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Breast: Original Articles

Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction

Schaverien, Mark V. M.D., M.B., Ch.B., M.Sc., M.Ed.; Kuerer, Henry M. M.D., Ph.D., C.M.Q.; Caudle, Abigail S. M.D., M.S., C.M.Q.; Smith, Benjamin D. M.D.; Hwang, Rosa F. M.D.; Robb, Geoffrey L. M.D.

Author Information
Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 14-27
doi: 10.1097/PRS.0000000000006911

Abstract

Oncoplastic breast-conserving surgery (OBCS) is well established for improving aesthetic outcomes following lumpectomy. It is indicated for defects treatable with wide local excision in cosmetically sensitive areas of the breast, where there is a high tumor size–to–breast volume ratio, or where the patient would be well served by bilateral breast reduction. Established approaches for oncoplastic breast reconstruction use volume displacement oncoplastic breast-conserving surgery (VD-OBCS) techniques involving standard or modified breast reduction procedures, or parenchymal flaps (local tissue rearrangement) from within the breast volume.1–4

Volume replacement oncoplastic breast-conserving surgery (VR-OBCS) uses islanded or pedicled chest wall fasciocutaneous perforator flaps from outside of the breast footprint to replace the volume that has been excised during the lumpectomy5–13 (Fig. 1). These techniques are best indicated in patients where the tumor size is large relative to breast volume with minimal breast ptosis, and therefore the excisional defect cannot be reconstructed by VD-OBCS techniques, in patients that desire breast conservation and wish to avoid mastectomy.

Fig. 1.
Fig. 1.:
Illustration of local pedicled chest wall perforator flap options for volume replacement oncoplastic breast-conserving surgery (© 2017 University of Texas M. D. Anderson Cancer Center).

Perforator flaps harvested from the lateral chest wall, including lateral intercostal artery perforator8,14–17 and lateral thoracic artery perforator18–34 flaps, are indicated for VR-OBCS for lumpectomy defects in the lateral third of the breast.5–16,18,35,36 They avoid the need for the thoracodorsal artery perforator flap,8,9,11 thereby preserving the pedicle to the latissimus dorsi muscle in the rare instance that completion mastectomy and total breast reconstruction (TBR) are required, and avoid the morbidity of intramuscular perforator dissection. Perforator flaps raised from the anterior chest wall, including the anterior intercostal artery perforator37–39 and medial intercostal artery perforator flaps,40 are used for reconstruction of the inferior and medial regions of the breast, respectively.

Reports of outcomes of VR-OBCS techniques to date have been limited to European and South American centers.8,15,16,18,37,38 The oncologic and complication comparisons of VR-OBCS, VD-OBCS, and mastectomy with immediate total breast reconstruction, however, remain unknown. This study compares the clinicopathologic factors and long-term outcomes for VR-OBCS, VD-OBCS, and mastectomy with immediate TBR, in a well-controlled cohort study in a U.S. population, and reviews indications, surgical techniques, and oncologic considerations.

MATERIALS AND METHODS

A retrospective cohort study of consecutive patients who underwent immediate breast reconstruction using either VR-OBCS or VD-OBCS, or mastectomy with immediate TBR, from March of 2016 to September of 2017 at a single institution was conducted. The study was approved by the institutional review board (PA17-0901). All patients were followed-up until their reconstruction was completed and they were discharged, with all completing a minimum of 12 months’ follow-up. Demographic data, clinicopathologic factors, surgical details, and postoperative events were collected and compared between the groups.

Complications affecting the breast area/chest wall including mastectomy skin flap necrosis, infection, delayed wound healing, wound dehiscence, hematoma, seroma, prosthesis explantation, flap failure, and fat necrosis were recorded, as were documented delays to commencement of adjuvant therapy, defined as greater than 8 weeks.41–46 Mastectomy skin flap necrosis was defined as nonviable breast skin that required débridement or took more than 2 weeks to heal. Fat necrosis was defined as any palpable firmness, nodule, or mass greater than 1 cm in diameter that was present beyond 3 months after surgery. Delayed wound healing was defined as the presence of a wound greater than 1 cm in length that had not healed by 4 weeks after surgery. Major complications were defined as those that required hospital readmission or return to the operating room or resulted that in a delay to adjuvant therapy.

