral mastopexy or breast reduction (41%). The distribution of operative techniques is depicted in Figure 1. Twenty-three percent of patients had multiple types of procedures at their partial breast reconstruction and were categorized by the most complex one.
More severe deformities in general mandated more complex reconstructions. Eighty-three percent of grade 4 deformities required a myocutaneous flap transfer, whereas all grade 1 deformities were managed with minor, local procedures (Table 2). Pure asymmetries (grade 2) were treated most often with bilateral breast reductions (53%), and nearly one third of patients underwent reduction only of the contralateral breast. Grade 3 deformities were addressed with a mix of reconstructive methods. Overall, 89 % of patients underwent a procedure on the contralateral breast.
Thirty-five percent of patients (n = 22) developed a postoperative complication, the most common of which were infection (15.9%, n = 10) and seroma (9.5%, n = 6). Although there was a clear trend toward higher complication rates with increasing defect severity (0% for grade 1, 32% for grade 2, 39% for grade 3, and 50% for grade 4), this did not achieve statistical significance. Similarly, complications were most frequently observed with autologous tissue transfer, but the rates were not discernably different across the 5 reconstructive categories (Table 3).
Although 80% of patients had a satisfactory outcome after 1 reconstructive surgery, 14% required a second operation, and 6% a third. Defect severity was not associated with increasing number of procedures, but the reconstructive strategy was. Local revisions required a mean of 1.6 procedures, whereas mastopexies and reductions were accomplished in 1 procedure (P = 0.06, Table 3).
Twenty-eight patients completed the Breast Q patient satisfaction survey postoperatively. Overall satisfaction was fair, with the highest rates of satisfaction achieved among women reconstructed with breast augmentation (94.2/100). Satisfaction scores were lower among women who underwent breast reduction (63.6) and autologous tissue transfer (45.5), though comparisons across reconstructive techniques are limited by small sample sizes (local = 1 patient).
When stratified by the Fitoussi grade of deformity, similar levels of satisfaction were achieved across the 3 levels of severity represented (grade 2, 68.7; grade 3, 67.9; and grade 4, 60.0; P = 0.92).
Although the Breast Q captures various elements of the patient’s perception of their breasts, 1 question is particularly germane to the current study. When asked how the reconstructed breasts looks compared to before surgery, most patients (60.7%) stated that they were very satisfied.
The mean score for overall cosmesis across the entire cohort was 5 out of a possible 7. Considering the severity of the original BCT defect, postoperative esthetic scores in all domains were consistently highest for grade 1 defects and declined with increasing defect severity. This trend approached statistical significance for both overall cosmesis and position of the nipple areola complex (P = 0.07 for both).
The best esthetic results were observed among patients treated only by contralateral reduction, but there were no statistically significant differences across the 5 reconstructive techniques in any esthetic domain (Fig. 2).
The correction of BCT deformities can be challenging, and the type of reconstruction will depend on the extent and pattern of deformity. Although the type of deformity varies, a common denominator includes a history of regional scar tissue and previous radiation therapy, which can significantly alter treatment options. We have shown that different reconstructive techniques and often multiple techniques can be used to treat all types of deformities with acceptable morbidity, patient satisfaction, and esthetic outcome.
An organized approach to the treatment of BCT-related deformities begins with a clear and meaningful system of describing those defects. Previous classification schemes have established different patterns of deformity based on the extent of the lumpectomy defect and breast size,13,14 the etiology (e.g., tissue deficiency vs radiation fibrosis), 15 or the timing of consultation relative to radiation (e.g., before or after breast radiation).16 Seeking to devise a more usable system that facilitated surgical decision-making, Clough et al6 proposed a 3-tier system that distinguishes pure asymmetries (type I), deformities generally correctible with local tissue rearrangement (type II), and major deformities that required mastectomy and immediate breast reconstruction (type III). Although this scheme is straightforward and relatively easy to apply, type II defects proved a sufficiently heterogeneous group that guidance on a surgical approach was limited. This prompted Fitoussi et al11 to expand upon that system and divide the former type II defects into three levels of severity. In our series, we have found the Fitoussi classification to be easy to apply and to generally correlate with the reconstructive strategies undertaken.
The extent of the deformity was a major contributing factor in the corrective procedure chosen. Less severe deformities and asymmetries tended to be more amenable to local procedures and fat grafting, whereas the more pronounced deformities often required reconstruction with vascularized nonirradiated tissue, with the latissimus dorsi myocutaneous flap being the most versatile. This is in agreement with previously published data where flap reconstruction was more commonly required for correction of the BCT defect in a delayed fashion.10,13,16 In this situation, the skin island provides the ability to improve contour, add volume, and correct nipple translocation, especially when it is too lateral (Fig. 3). When the mound is relatively soft and radiation changes to the skin are minimal, local tissue rearrangement will often suffice. Reduction and mastopexy technique are used with caution and require strict patient selection (Fig. 4). Complication rates have been shown to be significantly higher when these techniques are performed in a delayed fashion compared to the time of lumpectomy (60% vs 21%, P < 0.001).17 Despite complications being 3 times more likely in the delayed reconstruction group, the authors found that although patient satisfaction was slightly lower in the delayed group (62% vs 73%, P = NS), the overall esthetic outcome was similar (60% vs. 63%, P = NS). Kronowitz et al18 have similarly shown complication rates being higher when reductions are performed after radiation therapy (50%) compared to the time of lumpectomy (24%), as have others.19 In addition to careful patient selection, conservative reductions in irradiated patients require minimal undermining and limited nipple reposition.
Implant placement is also considered risky in the previously irradiated patient; however, we have shown that in the well-selected patient the esthetic results are good, and patients are satisfied with the outcome. Once again, the skin envelope will dictate the ability to choose this procedure, and very conservative augmentations are preferable. As in any technique, the actual deformity will occasionally need to be recreated with radial scoring or scar release before the attempted reconstruction.
Autologous fat grafting has become a popular technique for contour adjustment in post-mastectomy breast reconstruction.20 It has also proven to be a useful adjunct to the correction of BCT deformities.21,22 Success relies on the quality of the overlying skin envelope and surgical technique. Fat grafting was more useful in our series as an adjunct to other techniques and in minimal contour irregularities with soft skin coverage (Fig. 3B).
The ideal situation is when the radiated breast has reasonable shape but is smaller than the opposite side and a contralateral reduction is sufficient (Fig. 5). This was shown in our series to have the best esthetic outcome.
It is reasonable to expect lower-grade deformities to have fewer complications and superior outcomes. However, if the appropriate procedures were selected based on the extent of the defect, then outcomes should be similar across the classification type. The more extensive defects did require more complex reconstructions with the associated higher risk of complications. Patients were generally satisfied with the result, although when lesser surgery was performed, they tended to be less satisfied. Perhaps given the radiated nature of the breast, even perceived smaller defects are better managed by more extensive reconstruction in select patients.
We have demonstrated that there are numerous reconstructive procedures that can be used to correct the BCT deformity, the choice of which will depend on the extent of the defect and size of the breast. Careful patient selection is important and will dictate surgical morbidity, esthetic result, and patient satisfaction. These are often difficult reconstructions that will frequently require multiple techniques and additional trips to the operating room to achieve the desired outcome.
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