Statistical Analysis

Statistical analysis of the collected data included the use of means and standard deviations for description of most measured outcomes. Continuous variables were compared using the t test and analysis of variance test. Parametric variables were compared using chi-square analysis or Fisher’s exact test, as statistically appropriate. All tests were two-sided. A value of p < 0.05 was considered significant. All analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, N.C.).

VD-OBCS

VD-OBCS involving mastopexy/breast reduction techniques was defined as parenchymal rearrangement with nipple relocation based on an established vascular pedicle with breast skin envelope resection/reshaping. Local tissue rearrangement was defined as development of advancement or rotation parenchymal flaps for reconstruction of the lumpectomy defect.

Lateral Intercostal Artery Perforator and Lateral Thoracic Artery Perforator Flaps

Indications

Lateral chest wall perforator flaps are indicated for volume replacement for excisional defects in the lateral third of the breast.5–16,18,35,36 Horizontal flap designs take advantage of the soft-tissue excess of the axillary roll with a resultant scar that is well-hidden in the bra-strap line and lateral breast fold. The abundance of blood supply options in the lateral chest wall region allows for a plethora of flap options and versatility in flap design. These flap options include the lateral intercostal artery perforator8,14–17 (Fig. 2), lateral thoracic artery perforator18,19–34 (Fig. 3), and thoracodorsal artery perforator flaps.8,9,11 Although the transverse flap design can be based on any of these contributions, the thoracodorsal artery perforator flap was not used in this case series, preserving the thoracodorsal pedicle and thus the latissimus dorsi flap.

Fig. 2.
Fig. 2.:
Lateral intercostal artery perforator flap. (Above, left) Preoperative photograph. (Above, center) Preoperative flap markings, with both the lateral thoracic artery and lateral intercostal artery perforator identified using Doppler ultrasound and marked. (Above, right) Intraoperative photograph following reconstruction of a large superolateral breast parenchymal defect following raising the flap on a large lateral intercostal artery perforator. (Center) Postoperative photographs 12 months after radiation therapy, with resultant scar on the lateral chest wall well hidden within the bra-strap line. (Below) Radiation therapy plan for breast tangents and boost. The donor scar is not included in the fields.
Fig. 3.
Fig. 3.:
Lateral intercostal artery perforator flap. (Above, left) Preoperative photograph. (Above, right) Intraoperative photograph demonstrating the large upper central breast defect; the flap has been deepithelialized. (Below, left) The flap is pedicled on the lateral thoracic pedicle then tunneled and transposed to reconstruct the defect. (Below, right) Postoperative photograph 12 months after radiation therapy.

Although predominantly used for reconstruction of the lateral breast, where abundant soft-tissue volume is present or where the flap can be islanded and transposed on the lateral thoracic artery perforator, selected defects extending up to the breast meridian can be reconstructed. Depending on the soft-tissue availability from the axillary roll, and the volume of the breast parenchyma, excisional defects of up to one-third of the breast volume can be reconstructed. In selected cases, more medial defects can be reconstructed by a parenchymal rotation advancement flap, with a lateral intercostal artery perforator/lateral thoracic artery perforator flap used for reconstruction of the secondary defect.

Surgical Techniques

Preoperative handheld acoustic Doppler imaging is used to identify and mark all lateral chest wall perforators. The lateral intercostal artery perforator perforators are commonly found in the fifth to seventh intercostal spaces between the lateral border of the breast and the anterior border of the latissimus dorsi muscle, most frequently in the sixth intercostal space15; perforators located closest to the lateral breast border generally allow the greatest mobility of the flap. The lateral thoracic artery perforator pedicle, where present, is found within 2 cm of the lateral breast crease and is identified by vertical axial Doppler sounds.18,19–26 With the patient sitting, the lateral breast crease is marked up to the breast equator or curved slightly above to include all marked perforators, and then continued horizontally, dependent on the required flap size/volume/reach; this conceals the donor-site scar within the bra-strap line. Flap height is usually restricted to 8 to 10 cm; a curvilinear line then connects these to complete the flap design.

Following completion of the lumpectomy, the flap is harvested with the patient in the supine position. If suitable perforators have been identified preoperatively using the Doppler device, the flap is raised from lateral to medial (Figs. 2 and 3). If perforators could not be identified preoperatively, or where axillary lymphadenectomy is performed and the lateral thoracic vessels ligated, either the perforators can be explored from the medial flap edge, or a dermal bridge is preserved inferiorly until the lateral intercostal artery perforators have been appraised—if these perforators are insufficient, the flap is pedicled inferiorly, although reach is limited. (See Figure, Supplemental Digital Content 1, which shows a pedicled lateral intercostal artery perforator flap. 1. Preoperative photograph of a patient with a large area of high-grade ductal carcinoma in situ in the inferolateral quadrant of the left breast. 2. Preoperative flap markings. 3. Intraoperative photograph of the large inferolateral breast defect following quadrantectomy; the inferior dermal bridge is preserved until the perforators have been appraised. 4. Intraoperative photograph after raising the flap from lateral to medial with identification and preservation of the lateral intercostal artery perforator perforators. 5. Intraoperative photograph following reconstruction of the defect; the flap had sufficient mobility without the need to divide the inferior dermal bridge. 6. Postoperative photograph 12 months after radiation therapy, http://links.lww.com/PRS/E99.)

Additional adipose tissue can be recruited from under the Scarpa fascia laterally and inferiorly. Any medium or large-sized lateral intercostal perforators are confirmed to have suitable flow using the Doppler probe and preserved. Depending on the presence and relative contribution of the lateral thoracic artery perforator and lateral intercostal artery perforators, the decision is made whether to base the flap solely on the lateral thoracic artery perforator or on the lateral thoracic artery perforator and/or lateral intercostal artery perforators. As many blood supply options as possible are preserved within the flap design, sacrificing only those vessels that restrict flap movement and reach.

Anterior Intercostal Artery Perforator and Medial Intercostal Artery Perforator Flaps

Indications

The anterior intercostal artery perforator flap uses soft-tissue excess from below the inframammary fold islanded on perforators from the anterior intercostal vessels arising about the breast meridian for reconstruction of central inferior breast defects37–39 (Fig. 4). The breast volume that can be reconstructed is dependent on the soft-tissue availability/laxity. In selected cases, the flap can be extended transversely onto the lateral chest wall region to recruit additional soft tissue and increase reach and volume (Fig. 5). The medial intercostal artery perforator flap, based on perforators arising from the internal mammary or anterior intercostal vessels, is indicated for reconstruction of medial inferior and central breast defects where there is a sufficient soft tissue below the inframammary fold40 (Fig. 6).

Fig. 4.
Fig. 4.:
Anterior intercostal artery perforator flap. (Above, left) Preoperative photograph. (Above, center) Preoperative photograph demonstrating markings including the inframammary fold, caudal flap markings based on skin laxity, and anterior intercostal artery perforator location using Doppler ultrasound with the patient in the supine position. (Above, right) Intraoperative photograph demonstrating the large inferior breast defect, with skin paddle deepithelialized. (Below, left) The flap is raised in the suprafascial plane until the large perforator found on ultrasound is visualized; then, the flap is islanded on this perforator. (Below, center) Postoperative on-table photograph following reconstruction of the defect and closure of the donor site with repositioning of the inframammary fold. (Below, right) Postoperative photograph 6 months after radiation therapy.
Fig. 5.
Fig. 5.:
Extended anterior intercostal artery perforator flap. (Above, left) Preoperative photograph. (Above, right) Intraoperative photograph following excision of the tumor with anterior intercostal artery perforator location using Doppler ultrasound marked. (Below, left) The flap is deepithelialized and raised in the suprafascial plane, extended on the lateral chest wall to increase reach and flap volume, islanded on the perforators identified preoperatively. (Below, right) Postoperative photograph 6 months after radiation therapy.
Fig. 6.
Fig. 6.:
Medial intercostal artery perforator flap. (Above, left) Preoperative photograph. The patient had breast ptosis but did not want a breast mastopexy/reduction procedure or symmetrizing surgery to the contralateral breast. (Above, right) Intraoperative photograph demonstrating large inferomedial breast defect; the flap has been deepithelialized. (Below, left) Flap is islanded on a large medial intercostal perforator identified preoperatively using Doppler ultrasound. (Below, right) Postoperative photograph 6 months after radiation therapy.

Surgical Techniques

Preoperatively, hand-held Doppler ultrasound is used to identify and mark the perforators (Fig. 4, above, left, and 5, above, right). Anterior intercostal artery perforators arise about the breast meridian, most frequently located in the fifth and sixth intercostal spaces37; medial intercostal artery perforators from the internal mammary artery or the anterior intercostal arteries are found in the medial region of the inframammary fold, most frequently in the fifth and sixth intercostal spaces38—perforators closest to the inframammary fold allow for maximal flap mobility and reach. The inframammary fold is the superior border of the flap, marked from the 4- to 8-o’clock position with the patient seated, and the inferior flap marking/width is dependent on the soft-tissue laxity; then, a curvilinear lower line is drawn. For the anterior intercostal artery perforator flap, markings can be extended transversely onto the lateral chest wall if additional flap length and/or volume is required.

For flap harvest, the patient is positioned supine and the lumpectomy is performed by means of an incision in the inframammary fold crease. The flap is raised in the suprafascial plane, although the deep fascia can be included to increase flap volume if required, until the perforators identified preoperatively are encountered. For the medial intercostal artery perforator flap, if the perforators are found to be small, the flap can also be pedicled on the medial dermal bridge to augment flap perfusion. Care is taken to reposition the inframammary fold at the same level as the unoperated breast (Fig. 4).

Oncologic Considerations for VR-OBCS

Surgical Considerations

Careful communication between the plastic surgeon, surgical oncologist, and radiation oncologist with regard to the surgical plan is crucial to optimize patient outcomes. Preoperative review of the breast imaging is essential to define the tumor extent and three-dimensional target area that will need to be resected. More complex lesions and sometimes larger areas are suitable for potential breast conservation because of the introduction of seed technology and wider application of OBCS techniques.3,47,48

Achieving negative surgical margins is important to minimize the rate of local recurrence after breast-conserving surgery, and intraoperative assessments using specimen radiographs or frozen section analysis may be used.49–52 Another key component is careful marking of the surgical specimen(s) with multiple colored inks such that, in the case of a positive margin, the exact region of the cavity can be resected either at the time of initial intraoperative evaluation or following full processing at a subsequent operation. If delayed reexcision of margins is required, the perforator flaps can be retracted to allow access to the excision cavity; patients therefore do not need to undergo mastectomy for margin control. At the completion of the procedure, radiopaque surgical clips should be placed generously around the surgical cavity to define the area at risk for radiation field planning.

If completion mastectomy is required to achieve negative margins, all TBR options remain available, and mastectomy can often be performed through the existing incisions. Joint decision-making between the ablative and reconstructive surgeons regarding the reconstructive plan for optimal incision placement is also vital.

Radiotherapy Considerations

The area at greatest risk for local recurrence is the breast parenchyma residing within 1 to 2 cm of the resection volume. Delineating this area is challenging in the setting of VR-OBCS techniques because the flap is placed within the lumpectomy bed and is relatively isointense to the surrounding breast parenchyma on the simulation computed tomographic scan. The donor site for the chest wall perforator flap is not generally considered a target, and the radiation oncologist should not generally attempt to cover scars or surgical changes outwith the breast footprint (Fig. 2, below). It is preferable for the plastic surgeon to avoid using hemostasis clips at the donor site, to ensure that the radiation oncologist does not inadvertently consider the donor site as a component of the target volume. When a boost is indicated, the radiation oncologist should delineate the 1.0 to 1.5 cm of rim of breast parenchyma adjacent to the lumpectomy bed and treat this with either appositional electrons or conformal photons based on the tumor bed geometry.

RESULTS

Surgical Factors

Ninety-seven consecutive patients that underwent 109 immediate breast reconstruction procedures during the study period were included: 21 patients (22 percent) underwent VR-OBCS, 42 (43 percent) underwent standard VD-OBCS (45 procedures), and 34 (35 percent) underwent mastectomy with immediate TBR (43 procedures). The excisional procedures were performed by six breast surgical oncologists and reconstructions were performed by one plastic surgeon. Mean length of follow-up was 19.1 ± 5.1 months (Table 1).

Table 1. - Patient Characteristics by Type of Reconstruction
Total (%) VR-OBCS (%) VD-OBCS (%) Mastectomy and Immediate TBR (%) p
No. of patients 97 (100) 21 (21.6) 42 (43.3) 34 (35.1)
No. of breasts 109 (100) 21 (19.3) 45 (41.3) 43 (39.4)
Mean age ± SD, yr 55 ± 11.5 54.9 ± 10.4 58.5 ± 12.1 50 ± 9.7 0.0012* (VD-OBCS vs. TBR)
Mean BMI ± SD, kg/m2 27.9 ± 5.9 26.6 ± 5 30.2 ± 6.5 25.8 ± 4.5 0.0092* (VD-OBCS vs. VR-OBCS, TBR)
Mean length of follow-up ± SD, mo 19.1 ± 5.1 17.5 ± 5.7 19 ± 5.1 21 ± 4.2 0.043* (TBR vs. VR-OBCS, VD-OBCS)
Bra size <0.001* (VD-OBCS vs. VR-OBCS, TBR)
A 1 (1) 1 (2.9)
B 20 (20.6) 7 (33.3) 3 (7.1) 10 (29.4)
C 40 (41.2) 11 (52.4) 17 (40.5) 12 (35.3)
D 18 (18.6) 3 (14.3) 9 (21.4) 6 (17.6)
DD 10 (10.3) 9 (21.4) 1 (2.9)
DDD 8 (8.2) 4 (9.5) 4 (11.8)
Ptosis grade 0.019* (VD-OBCS vs. VR-OBCS, TBR)
I 17 (17.5) 7 (33.3) 3 (7.1) 7 (20.6)
II 61 (62.9) 12 (57.1) 27 (64.3) 22 (64.7)
III 19 (19.6) 2 (9.5) 12 (28.6) 5 (14.7)
Preoperative chemotherapy 33 (34) 6 (6.2) 15 (15.5) 13 (13.4) 0.53
Preoperative radiotherapy 2 (2.1) 2 (5.9)
Postoperative chemotherapy 22 (22.7) 6 (28.6) 7 (16.7) 9 (26.5) 0.44
Postoperative radiotherapy 72 (74.2) 20 (95.2) 40 (95.2) 12 (35.3) <0.001* (TBR vs. VR-OBCS, VD-OBCS)
Diabetes mellitus 8 (8.2) 2 (9.5) 5 (11.9) 1 (2.9) 0.6
Active cigarette smoker 4 (4.1) 2 (4.8) 2 (5.9) 1
BMI, body mass index.
*p < 0.05.

In the VR-OBCS group, 21 patients underwent unilateral procedures, of whom 16 received lateral chest wall perforator flaps (seven islanded lateral intercostal artery perforator flaps, two pedicled lateral intercostal artery perforator flaps, three combined lateral intercostal artery perforator and lateral thoracic artery perforator flaps, and four islanded lateral thoracic artery perforator flaps). Five patients underwent anterior chest wall perforator flaps (three anterior intercostal artery perforator flaps and two medial intercostal artery perforator flaps) (Table 2).

Table 2. - Operations Performed during Initial Reconstruction
VR-OBCS VD-OBCS Mastectomy and Immediate TBR
No. of patients 21 42 34
No. of breasts 21 45 43
VR-OBCS
Lateral intercostal artery perforator flap 12 1
Lateral thoracic artery perforator flap 4
Anterior intercostal artery perforator flap 3
Medial intercostal artery perforator flap 2
VD-OBCS
Local tissue rearrangement 7
Oncoplastic breast mastopexy/reduction 1 35
Contralateral oncoplastic breast mastopexy/reduction 1 3 1
Contralateral breast mastopexy/reduction 25
Mastectomy and immediate TBR
Tissue expander placement 31
Implant placement 5
Deep inferior epigastric artery perforator flap 4
Transverse upper gracilis flap 2
Extended latissimus dorsi flap 1
Contralateral mastectomy with immediate TBR 9
Axillary surgery
No axillary surgery 1 4 3
Sentinel lymph node biopsy 15 27 22
Axillary lymph node dissection 5 10 9
BMI, body mass index.

Of the 34 patients in the mastectomy with immediate TBR group (43 procedures), nine underwent a nipple-sparing mastectomy procedure. Simultaneous contralateral prophylactic mastectomy and immediate TBR was performed in nine patients, and five patients underwent delayed contralateral prophylactic mastectomy and immediate reconstruction. Immediate autologous breast reconstruction was performed in seven patients, five underwent direct-to-implant reconstruction, and 31 underwent tissue expander placement for delayed-immediate breast reconstruction (Table 2). Of the tissue expanders placed, 18 were placed for delayed-immediate breast reconstruction with the expectation that the patient would require postmastectomy radiation therapy; 10 of these patients actually received radiation therapy. Subgroup analysis of the patients that underwent autologous or implant-based TBR revealed that the number of additional operations (1.3 ± 0.9 and 1.5 ± 1.0, respectively; p = 0.61) and time to completion of the reconstruction (9.4 ± 5.9 and 10.9 ± 7.4, respectively; p = 0.57) were similar between the groups.

In the VD-OBCS group, 42 patients underwent 45 procedures: seven patients underwent local tissue rearrangement only, and 35 patients underwent VD-OBCS by mastopexy/breast reduction procedures; 33 of these were vertical scar procedures (Table 2). Synchronous contralateral mastopexy/breast reduction for symmetry was performed in 25 patients; three patients had bilateral cancers and underwent contralateral OBCS procedures.

Clinicopathologic Factors

The VR-OBCS and TBR groups were similar in body mass index, breast size, and grade of ptosis; however, all were significantly lower in the TBR group than in the VD-OBCS group (p = 0.02, p < 0.001, and p = 0.007, respectively). Tumor and nodal stages were similar between the groups (Table 3). Mean whole tumor size was similar in the VR-OBCS and TBR groups (31 ± 18.4 mm and 32 ± 21.9 mm, respectively), and higher than for the VD-OBCS group (22.5 ± 16.2; p < 0.05). There were no significant differences in wide local excision volume or tumor multifocality between the groups.

Table 3. - Tumor Characteristics by Type of Reconstruction
Total (%) VR-OBCS (%) VD-OBCS (%) Mastectomy and Immediate TBR (%) p
No. of patients 97(100) 21 (21.6) 42 (43.3) 34 (35.1)
No. of breasts 109 (100) 21 (19.3) 45 (41.3) 43 (39.4)
Breast cancer tumor (T) stage 0.37
Tis 13 (13.4) 3 (14.3) 4 (9.5) 6 (17.6)
T1 36 (37.1) 6 (28.6) 21 (50) 9 (26.5)
T2 39 (40.2) 11 (52.4) 15 (35.7) 13 (38.2)
T3 9 (9.3) 1 (4.8) 2 (4.8) 6 (17.6)
T4
Breast cancer nodal (N) stage 0.98
N0 61 (62.9) 14 (66.7) 23 (54.8) 24 (70.6)
N1 24 (24.7) 5 (23.8) 10 (23.8) 9 (26.5)
N2 3 (3.1) 3 (7.1)
N3 5 (5.2) 2 (9.5) 2 (4.8) 1 (2.9)
Breast cancer type 0.97
DCIS 12 (12.4) 3 (14.3) 4 (9.5) 5 (14.7)
LCIS 1 (1) 1 (2.9)
IDC 75 (77.3) 16 (76.2) 36 (85.7) 23 (67.6)
ILC 9 (9.3) 2 (9.5) 2 (4.5) 5 (14.7)
Mean pathologic tumor size ± SD, mm 27.6 ± 19.2 31 ± 18.4 22.5 ± 16.2 32 ± 21.9 0.049*
Multifocality 27 (27.8) 3 (14.3) 10 (23.8) 14 (41.2) 0.072
Tumor location 0.1
Upper outer quadrant 37 (38.1) 6 (28.6) 16 (38.1) 16 (47.1)
Lower outer quadrant 19 (19.6) 7 (33.3) 6 (14.3) 6 (17.6)
Upper medial quadrant 32 (33) 4 (19) 16 (38.1) 10 (29.4)
Lower medial quadrant 9 (9.3) 4 (19) 4 (9.5) 2 (5.9)
Mean wide local excision volume ± SD, cm3 120 ± 99 132 ± 28.4 0.68
DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma.
*p < 0.05.

Surgical Complications

The overall complication rate was significantly higher in the TBR group than in both the VR-OBCS (p = 0.0017) and VD-OBCS groups (p < 0.01); however, the major complication and delay to adjuvant therapy rates were similar between the groups (Table 4). Additional operations to the index and/or contralateral breasts were significantly higher in the TBR group than for the VR-OBCS and VD-OBCS groups (85.3 percent versus 23.8 percent and 14.3 percent, respectively; p < 0.001); only one patient in the VR-OBCS group required symmetrizing surgery to the contralateral breast. The rate of additional surgery for reexcision of positive margins was 14.3 percent in both the VR-OBCS and VD-OBCS groups, and 0 percent in the TBR group. Time to completion of reconstruction was significantly longer in the TBR group than in the VR-OBCS and VD-OBCS groups (10.5 ± 6.9 months versus 1 ± 2 months and 1.2 ± 3.9 months, respectively; p < 0.001).

Table 4. - Outcomes for Immediate Breast Reconstruction
VR-OBCS (%) VD-OBCS (%) Mastectomy and Immediate TBR (%) p
No. of patients 21 (21.6) 42 (43.3) 34 (35.1)
No. of breasts 21 (19.3) 45 (41.3) 43 (39.4)
Overall breast area complications 0 4 (9.5) 12 (38.2) <0.001*
Major complications 0 1 (2.4) 5 (14.7) 0.084
Complication delaying adjuvant therapy 0 1 (2.4) 0 0.52
Reconstruction failure 1 (2.9)
Breast area complications
Mastectomy skin flap necrosis 3 (8.8)
Infection/cellulitis 0 0 3 (8.8) 0.057
Delayed wound healing 0 4 (9.5) 3 (8.8) 0.35
Wound dehiscence 0 0 1 (2.9) 0.39
Hematoma 0 0 0
Seroma 0 0 0
Fat necrosis 0 0 2 (5.9) 0.15
Reexcision for involved margins (as an additional surgical procedure) 3 (14.3) 6 (14.3) 0 (0) 1
Additional surgery to index breast 4 (19) 6 (14.2) 29 (85.3) <0.001*
Additional surgery to contralateral breast 1 (4.8) 2 (4.8) 26 (76.5) <0.001*
Mean no. of additional operations ± SD 0.2 ± 0.4 0.1 ± 0.4 1.5 ± 1 <0.001*
Mean no. of additional individual procedures ± SD 0.4 ± 0.7 0.2 ± 0.6 3.1 ± 2 <0.001*
Mean time to complete reconstruction ± SD, mo 1 ± 2 1.2 ± 3.9 10.5 ± 6.9 <0.001*
*p < 0.05.

DISCUSSION

VR-OBCS involves importing soft tissue from outside of the breast and extends the indications for OBCS to defects where mastectomy would typically be required, and preserves nipple-areola complex sensation. These techniques are best indicated in patients where the tumor size is large relative to breast volume with minimal breast ptosis and who are therefore not candidates for standard VD-OBCS approaches such as local tissue rearrangement or breast mastopexy/reduction, in particular for tumors located in the lateral and inferior aspects of the breast.

The abundance of blood supply options in the lateral and anterior chest wall regions affords transverse extended flap designs with long length-to-width ratios, resulting in aesthetically well-placed scars within the natural boundaries of the breast that can be well-hidden in the bra-strap line. The donor-site morbidity of these local fasciocutaneous flaps is low, as intramuscular dissection is not required. These flaps preserve the thoracodorsal pedicle so that the latissimus dorsi flap remains available in case of need for completion mastectomy for involved margins, or for mastectomy following local recurrence, although in certain circumstances, the latissimus dorsi flap can be based on the serratus branch even after raising a thoracodorsal artery perforator flap.

At our institution, patients that desire breast conservation but are judged to be “borderline” on the basis of clinical/radiologic tumor size relative to breast volume and ptosis are considered for VR-OBCS. Suitable patients with tumors located in the lateral or inferior region of the breast with adequate local soft-tissue availability can be offered VR-OBCS using local chest wall perforator flaps; selected patients with more medial defects may be candidates for a thoracodorsal artery perforator flap. Contralateral mastopexy for symmetry is typically not required because of the minimal breast ptosis (4.8 percent in this series).

The VR-OBCS techniques were introduced and popularized by European centers,8,15,16,18,37,38 where the average population body mass indexes are lower,53 and therefore VD-OBCS techniques are less suitable for larger tumor-to-breast volume ratios. This study has made the following original observations. First, in this consecutive series of patients undergoing immediate breast reconstruction in a U.S. population, VR-OBCS techniques were used in 22 percent of patients and therefore have frequent application, even in a high–body mass index population. Second, patients who underwent VR-OBCS and those that underwent mastectomy were similar in breast size, degree of breast ptosis, and tumor size. Third, the breast area complication rate, rate of additional surgery to the index or contralateral breast, and time to completion of the reconstruction were significantly less for patients that underwent VR-OBCS than for those that underwent mastectomy with immediate TBR. Fourth, these fasciocutaneous chest wall perforator flaps seem to undergo minimal volume loss following radiotherapy, with low rates of revision surgery to the index breast (in four of 21 patients) over short-term follow-up (mean, 17.5 ± 5.7 months). Other studies have demonstrated stable aesthetic results for pedicled perforator flaps used for VR-OBCS over medium-term follow-up (average, 4 years), although the majority were thoracodorsal artery perforator flaps, and longer follow-up with objective evaluation is necessary to determine the long-term stability of these techniques.54

Most importantly, this study has demonstrated that these VR-OBCS procedures are typically single-stage procedures, enabling lumpectomy and reconstruction to be performed in one outpatient operation with a single recovery time, and avoiding unwanted surgery to the contralateral breast for symmetry. Of note, 18 of 34 patients underwent immediate tissue expander reconstruction for delayed-immediate breast reconstruction in anticipation of postmastectomy radiation therapy, which is a complex and prolonged reconstructive course typically with multiple revision procedures required. In addition, higher body mass index patients are at risk of tissue expander complications55 yet are typically ideal VR-OBCS candidates because of local soft-tissue availability. In this study, the rate of additional surgery for reexcision of positive margins, despite intraoperative margin assessment, was 14.3 percent in both the VR-OBCS and VD-OBCS groups. By comparison, a previous large study from our institution found that the rate of positive or close margins was 5.8 percent in those that underwent OBCS,4 suggesting confounding attributable to small group size. Although nipple-sparing mastectomy with immediate TBR may be a one-stage procedure in suitable patients, there is a risk of positive margins on permanent pathologic evaluation necessitating delayed excision of the nipple-areola complex,56 or necrosis necessitating reoperation,57 and patients need to be counseled appropriately.

This study has several limitations. Although the study is well-controlled with regard to reconstructive surgeon factors, this may limit generalizability of the results, and the study groups were small. Given the small study group size, multivariate analysis to control for confounders was not possible when comparing complication rates between the groups. The study also did not evaluate cosmetic results following surgery or patient-reported outcomes measures, which are currently being investigated for a follow-up study.

CONCLUSIONS

This study has demonstrated the clinical utility of pedicled chest wall perforator flaps used for VR-OBCS, extending the options for breast conservation to many patients that would otherwise require mastectomy. This approach is particularly helpful for patients with small breast size who are not candidates for standard VD-OBCS approaches such as local tissue rearrangement or breast mastopexy/reduction. The complication rate is lower, fewer procedures are necessary, and less time is required to complete the reconstruction when compared with mastectomy and immediate TBR, which would be the alternative. Wider application of these techniques may allow more women to achieve breast conservation, with preservation of nipple-areola complex sensation and reduction of the need for symmetrizing surgery to the contralateral breast.

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